Does the gender of nurses matter to patients? A qualitative analysis of gender preferences of patients

Abstract

Background:

This study argues that the gender of a nurse could give patients the emotional and psychological support they need in their healing process. Nonetheless, in many developing countries, these intricate preferences of patients are usually ignored due to poor staffing and logistical capacities of health facilities. As a contribution to this professional and operation gap, this paper explores patients’ preference for nurses’ gender in health care at the Komfo Anokye Teaching Hospital in Ghana. The paper further explores the importance of these preferences to the delivery of patient-centred care in Ghana and across Africa.

Objective:

The paper has two specific objectives: (a) to explore patients’ preferences for the gender of nurses who attend to them while on admission; and (b) to find out the range of factors that inform these preferences.

Methods:

Qualitative exploratory descriptive design was used to select adult patients who were not seriously ill and nursed by male and female nurses at the medical and surgical wards of the Komfo Anokye Teaching Hospital in Ghana for at least 5 days from January to March 2017 and before their discharge. Participants were recruited using purposive sampling technique. A semi-structured interview guide was used to elicit information from 14 participants after seeking their written informed consent. The data were analysed using content analysis.

Results:

Two major themes emerged. These were: the Preferred Gender of a Nurse in Nursing Care and the Reasons for the Preference or no Preference for Nurses’ Gender in Nursing Care. Under each of these themes, the associated aspects were also discussed. Patients had varying preference for a particular nurse during care but gender was not particularly significant in patients’ preference for nurses. Majority of the participants emphasized their preference for nurses with professional expertise and good virtues to determine a preferred nurse and both genders of nurses can possess these qualities. However, nurses of the same gender as the patient were preferred for intimate procedures to ensure privacy and satisfaction.

Conclusion:

The gender of a nurse is not on top of the preferences list of patients in the study context. This may be attributed to the long-term practice that the participants have not had the chance to be choosing a preferred nurse’s gender, so most patients are tolerant and familiar with both male and female nurses. Instead, patients’ preferences are determined by the performance and quality of service provided by nurses. Age, maturity and social connections were also found to influence patients’ preferences.

Keywords

patients preference nurses gender nursing care male;female

What is already known about the topic and what this paper adds to the literature

Patients’ preferences for the gender of care providers have been studied in many jurisdictions around the world.

Factors that determine these gender preferences have also been explored in developed countries where the views of patients are taken seriously.

This study extends the conversation by exploring the patients’ preferences for the gender of nurses in Ghana, a country in which the respect for the wishes of patients is still evolving and the general perception about clinical nursing and care-provision are the preserve of females.

The study also adopts an exploratory descriptive design and qualitative data collection methods that describes the candid views of patients who hitherto may not want to disclose their preferences for fear of victimization.

Contrary to the dominant narrative from the developed world that gender is key on the preferences list of patients, this study reveals that patients in the case context are more interested in the quality of health service delivery, performance of nurses and the level of nurse–patient relationship developed as such, the performance of nurses and the quality of health service delivered have nothing to do with gender.

Background

The nursing profession focuses on the care of individuals and their families to help them recover from sickness and maintain optimum health and quality lifetime. Nurses are required to perform activities contributing to the patent health and recovery.¹

These include intimate procedures that require constant contact with the patients, no matter the body part involved in order to promote recovery.^2,3 Although these procedures involve touches that are task-oriented, they might produce feelings of discomfort, anxiety, and fear or might be misinterpreted as having a sexual purpose.⁴ These procedures include: bed bathing, examining the cervix for dilation, shaving of the perineum, circumcision, examination of the breast, giving an enema, inserting urinary catheters, bandaging the scrotum and sterilizing the vaginal area.⁵ Furthermore, procedures that require intimate touch can cause feelings of embarrassment, discomfort, anxiety and fear for both the nurse and the patient.⁶ Consequently, there may be the preference for a particular gender of a nurse to ensure comfort and relaxation of patients during such intimate procedures.

Globally, existing researches indicate that patients have varying preferences when it comes to the gender of their nurses.^7,8 A study in Jamaica by⁹ indicates that gender preferences are stronger among female patients than among male patients. This is because women have been found to prefer female nurses for matters of reproductive, sexual health and intimate or psychosocial issues, whereas men also demonstrate a similar trend, but to a lesser degree. According to,¹⁰ younger females may care about female nurses more than older females because older women are used to receiving care from male gynaecologists and some are reluctant to admit they prefer women because much attention was not paid to a patient’s preference in the prior years. Other studies reported that most patients had no preference for their care providers and practitioners.^11–13 A study by¹⁴ identified that the level of intimacy in a clinical situation predicted same-gender preferences.

Nursing and Midwifery code of professional conduct also indicates that nurses must recognize and respect the role of patients as partners in their care.¹⁵ The nursing profession also lays emphasis on providing holistic care and ensuring that patient values guide all clinical decisions and also emphasizes that patients have the fundamental right to be treated as individuals. This in turn enhances their personal dignity and shows respect for their cultural, psychosocial and spiritual needs.¹⁶ According to nursing theorists Watson and Leininger, a patient is a unique individual and should be respected, nurtured, understood and assisted and provided with culturally competent care.¹⁷ As human beings, they have diverse beliefs, desires, values, needs and preferences. To satisfy the needs of a patient and render proper and individualized nursing care, one needs to appreciate the preferences of patients and offer them accordingly to satisfy the needs of the patient.

This study describes patients’ preference for the gender of their nurses in developing country settings. The study also explores the range of factors that determine these gender-related preferences, in settings where the views of patients are not critically considered in the overall health delivery system. The study is particularly timely due to the many lapses observed in the health care provision in Ghana.

Method

Design

The study adopted an exploratory descriptive design. This allows for in-depth exploration, understanding and narration of patient’s preferences for their nurses’ gender.

Setting

Participant recruitment and data collection took place at a Teaching Hospital in Ghana. This Hospital is the second largest hospital in the country and the only tertiary health institution in the Ashanti Region. Besides, the Ashanti region of Ghana is believed to be the region with the most diverse culture, therefore, preferences of patients in this region may represent preferences of a cross-section of Ghanaians.

Population

Participants consisted of male and female patients, 18 years and above admitted to the medical and surgical adult wards, not bed ridden or seriously ill and nursed by both female and male nurses for at least 5 days from January to March 2017.

Sampling and sample size

The purposive sampling technique was used to select the participants for this study. After gaining ethical approval with the management of the hospital, the target population were introduced in the various wards, contact was made with the patients to gain their confidence, inform them about the purpose and processes involved in the study and written informed consent sought from those who met the inclusion criteria and willing to participate. Information sheet and consent form were provided to them to sign or thumbprint. The sampling size depended on the data saturation when there was no new information forthcoming during interviews with research participants. The data was saturated at the 14th participant.

Data collection

All guiding interview questions were pretested using two (14%) participants at a university Hospital in Ghana and analysis of their responses were used to effect changes in the interview guide before it was administered to the main participants. A semi-structured interview guide (file attached) was used to conduct a one-on-one face-to-face interview to explore the choice of the gender of a nurse that is preferred by patients during nursing care. Most of the interviews were conducted at the nurse manager’s office when they were not in use and at the time when there were no routine medical or nursing activity going on to ensure maximum privacy and relaxation of the participants. None of the patients approached refused to participate in the study. The interviews were recorded on a voice recorder with the permission of the participants. Moreover, non-verbal responses and behaviour including gestures and moment of confusion were also written down. The interviews lasted for at most 1 h and at least 45 min. The data collection and the data analysis were done concurrently.

Data analysis

The data were analysed using content analysis,¹⁸ approach. The recorded interviews were transcribed verbatim. The researchers familiarized themselves with the data by reading over and over for several times and paid attention to details that captured their attention. Notes were made from the transcripts to identify phrases and sentences which captured the attention of the researchers. Statements and words which were similar, same or common were grouped to form different files. Unique names were then given to these files. Similar files were brought together during this process. Initial codes were generated by organizing the data into meaningful units. The generated codes were combined to form themes. Field notes taken during the period of audio-taped interviews were also read and analysed together with the transcribed data. Through the process of creating different files, themes and their subthemes were named to describe patients’ preference for nurses’ gender in nursing care in which descriptive report has been provided to capture the responses of participants in the write up under the findings section backed by verbatim quotes from participants. The main themes and the sub-themes are presented and supported with their anonymized verbatim quotations from the participants below.

Trustworthiness

Firstly, credibility was ensured by demonstrating that a true picture of the phenomenon under scrutiny is being presented. A purposive sampling was used to select the required respondents who could share ideas on their gender preference in nursing care. Same questions were asked in different ways to ensure the honesty of responses. Besides, member check was conducted by verifying the responses with the respondents after the interview to ensure that their stories have been well documented before conclusions drawn. The participants were assured of the confidentiality and anonymity of information provided. This made participants talk freely without fear because they believed their real names were not used for them to be identified. To achieve transferability, the study sample taken was 14 patients based on saturation. In addition, participants were selected from different wards, tribes, religious background, educational level and age groups (see Table 1). Also, vivid description of the setting was done to provide sufficient detail of the context of the fieldwork for a reader to be able to decide whether the prevailing environment is similar to another situation. To achieve dependability of a study, clear questions were asked to elicit the responses that could answer the research objectives as well as research questions. The participants expressed interest in the research topic and joyfully responded to the questions asked. Also, the researchers identified correctly the themes and subthemes from the data. The researchers presented the findings that emerged from the data as a true reflection of the respondents’ views and ideas about patients’ preference for nurses’ gender in nursing care. Moreover, the researchers bracketed their thoughts and values on the study. Also, the participant’ responses were recorded, transcribed verbatim and the themes that emerged were supported with direct quotations from the participants to ensure confirmability. Transcripts were returned to the participants for comments and corrections.

Table 1.

Bio-data, medical condition and health needs of participants.

Patient ID	Age (years)	Gender/sex	Diagnosis	Ward and time spent	Procedure and type of care needed	Gender preference of nurse
P01	18	F	Pelvic Inflammatory disease	Surgical special, 7 days	Routine care	Male
P02	62	F	Severe Hypertension	Medical Special, 10 days	Routine care	Female
P03	36	F	Sickle cell	Medical special, 5 days	Routine care	No Preference
P04	35	M	Gastritis	Medical Special, 5 days	Routine care	Male
P05	46	M	Road traffic accident with multiple fractures	Surgical B2, 7 days	Routine/orthopaedic care	No Preference
P06	23	F	Ruptured Appendicitis	Surgical C4, 5 days	Routine care/surgical procedures	Female
P07	36	M	Hypertension	Medical D3, 5 days	Routine care	Male
P08	40	M	Cellulitis	Medical D4, 10 days	Routine care	Female
P09	51	M	Right inguinal hernia	Surgical B1, 5 days	Routine care/surgical procedures	Female
P10	25	F	Bowel obstruction	Surgical C3, 6 days	Routine care/surgical procedures	Female
P11	24	M	Severe Burns	Surgical BICU, 14 days	Routine care/wound dressing	Male
P12	31	F	Diabetes	Medical D5, 6 days	Routine care	No Preference
P13	61	M	Right lobar pneumonia	Medical D3, 7 days	Routine care	No Preference
P14	70	F	Severe Burns	Surgical BICU, 27 days	Routine care/wound dressing	No Preference

Source: Field data collection, January–March, 2017.

Results

Although participants indicated that currently they were not asked of their preferred gender of a nurse when receiving nursing care, they mentioned the gender they would have preferred in case they were asked to choose. Two main themes emerged from the data and these were: the preferred gender of a nurse in nursing care and the reasons for the preference or no preference for nurses’ gender in nursing care. The demographic characteristics of participants in the study will be discussed and this will be followed by the presentation of the themes identified.

Demographic characteristics of participants

Fourteen participants (patients) admitted to the Adult Medical and Surgical Wards between January and March 2017 were sampled. Seven patients were interviewed from both the Medical and Surgical Wards for the study. The department included Male Medical (D3 and D4) and female medical (D5), male surgical (B1 and B2), female surgical (C3 and C4), Burns unit (B ICU) and Special Wards. Each patient had spent at least 5 days on the ward. The ages of the participants ranged from 18 to 70 years. See details in Table 1.

Organization of themes

The analysis of the study revealed two themes and six subthemes. See Table 2 for the details.

Table 2.

Themes, sub-themes and quotations.

Themes	Sub-themes	Quotations
The Preferred Gender of a Nurse in Nursing Care.	Patients’ Preference for Male Nurses in Nursing Care.	“you may be indifferent but will prefer a male nurse who is smart and hardworking. . .. They were very, very smart in movement, compared to the women. Mostly the men are very energetic” (PO3, 36 years, F, medical special ward)
	Patients’ Preference for Male Nurses in Nursing Care.	“A male nurse will be chosen in some instances. . . A male nurse is energetic and skillful in the management of procedures involving machines” (PO1,18 years, F, surgical special ward)
	Patient’s Preference for Female Nurses in Nursing Care.	“I prefer a female nurse. The elderly female nurse is a woman and therefore a mother. My mother and my sisters take care of me when I am not well. . .” (PO8, 40 years, M, medical D4)
	Patient’s Preference for Female Nurses in Nursing Care.	“I feel so relaxed and comfortable when I am being nursed by a nice-looking young nurse” (PO8, 40 years, M, surgical B4)
	Patients with no Preference for a Particular Gender of a Nurse.	“A nurse may treat you well because she is in a good mood but, the next day her mood may change, and will be fighting with you. Human character is not static, it changes most of the time. As at now, I cannot say I prefer this gender of a nurse or the other” (PO11, 24 years, M, surgical BICU.
		“I don’t have a preference. No ooo. In all situations, I will be indifferent. For almost every aspect of the hospital treatment I have met both the men and the women and almost in all situations, it depends on the person and not the gender. Whether a radiologist, a nurse or a doctor” (PO12, F, 31 years, medical D5).
Reasons for the Preference or no Preference for Nurses’ Gender in Nursing Care.	Patients’ Gender as a Reason for the Preference of the Gender of a Nurse in Nursing care.	“It feels more comfortable . . .It is easier to talk to them about several things than the opposite gender. Like, menstrual cramps. It feels like they understand you better because they also experience it” (PO6, 23 year, F, surgical C4).
		“In terms of privacy I would prefer a male nurse (same gender) because I will feel shy before a female nurse when I am naked. The male nurse is my fellow man and will not gossip about my private parts” (P08, 40 years, M, medical M4).
		“When the nurse of the opposite gender dressed the wound on my penis it wasn’t well done. She couldn’t take her time to clean the wound around the penis and scrotum. She also couldn’t hold the penis well enough to bandage. It didn’t take much time for the bandage to loosen and remove. But the male nurse took his time to clean around the scrotum and the penis and bandaged them properly the previous day” (P09, 51 years, M, surgical B1).
	Health Status and as a determinant for Patients’ Preference for Nurses’ Gender.	“I remember at my initial stay at the ward I was always naked and it got to a time that the female nurses told me to cover my nakedness and stop scaring them but I never mind them because that time the pains were unbearable and I did not notice anybody as a female or a male, my main concern was with my injury and the pains and how to recover” (PO11, 24 years, M, surgical BICU).
		“If you are unconscious, what can you do? Look at this man (he pointed to the ward). He has been soiling himself. The nurses bath him every morning and change his diaper, do you think he will be able to tell them that he wants a male or a female nurse?” (P05, 46 years, M, Surgical B2).
	Qualities of Nurses not Gender as a determinant for Patients’ Preference of Nurses in Nursing Care.	“My preference is not about the gender of a nurse but about the good qualities in a nurse such as expertise, caring, efficient, empathetic, neat and attentive because that shows the difference” (PO12, F, 31 years, medical D5).
		“The things that I will look out for in a good nurse are not gender based. . . .Someone who is tolerant, compassionate and pays attention to patients. Yes, that is what I look out for. It is just the person’ s behaviour that makes the difference and not the gender” (PO3, 36 years, F, medical special ward).

The preferred gender of a nurse in nursing care

This theme focuses on the choice of the gender of a nurse by patients during nursing care. Three sub-themes emerged from the data collected. These were: Patients’ Preference for Male Nurses in Nursing Care, Patient Preference for Female Nurses in Nursing Care and Patients with no Preference for a Particular Gender of a Nurse in Nursing care.

Patients’ preference for male nurses in nursing care

Four participants which included the two youngest participants indicated their preference for a male nurse due to their unique characteristics of being smarter, healthier, energetic, hardworking and skillful in the management of conditions which requires the use of medical equipment as compared to the female nurse. This is how one of them verbalized it:

A male nurse will be chosen in some instances. . . A male nurse is energetic and skillful in the management of procedures involving machines (PO1, 18 years, F, surgical special ward)

A participant added that male nurses are smarter and hardworking.

You may be indifferent but will prefer a male nurse who is smart and hardworking. . .. They were very, very smart in movement, compared to the women. Mostly the men are very energetic (PO3, 36 years, F, medical special ward)

In a less straightforward manner on the issue of patients’ preference of male nurses for nursing care, participants revealed their preference for male nurses after intensive probing about their preference for nurses’ gender in nursing care but three of them including a female participant were not consistent with their preference.

Two of the participants had this to say:

I prefer a male nurse only when I am asked about my preference (PO4, 35 years, M, medical special ward)

I will prefer a male nurse but not in all instances (PO7, 36 years, M, medical D3)

From participants’ views, it looks like a lot of male nurses are needed in the nursing profession especially, to complement the services of female nurses due to their greater strength and technical know-how.

Patients’ preference for female nurses in nursing care

Five out of the fourteen participants boldly indicated that they preferred “elderly” female nurses and young beautiful nurses to take care of them when ill. This points to the age as a factor that defines their gender preferences. Such preferences could be attributed to the socio-cultural structure in Ghana, where elderly women are seen as mature and caring, when it comes to health care provision.

Some participants specified that they prefer elderly female nurses who are mothers, more tolerant and polite in dealing with patients. This is what one of them had to say:

I prefer a female nurse. The elderly female nurse is a woman and therefore a mother. My mother and my sisters take care of me when I am not well. . . (PO8, 40 years, M, medical D4)

Two participants added the following expressions:

I prefer elderly female nurses who have patience. Especially the old women they have respect for patients. . . because they are mothers and they have children who can get the same problem (PO14, 70 years, F, surgical BICU)

From participants’ voices, elderly female nurses have the natural tendency to render proper nursing care to patients because of the care-giving role of elderly females in the society.

However, two male participants revealed that they always preferred a female nurse who is young and attractive. They said that with smiles on their face.

I prefer young, beautiful nurses. . .I would like to see beautiful ladies with nice faces and converse with them (PO9, 51 years, M, surgical B1)

I feel so relaxed and comfortable when I am being nursed by a nice-looking young nurse (PO8, 40 years, M, surgical B4).

According to the participants, it appears that being nursed by a young good-looking female nurse makes them relaxed and relieved from their illness.

Patients with no preference for a particular gender of a nurse in nursing care

This sub-theme describes participants who had no preference for a particular gender of a nurse. That is, participants who preferred both genders equally or do not prefer any of the genders of nurses. Five participants emphatically stated that no matter the situation they were indifferent.

Firstly, they disclosed that the gender of a nurse does not determine the attitude of a nurse. They preferred any gender of a nurse with the characteristics such as nice and good. One of them remarked:

I don’t have a preference for a particular gender of a nurse. Some female nurses are good and some male nurses too are good so, the gender does not tell who is good and who is not good. I prefer a good nurse (PO13, 61 years, M, medical D3)

Likewise, a participant said this boldly:

I don’t have a preference. No ooo. In all situations, I will be indifferent. For almost every aspect of the hospital treatment I have met both the men and the women and almost in all situations, it depends on the person and not the gender. Whether a radiologist, a nurse or a doctor (PO12, F, 31 years, medical D5).

Some participants revealed that, they have also observed that human character is unstable, it depends on the sentiment of the person at the time of interaction. This was how two of the participants expressed it:

A nurse may treat you well because she is in a good mood but, the next day her mood may change, and will be fighting with you. Human character is not static it changes most of the time. As at now, I cannot say I prefer this gender of a nurse or the other (PO11, 24 years, M, surgical BICU.

Hmmm! I cannot prefer one to the other because, human beings cannot be predicted. It depends on the mood of the person when interacting with you (PO3, 36 years, F, medical special ward)

Reasons for the preference or no preference for nurses’ gender in nursing care

Three sub-themes emerged from this theme. These included: Patients’ Gender as a Reason for the preference of a particular gender of a nurse in nursing care, Health status as a determinant for Patients’ Preference for Nurses’ Gender and Qualities of a nurse as a determinant for Patients’ Preference of a nurse in Nursing Care.

Patients’ gender as a reason for the preference of the gender of a nurse in nursing care

Participants revealed that the reasons for preferring a particular gender of a nurse for nursing care were because of their gender. Some participants had a preference for the nurse of the same gender whiles others have a preference for a nurse of the opposing gender.

Participants indicated that it feels more comfortable to be nursed by the same gender. It is easier to open up and communicate to them about several things and ask questions because they understand them better. Additionally, they were relaxed during procedures requiring them to talk about sensitive issues or exposure of the nakedness without feeling shy when a nurse of the same gender was providing the care than the opposite gender.

The participants had this to say:

It feels more comfortable . . .It is easier to talk to them about several things than the opposite gender. Like, menstrual cramps. It feels like they understand you better because they also experience it (PO6, 23 year, F, surgical C4).

Usually, it’s ok to relate to a female nurse . . . But if it was a male nurse, I wouldn’t feel comfortable to tell him. . . so I might keep it to myself until I get a female nurse to help me because, they understand my emotions . . . (P10, 25 years, F, Surgical C3).

In terms of privacy I would prefer a male nurse (same gender) because I will feel shy before a female nurse when I am naked. The male nurse is my fellow man and will not gossip about my private parts (P08, 40 years, M, medical M4).

In a similar way, it was found that a nurse with the same gender was able to perform procedures around the genitals better than the opposite gender because the nurse of the opposite gender becomes nervous when handling the genitals.

When the nurse of the opposite gender dressed the wound on my penis it wasn’t well done. She couldn’t take her time to clean the wound around the penis and scrotum. She also couldn’t hold the penis well enough to bandage. It didn’t take much time for the bandage to loosen and remove. But the male nurse took his time to clean around the scrotum and the penis and bandaged them properly the previous day (P09, 51 years, M, surgical B1).

Moreover, a female participant shared her experience that relating to the opposite gender was not easy due to opposite gender attraction because she could not conclude on the psychological impact of her interaction with the male nurse. She noted:

A male will misunderstand you and wouldn’t want to get too attached to you perhaps he might have a different feeling for you. The female is all general about female emotions (PO12, F, 31 years, medical D5).

However, some participant confidently said that, there should be no problem when nurses are providing intimate care for the opposite gender because nurses have the duty to provide all manner of care for patients of all genders. So far as they are carrying out their responsibility appropriately, it should be accepted. One participant had this to say:

I feel so long as there are no inappropriate things done, it’s ok. To bath you, he needs to touch you. If he is not doing it under sexual context then, it’s ok. He is going about his duty. I felt the same way as a female nurse would have done it. I mean I am still naked (PO3, 36 years, F, medical special ward).

Participants who preferred the opposite gender for nursing care were all males. One participant indicated that, a nurse with the opposite gender shows a lot of attention and compassion to him when performing procedures but the same gender nurses do not.

Because you are a man and he is also a man he doesn’t look at your face during the procedure but the female nurses show a lot of concern. . . (PO4, 35 years, M, medical special ward).

The expressions of participants give the impression that some patients consider attentiveness of a nurse as a necessity and not just going about the duty.

Another participant also indicated that by the nature of his work he hardly comes across females so he preferred to be nursed by a female nurse. Secondly, the beauty, the therapeutic touches and the tender loving care of female nurses enhance his recovery.

With the nature of my work, I hardly come across women so, I would like to see beautiful ladies with nice faces and converse with them. Also, when female nurses touch me or hold any part of my body, it serves as a massaging point and sends chemical messages, positive ones to enhance the healing of my body.(P13, 61 years, M, medical D3).

Health status as a determinant for patients’ preference for nurses’ gender

Participants pointed out that the reason behind their choice of a preferred nurse was due to the condition on admission. Participants confirmed that when you are seriously ill, unconscious or in a critical condition, you cannot indicate your preference because you may not be aware of yourself, not having the energy to talk and the gender of a nurse might not concern you in that state. Moreover, your concern will be on your health and whoever will help you recover, not necessarily on a male or a female nurse. This participant had this to say:

If you are unconscious, what can you do? Look at this man (he pointed to the ward). He has been soiling himself. The nurses bath him every morning and change his diaper, do you think he will be able to tell them that he wants a male or a female nurse? (P05, 46 years, M, Surgical B2).

Similarly, some participants shared their stories below:

When the male nurses are coming, I don’t even see them as males. I only see them as human beings. My mind is always on my pains. So, it depends on the situation. . .I have been naked severally before the male nurses and the female nurses when they are dressing my wound and I have never been shy, my focus is on how I will get my healing without complications (PO14, 70 years, F, surgical BICU).

I remember at my initial stay at the ward I was always naked and it got to a time that the female nurses told me to cover my nakedness and stop scaring them but I never mind them because that time the pains were unbearable and I did not notice anybody as a female or a male, my main concern was with my injury and the pains and how to recover (PO11, 24 years, M, surgical BICU).

It may be true that preference for nurses’ gender is mainly for patients who are fairly ill and not seriously ill. Moreover, patients’ condition matters to them and not the choice of nurses’ gender in nursing care.

Qualities of a nurse not gender as a determinant for patients’ preference of a nurse in nursing care

Most participants who declared of not having a preference for nurses’ gender explained that their preference was not based on the gender of a nurse but rather on the good morals and professional qualities of a nurse because that indicates a competent and a good nurse and not the gender.

My preference is not about the gender of a nurse but about the good qualities in a nurse such as expertise, caring, efficient, empathetic, neat and attentive, because that shows the difference (PO12, F, 31 years, medical D5).

The participants also noted that, a nurse with good qualities exhibits characteristics such as caring, attentiveness, patience, encouraging patients, having a cheerful face and showing concern for patients.

The things that I will look out for in a good nurse are not gender based. . . .Someone who is tolerant, compassionate and pays attention to patients. Yes, that is what I look out for. It is just the person’s behavior that makes the difference and not the gender (PO3, 36 years, F, medical special ward).

Additionally, other participants indicated that when a nurse is assigned to take care of patients, it is an indication that the nurse is a professional with the capabilities and have the license to practice and render proper nursing care to patients. Therefore, there would be no need to worry about the gender of the nurse.

When the nurse is a professional and licensed, the gender will not be considered. She will be able to render proper care (PO14, 70 years, F, surgical BICU)

A synthesis of the patients’ views quoted above shows that the gender of nurses is not as important as their quality of service, performance, professionalism and ability to effectively carry out the procedure involved. Even in the instances where patients suggested their preferences for specific gender of a nurse, it was related to the kind of activity they expect the care provider to perform. Thus, patients connected their gender preferences more to the procedures and activities involved in providing care than other reasons related to their fears, anxieties and emotions. It must also be noted that job at the Komfo Anokye Teaching Hospital does not have a clear policy on providing for the gender preferences of patients who come to the facility. Consequently, most patients have not developed the need to consider gender in the criteria for choosing their nurses.

Discussion of findings

Findings from this study points to varied reactions of patients to their gender preferences for nurses. The result of several studies conducted in different geographical location worldwide with different methodology reviewed that, participants had varying preference for the gender of their nurses as a result of their individual demographic characteristics.^19,20 While the earlier studies cited above present some related knowledge on patients’ gender preferences of nurses who provide them health care, the current study extends the discourse with deeper qualitative engagements to unpack the varied factors influencing these choices, in a facility where there were limited options.

The current study appears to have the choice of female nurses embedded in the preferences of most of the patients studied. This seems to have a link with the inherent socio-cultural belief that nursing and health care provision is a female-dominated work.

Consequently, only few participants preferred male nurses to provide care for selected conditions (See Table 1). This study findings are similar to the findings of other studies with different health workers which noted that only few participants prefer male practitioners.^21,22 In contrast, the findings of²³ showed that majority of patients prefer male doctors to attend to them. Though this study did not explore patients’ preferences for the gender of doctors, it connects with another socio-cultural belief that most doctors are males. The choice of female nurses and male doctors by a typical patient could be linked to socio-cultural connotations. Thus, in the current study, male participants chose male nurses only when they were hard-pressed to make a choice.

Again, the present study found that the preference for a male nurse was due to their unique characteristics of being smarter, healthier, energetic, hardworking and skillful in the management of conditions which requires the use of medical equipment as compared to the female nurse. The preferred characteristics of male nurses in this study’s findings corroborate with the findings of a number of literatures^24,25 which stated that male nurses are suitable for tasks involving physical labour and dealing with violent and irritable patients. Additionally, male nurses are believed to be perfect in performing job requiring technical skills because men are good at handling machines.²⁶

A female participant in this study added that for female nurses, age and stress of the work often show on their appearance, they easily get fatigued and emotionally down unlike the male nurses and are less likely to perform the expected task at the workplace. The above findings reflect the findings of²⁷ and.²⁸ In addition,²⁹ reported about the differences in health, productivity and quality of care in younger and older nurses and concluded that almost all the older nurses had higher pain scores, and a higher prevalence of having health problems, and reported a higher health-related productivity loss than younger nurses. They added that, nurses who are 50 years and above are less likely to accomplish the expected task at work. This also challenges with the findings reported in earlier studies which stated that older student nurses had more positive attitudes leading to more productivity and this was attributed to more mature views about the reality of ageing.³⁰ Another study by³¹ contrasted that, elderly nurses are highly skilled and productive and reported less aches and pains; moreover, their accumulated experience, communication skills, dedication and loyalty often exceed that of their younger colleagues but were not specific to female or male nurses. Another contradictory finding of³² revealed that age, gender and clinical practice experience do not impact on caring behaviour. Moreover, some studies revealed that, male nurses are respectful, considerate, good listeners, and have good interpersonal relationship with patients than female nurses. In the same vein, they were observed to show concern for their patients.^33,34 Furthermore, a number of participants in the present study preferred elderly female nurses because they are perceived to be mothers and have respect and time for patients. This corroborate with the findings of³⁵ who stated that participants who preferred female obstetricians believed that they are more understanding because of going through childbirth themselves, they have sympathy for patients. But contrary to other studies, elderly female midwifes are found to be rude to women during delivery, ignoring and neglecting them during suffering despite their yelling for help.^36,37 Moreover, young beautiful nurses were preferred by some participants of this current study because of their attraction and beauty. Closest findings from the literature were not found, however according to,³⁸ younger Chinese student nurses have more positive attitudes towards patients.

Contrary to the discovery of most previous published studies that nurse’s gender is an important factor in determining the majority of patient’s choice of a nurse in nursing care^39,40 in this current study, participants both men and women had no specific preference regarding the gender of their nurses. This study observed that, gender does not determine the quality of a nurse’s performance, human character is not static, it depends on the sentiment of the person at the time of interaction. These support the findings of ⁴¹ that both male and female nurses are good no matter the environment in which they are working, they are able to make a difference in the lives of many. The study of ⁴² also confirmed that personality traits showed consistency, however, can change systematically. This was also agreed by⁴³ that human behaviour is unpredictable.

However, some participants in this study expressed that it feels more comfortable and there is little or no shyness to be nursed by same gender. Similarly, most patients preferred a same-gender urologist and nurse because they feel less embarrassed with them during treatment.⁴⁴ The participants in the current study went further to explain that it is also easier to communicate with the same gender about several things including sensitive issues and also ask questions because they understand them better than the opposite gender. These findings identify with related studies in Iran and Saudi Arabia which indicated that practitioners and nurse–patient gender differences are one of the hindrances to proper communication between nurses and patients, which affects nursing care. The research further stated that adequate nurse–patient communication creates hope, increases compliance with a care plan and treatment regimen and improves treatment outcome.^45,46 The views of the participants in this study seem to suggest that it would be difficult to relate to the opposite gender and there may be tension on the part of both the nurse and the patient when care that requires exposure of the genitalia of patients of the opposite gender is required.

Other studies found that physician gender had a variable impact on female patient’s preference for a chaperone. Almost all the participants⁴⁷ considered the presence of a chaperone appropriate during intimate physical examination. The most commonly cited reasons included the protection against sexual harassment, and to provide psychological support.⁴⁸

It was identified by participants of the present study that, if you are seriously ill or unconscious you would not be able to make your preference known; as a result, you accept any gender of a nurse for nursing care.⁴⁹ This showed that the severity and types of illnesses determine the level of participation of a patient in his care and this is consistent with the findings of the present research. Similarly, patients’ participation in medical encounters depends on the degree to which patients asked questions, were assertive, and expressed concerns. Therefore, an unconscious patient cannot indicate preferences.⁵⁰

The participants in the current study went further to emphasize that they mostly prefer nurses with characteristics such as good, nice, expertise, caring, efficient, empathetic, neat, attentive and hardworking to determine a preferred nurse and both genders of nurses can possess these qualities. This agrees with a study by¹¹ that most Israel women reported that the gender of their gynaecologist or obstetrician was not an important determinant when choosing a gynaecologist or an obstetrician. Their major consideration in their choice of a gynaecologist or an obstetrician included professionalism, good manners and board certification. Secondly, this study’s findings are in agreement with the findings of.^51,52 In their research, respondents consistently reported that they considered the qualifications, experience and technical skills important when choosing a urogynaecologist, obstetrician and gynaecologist while the gender of a practitioner was less important to them.^51,52 By comparison it was found that the current study and the study of ⁵¹ had similar result but uses different words in describing the characteristics of a preferred nurse, for example, experience and expertise, good manners and hardworking.

The present study additionally revealed that being nursed by a professional nurse who has the license to practice gives much confidence and does not make one worry about the gender of a nurse. A study by⁵³ confirmed to the findings of this study that professional nurses are capable of providing effective and efficient care and the gender does not make a difference. Additionally,⁵⁴ found in their study that although patients with incontinence had a statistically significant preference for the gender of their provider, patients with different diagnoses did not place importance on their gender preference. Interestingly, participants with erectile dysfunction were also not worried about the gender of their urologist because participants’ concern were on the professionalism and the expertise of the care provider.

In other studies, there is evidence suggesting that stereotypes of the male identity being strong, independent and self-reliant make them reluctant in disclosing their preference due to fear of being embarrassed and victimized.⁵⁵ This may be the reason for majority of male participants not having preference for a particular gender of a nurse in this present study. In addition, some studies indicated that, majority of females have been identified to have preference for the gender of their care giver more than males because women have much concern with issues of modesty.^56,57 Interestingly, the results disagree with this current study’s findings. In the present study, few female participants were gender-biased and this finding is in line with the findings of.⁴⁴ In their study, they found that the female participants did not care about the gender of the health care provider because of being familiar with both male and female nurses as well as the good attitudes of male nurses.

Therefore, it appears that the current study’s finding of absent preference for nurse’s gender was as a result of diverse demographic characteristics of the sample such as age, tribe, religion and educational level. Interestingly, it showed that because patients in Ghana have not had the chance to be choosing a preferred nurse’s gender most patients were tolerant and familiar with both male and female nurses. Additionally, the setting of the study being medical and surgical ward may not require much exposure and technical skills for patients to care about the gender of a caregiver. Future research on determinant of women preference for their midwives in Ghana is recommended.

Limitations

The sample for the study was only limited to patients in a single Teaching Hospital in the urban setting, therefore, preferences of patients from the rural settings might be different. Again, all the participants were from the medical and surgical wards; therefore, preferences of patients from other wards might be different. As a result, a replication of the study is recommended with patients from other departments of the Komfo Anokye Teaching Hospital. Moreover, a subsequent quantitative version of this study in public, mission and private hospitals is recommended in Ghana to justify statistical connection.

Conclusion

Patients have preference for their nurses. They prefer a nurse with professional expertise and good qualities such as caring, efficient, empathy, neatness, attentive, respectful and hardworking yet others are interested in being nursed by a gender of a nurse as that enhances their wellbeing. It would be ideal to match patients with the nurses of their choice in order to ensure patient satisfaction. This, however, may not be possible in most hospitals as health facilities do not have adequate capacity to satisfy patients’ needs and preference and do not factor patients’ preferences into health policies. Other factors need to be taken into accounts such as nurses’ expertise, availability and attitude towards patients. These challenges prevent patients from becoming comfortable and satisfied with health care. It is essential that health care policy makers factor patients’ needs and preferences into health policy to satisfy the preferences of patients. It is also important that nurses demonstrate good attitude towards patients to improve the recovery process of patients. Health training institutions should increase the number of male intakes in the nursing training schools to cater to patients who prefer male nurses.

Supplemental Material

sj-docx-1-smo-10.1177_20503121231182514 – Supplemental material for Does the gender of nurses matter to patients? A qualitative analysis of gender preferences of patients

Supplemental material, sj-docx-1-smo-10.1177_20503121231182514 for Does the gender of nurses matter to patients? A qualitative analysis of gender preferences of patients by Akua Owusua Asante, Kwadwo Ameyaw Korsah and Clifford Amoako in SAGE Open Medicine

Supplemental Material

sj-docx-2-smo-10.1177_20503121231182514 – Supplemental material for Does the gender of nurses matter to patients? A qualitative analysis of gender preferences of patients

Supplemental material, sj-docx-2-smo-10.1177_20503121231182514 for Does the gender of nurses matter to patients? A qualitative analysis of gender preferences of patients by Akua Owusua Asante, Kwadwo Ameyaw Korsah and Clifford Amoako in SAGE Open Medicine

Footnotes

Acknowledgements

We would like to extend our sincere appreciation to the patients at the Adult Medical and Surgical Wards of the Komfo Anokye Teaching Hospital, Kumasi-Ghana who participated in the study.

Authors’ Contributions

AOA, KAK and CA were responsible for the conception and study design. AAO performed the data collection. AAO, KAK and AC contributed to the analysis of the data. AAO and AC were involved in drafting the manuscript and revising it critically for important intellectual content. All authors have read and approved the final manuscript.

Availability of data and materials

All datasets generated during the current study are included in the published article and its supplementary files.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Ethics approval and consent to participate

The study was approved by the ethics committees of the Komfo Anokye Teaching Hospital, Kumasi-Ghana with the registration number RD/CR17/021 and receipt number K/16/0163177. The participants signed consent form after indicating their willingness to participate in the study. All methods were performed in accordance with the relevant guidelines and regulations. Written informed consent was obtained from all participants.

Ethics approval

Ethical approval for this study was obtained from the ethics committees of the Komfo Anokye Teaching Hospital, Kumasi-Ghana with the registration number RD/CR17/021 and receipt number K/16/0163177

Consent for publication

Not applicable

Informed consent

Written consent was obtained from all subjects before the study.

Trial registration

Not applicable.

Experience or training of Researchers

All the researchers have academic experience with thesis writing and supervision of the project work of students. The second and third Authors have Ph.D. whiles the first Author has Mphil in Nursing

ORCID iD

Akua Owusua Asante

Supplemental material

Supplemental material for this article is available online.

References

Jennings

Baernholdt

Hopkinson

SG.

Exploringthe turbulent nature of nurses’ workflow. Nurs Outlook 2022; 70(30): 440–450.

While

Touch: knowledge and considerations for nursing practice. Brit J Commun Nurs 2021; 26(4): 190–194.

Durkin

Jackson

Usher

The expression and receipt of compassion through touch in a health setting; a qualitative study. J Adv Nurs 2021; 77(4): 1980–1991.

O’Lynn

Cooper

Blackwell

Perceptions, experiences and preferences of patients receiving the clinician’s touch during intimate care and procedures: a qualitative systematic review protocol. JBI Database Syst Rev Implem Rep 2016; 14(6): 96–102.

Williams

. Fundamental concepts and skills for nursing-e-book. Riverport Lane: Elsevier Health Sciences, 2021, p. 304.

Shakwane

Mokoboto-Zwane

Demystifying sexual connotations: a model for facilitating the teaching of intimate care to nursing students in South Africa. Afr J Health Prof Educ 2020; 12(3): 103–108.

Juliff

Russell

Bulsara

Male or nurse what comes first? Challengemen face on their journey to nurse registration. Austr J Adv Nurs 2016; 34(2): 45–52.

Anglade

Ibrahim

Abdel-Razig

Does provider gender matter iendoscopy? An international perspective. Gastrointestinal Endosc 2021; 93(5): 1160–1168.

Adeyemi-Adelanwa

Barton-Gooden

Dawkins

, et al. Attitudes of patients towards being cared for by male nurses in a Jamaican hospital. Appl Nurs Res 2016; 29: 140–143.

10.

Turan

Özge ÖNER Atasoy

Male and female nursing students’ opinions about gender and nursing as a career in turkey: a qualitative study. Nurs Educ Pract 2021; 53: 103078.

11.

Amir

Abokaf

Levy

, et al. Bedouin women’s gender preferences when choosing obstetricians and gynecologists. J Immigrant Minority Health 2018; 20(1): 51–58.

12.

Kamamni

Butt

Taufiq

, et al. Unique perspective of Muslim patients on gender preference for GI endoscopists: a multicenter survey. Gastrointestinal Endosc 2021; 94(6): 1110–1115.

13.

Leach

Gradison

Morgan

, et al. Patient preference in primary care provider type. In: Healthcare, Elsevier, Vol. 6, No. 1, 2018, pp. 13–16.

14.

Maryunani

Hariyati

RTS

Novieastari

Phenomenological study on the experience of male nurses in caring for female patients. Jurnal Keperawatan Indonesia 2021; 24(1): 32–41.

15.

Coward

Encouraging reflection in professional learning. Nurs Manag 2022; 25(2): 38–41.

16.

Marchetti

Piredda

Marinis

MG.

Centrality of body anembodiment in nursing care: a scoping study of the Italian literature. J Nurs Scholarship 2016; 48(1), 31–38.

17.

Laurent

CL.

A nursing theory for nursing leadership. J Nurs Manage 2000; 8(2): 83–87.

18.

Braun

Clarke

Using thematic analysis in psychology. Qual Res Psychol 2006; 3(2): 77–101.

19.

Aubrey

Chari

Mitchell

, et al. Gender of provider – barrier to immigrant women’s obstetrical care: a narrative review. J Obstetr Gynaecol Canada 2017; 39(7): 567–577.

20.

Ferdous

Goopy

Yang

, et al. Barriers to breast cancer screening among immigrant populations in Canada. J Immigr Minor Health 2020; 22(2): 410–420.

21.

Groutz

Gordon

Shimonov

, et al. Do women with pelvic floor disorders prefer to be treated by female urogynecologists?. Health Care Women Int 2020; 41(5): 543–552.

22.

Willis

King

Dwyer

, et al. Women and gynaecological cancer: gender and the doctor–patient relationship. Topoi 2017; 36(3): 509–519.

23.

Onchari

Factors affecting patients’ choice of health provider of outpatient services in Westlands Constituency, Nairobi County. Doctoral dissertation, United States International University Africa, http://erepo.usiu.ac.ke/11732/6072 (2020).

24.

Achora

Conflicting image: Experience of male nurses in a Uganda’s hospital. Int J Afr Nurs Sci 2016; 5: 24–28.

25.

Starc

Stress factors among nurses at the primary and secondary level of public sector health care: the case of Slovenia. Open Access Maced J Med Sci 2018; 6(2): 416.

26.

Saleh

Al-Amer

Al Ashram

, et al. Exploring the lived experience of Jordanian male nurses: a phenomenological study. Nurs Outlook 2020; 68(3): 313–323.

27.

Denton

Evans

Older nurses and midwives in the workplace: a scoping review. Collegian 2021; 28(2): 222–229.

28.

Uthaman

Chua

Ang

SY.

Older nurses: a literature review on challenges, factors in early retirement and workforce retention. Proc Singapore Healthcare 2016; 25(1): 50–55.

29.

Mc Carthy

Wills

Crowley

Nurses, age, job demands and physical activity at work and at leisure: a cross-sectional study. Appl Nurs Res 2018; 40: 116–121.

30.

Ayoglu

Kulakci

Ayyildiz

, et al. Attitudes of Turkish nursing and medical students toward elderly people. J Trans Nurs 2014; 25(3): 241–248.

31.

Ang

Ayoob

SBM

Hussain

NBS

, et al. Challenges faced by older nurses in Singapore: a mixed methods study. Int Nurs Rev 2017; 64(4): 502–510.

32.

Liu

Hsu

Hung

, et al. The effect of gender role orientation on student nurses’ caring behaviour and critical thinking. Int J Nurs Stud 2019; 89: 18–23.

33.

Sundus

Younas

Caring behaviors of male nurses: a descriptive qualitative study of patients’ perspectives. In Nursing Forum. Hoboken: Wiley, vol. 55, No. 4, 2020, pp. 575–581.

34.

Younas

Sundus

Experiences of and satisfaction with care provided by male nurses: a convergent mixed-method study of patients in medical surgical units. J Adv Nurs 2018; 74(11): 2640–2653.

35.

Bäckström

Mårtensson

Golsäter

, et al. “It’s like a puzzle”: pregnant women’s perceptions of professional support in midwifery care. Women Birth 2016; 29(6): e110–e118.

36.

Shimoda

Horiuchi

Leshabari

, et al. Midwives’ respect and disrespect of women during facility-based childbirth in urban Tanzania: a qualitative study. Reprod Health 2018; 15(1): 1–13.

37.

Rominski

Lori

Nakua

, et al. When the baby remains there for a long time, it is going to die so you have to hit her small for the baby to come out: justification of disrespectful and abusive care during childbirth among midwifery students in Ghana. Health Policy Plan. 2017; 32(2): 215–224.

38.

Xiao

Shen

Paterson

Cross-cultural comparison of attitudes and preferences for care of the elderly among Australian and Chinese nursing students. J Trans. Nurs. 2013; 24: 408–416.

39.

Attum

Hafiz

Malik

, et al. Cultural competence in the care of Muslim patients and their families. Treasure Island(FL): StatPearls Publishing, (2022). PMID: 29763108.

40.

Bal

Yılmaz

Beji

, et al. Muslim women choice forgender of obstetricians and gynecologist in Turkey. Int J Human Sci./Uluslararası İnsan Bilimleri Dergisi 2014; 11(2) 64–73.

41.

Alexander

Public trust in nursing goes beyond state lines. Journal of Nursing Regulation 2016; 7(2): 3.

42.

Boge

Dos Santos

Moreno-Walton

, et al. The relationship between physician/nurse gender and patients’ correct identification of health care professional roles in the emergency department. J Women’s Health 2019; 28(7): 961–964.

43.

Fan

Choy

Kwok

, et al. Chaperones and intimate physical examinations: what do male and female patients want. Hong Kong Med J 2017; 23(1): 35–40.

44.

Younas

Sundus

Patients’ experiences and satisfaction about care provided by male nurses in medical surgical units in Islamabad, Pakistan: a pilot study. In Nursing forum.Hoboken: Wiley, Vol. 53, No. 1, 2018, pp. 1219.

45.

Salam

Fatemeh

Khodayar

Facilitators of professional communication between nurse and opposite gender patient: a content analysis. Mædica 2020; 15(1): 45.

46.

Aboalshamata

Aljraryb

Damanhurib

, et al. Journal of Umm Al-Qura University for Medical Sciences. J Umm Al-Qura Univ Med Sci 2020; 6(1): 21–25.

47.

Ong

Garnett

MacFarlane

, et al. Do we need chaperones for intimate examination in urology clinics? Patients’ preferences and urologists’ practice in Scotland. Brit J Med Surg Urol 2010; 3(2): 46–51.

48.

Fan

Choy

Kwok

, et al. Find issues. Hong Kong Med J 2017; 23(1): 35–40.

49.

Vahdat

Hamzehgardeshi

Hessam

, et al. Patient involvement in health care decision making: a review. Iran Red Crescent Med J 2014; 16(1): e12454.

50.

Street

RLJ

Gordon

Ward

, et al. Patient participation in medical consultations: why some patients are more involved than others. Med Care 2005; 43(10): 960–969.

51.

Hoke

Berger

Pan

, et al. Assessing patients’ preferences for gender, age, and experience of their urogynecologic provider. Int Urogynecol J 2020; 31(6): 1203–1208.

52.

Setoodefar

Measurement model of women’s preferences in obstetrician and gynecologist selection in the private sector: exploratory and confirmatory factor analysis. Int J Commun Nurs Midwifery 2020; 8(2): 150.

53.

Nabizadeh-Gharghozar

Alavi

Ajorpaz

NM.

Clinical competence in nursing: a hybrid concept analysis. Nurs Educ Today 2021; 97: 104728.

54.

Ficko

Hyams

ES.

Urology is a sensitive area: assessing patient preferences for male or female urologists. Urol Pract 2018; 5(2): 139–142.

55.

Sun-Ouck

Kang

Kwon

Gender preferences for urologists: women prefer female urologists. Urol J 2017; 14(2): 3018–3022.

56.

Westra

Character and theory of mind: an integrative approach. Philos Stud 2018; 175(5): 1217–1241.

57.

Yılmaz

Ünal

Gençer

, et al. Static/unchangeable and dynamic/changeable nature of personality according to the nine types temperament model: a proposal. Int J Emerg Ment Health 2015; 17: 298–303.

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