Journal of Nursing Education

Research Briefs 

Stereotype Threat in Male Nurse–Patient Interactions

Andrew C. Tollison, PhD

Abstract

Background:

Stereotype threat describes the apprehension individuals experience from the prospect of confirming negative self-relevant stereotypes. Due to their minority status, male nurses are believed to be susceptible to stereotype threat effects in the field of nursing.

Method:

One hundred eighty-three male nursing students were randomly assigned to one of three evaluative frames (patient management, empathy, or control) and tasked with completing an online patient simulation experiment. With empathy serving as a form of stereotype threat, participant responses were analyzed for tentative language use.

Results:

An interaction effect (patient gender × frame) was observed, where participants were most tentative when the simulation involved a male patient in the empathy frame.

Conclusion:

Findings from the study offer encouragement as the communicative abilities of participants were not consistently influenced under conditions of stereotype threat. This provides support for the need to forearm male nurses against the pernicious effects of gender-based stereotypes. [J Nurs Educ. 2018;57(10):614–619.]

Abstract

Background:

Stereotype threat describes the apprehension individuals experience from the prospect of confirming negative self-relevant stereotypes. Due to their minority status, male nurses are believed to be susceptible to stereotype threat effects in the field of nursing.

Method:

One hundred eighty-three male nursing students were randomly assigned to one of three evaluative frames (patient management, empathy, or control) and tasked with completing an online patient simulation experiment. With empathy serving as a form of stereotype threat, participant responses were analyzed for tentative language use.

Results:

An interaction effect (patient gender × frame) was observed, where participants were most tentative when the simulation involved a male patient in the empathy frame.

Conclusion:

Findings from the study offer encouragement as the communicative abilities of participants were not consistently influenced under conditions of stereotype threat. This provides support for the need to forearm male nurses against the pernicious effects of gender-based stereotypes. [J Nurs Educ. 2018;57(10):614–619.]

Whether intentional or not, the field of nursing accurately captures occupational stereotyping. A considerable body of literature suggests that individuals make stereotypical judgments regarding gender and professions (Deaux, 1995; White & White, 2006), which historically has been predicated on the assumption that certain occupations are best suited for specific genders (Holland, 1973). Such occupational stereotypes can make it difficult or uninviting for individuals to enter nontraditional careers. Of the 3.3 million RNs within the United States (Kaiser Family Foundation, 2017), approximately 10% are men (U.S. Census Bureau, 2013). While “intelligent nurses do not belong to any specific gender, and both female and male nurses may be educated to deliver a professional nursing service” (Lo & Brown, 1999, p. 41), societal perceptions of what a nurse looks like appears to be a significant contributor to the reduced amount of practicing male nurses. Further, prevailing sociocultural stereotypes position nursing as an empathic field (Davies, 1995), with men perceived to be lacking in empathic ability compared with women (Flannery, 2000). White and White (2006) even went as far as to label female and nurse as a congruent pair that is completely acceptable under the social microscope, with male and nurse being incongruent.

As an occupational minority, male nurses are exposed to gender-based barriers that pose distinct challenges and compromise their ability to provide quality patient care. These barriers include, but are not limited to, gender-biased language and stereotypes (Meadus & Twomey, 2011; O'Lynn, 2004). Although research has addressed barriers and stereotypes associated with men in nursing, it has lagged in identifying consequences associated with exposure—aside from reluctance to enter the field and attrition rates (Mulholland, Anionwu, Atkins, Tappern, & Franks, 2008; Yurkovich, 2006). The current study addresses this need for outcomes-based diversity by investigating the communicative consequences of exposure to gender-based stereotypes among men in nursing through the lens of stereotype threat (Steele & Aronson, 1995).

Stereotype Threat as a Theoretical Lens

In their seminal work, Steele and Aronson (1995) coined the term stereotype threat as a means of explaining the psychological discomfort that comes from the fear of confirming a negative stereotype about one's group. When a stereotyped individual is placed in a threatening situation, the individual experiences a performance deficit that ultimately confirms the stereotype (Steele, Spencer, & Aronson, 2002). To demonstrate this vulner-ability to performance deficits under conditions of stereotype threat, Steele and Aronson (1995) tasked intellectually matched African American (six men, 18 women) and White (11 men, 12 women) undergraduate students at Stanford University with completing a 25-minute verbal section of the Graduate Records Examination. Half of the participants were asked to identify their race before completing the task, thus activating stereotypes associated with intellectual deficiencies of African American students compared with White students. Results from the study's analysis of covariance indicated that this subtle prime generated enough anxiety that the African American students performed significantly worse than their White counterparts when asked to identify their race prior to the task (p ⩽ .01). In contrast, the remainder of the sample that did not have to identify race prior to the task did not demonstrate a performance difference between the African American and White students.

Although stereotype threat is most keenly experienced among groups historically targeted by negative stereotypes, it is a predicament that can beset anyone when compared with another who is reputed to be at an advantage (Aronson, 2002). For example, White male university students bear no historical stigma associated with intelligence. Yet when told their performance (n = 12) on a challenging math assessment (18 items derived from the Graduate Records Examination) would be compared with that of Asian students, the performance of the White students was impaired, compared with those students who did not receive performance comparative instructions (n = 11; Aronson et al., 1999). Results from the one-way ANOVA indicated a strong effect size for this performance difference (p ⩽.01). Thus, it appears plausible that male nurses could also face deficits due to their status within the nursing profession.

Although a significant focus of stereotype threat research has centered on standardized testing, claims have been made regarding the ability to observe stereotype threat effects within any evaluative context (Aronson & McGlone, 2009). McGlone and Pfiester (2015), in a dyadic conflict resolution experiment of 209 undergraduate students (106 women, 103 men), observed via a two-way multivariate analysis of covariance that women were more tentative (p ⩽ .01) and disfluent (p ⩽ .01) in their communication when the experiment was framed as a study of leadership ability, and men were more tentative (p ⩽ .05) and disfluent (p ⩽ .01) when the experiment was framed as an assessment of relational maintenance abilities. Given that leadership characteristics are commonly attributed to men (Aries, 1996) and relational maintenance attributes to women (Flannery, 2000), these frames served as cross-gender threats. This study was the first to investigate the pernicious effects of stereotype threat within the evaluative context of communication and provides the foundation for the current investigation into the communicative impact of stereotypes on male nurses.

Stereotype threat is elicited when participants are placed in a situation they believe can diagnose their amount of some impugned ability—in this case, empathy. Extending on the above cited stereotype threat research, the primary objective of this study is to further investigate the influence that stereotype threat can have on interpersonal interactions, specifically when observing the communicative performance of male nursing students during a nurse–patient simulation. To address this goal, the following hypothesis is offered: Framing a nurse–patient simulation as diagnostic of a stereotypical feminine ability (empathy) induces stereotype threat in men, as indicated by higher rates of tentative language relative to the nonability (control) or masculine ability frame (patient management).

Method

Design and Procedure

This study used a 2 × 3 factorial design with patient gender (male, female) and diagnostic frame (patient management, empathy, or control) as between-participant factors and rates of tentative language as the study dependent variable. As male nursing students represent approximately 15% of the nursing student population (National League for Nursing, 2015), online recruitment and data collection were used to account for this gender disparity, as online methods have previously demonstrated efficiency in the recruitment of underrepresented populations (Couper, 2005). Recruitment announcements were distributed directly to nursing school program directors, as well as respective student e-mail lists (e.g., American Assembly for Men in Nursing, National Student Nurses Association, American Nurses Association, and Nursing Student Network). All recruitment messages labeled the study as “Communication in the Health Setting,” with interested participants being directed to Qualtrics, which hosted the online study.

Upon voluntarily accessing the online study, participants reviewed a brief description of the study and provided electronic informed consent and then were randomly and covertly assigned to one of three evaluative frames (patient management, empathy, or control). In the two experimental conditions (patient management and empathy), the paragraph stressed that the purpose of the study was to investigate gender differences in ability, along with an explanation of why the procedure under investigation was diagnostic of ability. The final sentence of the instructional paragraph, which was consistent across all three conditions, reiterated that participant responses would be analyzed for gender differences. The three instructional paragraphs are presented below, with relevant framing in italic—participants did not receive the italicized text. Participants in the patient management condition were provided with the following script:

The purpose of this research is to investigate differences in nurses' abilities to manage patients. Patient management ability entails understanding a patient's circumstances and acting upon that understanding to make the patient feel understood, comfortable, and secure regarding the care being provided. Numerous scientific studies have demonstrated that patient management ability can be predicted from observing people as they simulate the communication behaviors they use when interacting with others. In today's study, you will simulate the interaction you would use when entering an examination room to explain the results of a medical test to a patient. Patient managers must be able to articulate necessary information clearly, so your performance on this simulation provides one way to measure your patient management ability. Your simulation response will be analyzed later by a team of researchers studying nurses' patient management ability here at the university. They will compare your responses to those of other men and women participating in this study to examine gender differences in performance.

While referencing a different ability, participants in the empathy group were provided with the following:

The purpose of this research is to investigate differences in nurse's ability to empathize with patients. Empathy ability entails understanding a patient's circumstances and acting upon that understanding to make the patient feel understood, comfortable, and secure regarding the care being provided. Numerous scientific studies have demonstrated that empathic ability critically depends on communication behavior. This research has also found that empathic ability can be predicted from observing people as they simulate the communication behaviors they use when interacting with others. In today's study, you will simulate the interaction you would use when entering an examination room to explain the results of a medical test to a patient. Empathic individuals must be able to articulate necessary information clearly, so your performance in this simulation provides one way to measure your empathy level. Your simulation response will be analyzed later by a team of researchers studying nurses' empathic ability here at the university. They will compare your recording to those of other men and women participating in this study to examine gender differences in performance.

In contrast, the control condition introduced the simulation to the participants but did not articulate a purported rationale for diagnosing a specific nursing-related ability:

In today's study, you will simulate the interaction you would use when entering an examination room to explain the results of a medical test to a patient. Your simulation response will be analyzed later by a team of researchers here at the university. They will compare your simulation response to those of other men and women participating in this study to examine gender differences in performance.

After participants read the framing paragraph, they were presented with the following procedural simulation scenario and instructed to carefully review it.

Simulation Scenario

To establish the current simulation scenario, three practicing RNs who had recently graduated from their respective institutions (within the most recent 5 years) were interviewed concerning communication-based patient simulations that they had completed during their nursing curriculum. Based on the information obtained during these interviews, as well as reviewing similar published simulations (Comer, 2005), the following simulation was selected:

Today you will be assisting Dr. Smith with patient (Amy/James) Jones. Amy/James came to the physician's office today because she/he was not feeling well. Dr. Smith has diagnosed her/him with the flu (i.e., influenza). Due to an emergency in the office, Dr. Smith has asked you to inform the patient of his/her diagnosis, as well as instruct the patient on his/her prescription (including the name of the medication, medication instructions, and side effects). Dr. Smith will stop back by later to address any questions patient Jones may have before he/she leaves.

Patient gender was randomly and covertly alternated among participants, whereas physician gender was kept blind. Per simulation instructions, participants were to inform the patient of the diagnosis (influenza), prescribed medication (oseltamivir), proper administration of the medication (twice daily for 5 days, with or without food), and potential side effects (upset stomach and nausea). Participants were then provided 5 minutes to review the procedural paragraph and prepare for a 3-minute simulation on how they would interact with the patient. Participants were instructed to not take notes in advance. To complete the simulation, participants typed out their narrative of how they would interact with the patient before entering the room and providing the required information. Upon completion, participants provided demographic information and entered to win one of ten $50 Amazon™ gift cards. Institutional review board approval, from the author's home institution at the time, was granted prior to participant recruitment and data collection.

Simulation Coding

A pair of trained research assistants (RAs) who were naïve to the study hypothesis coded the procedural simulation data for tentative language use. See Palomares (2008) for an explanation of specific tentative language features, which include: hedges (e.g., “maybe”), disclaimers (e.g., “I may be wrong”), tag questions (e.g., “wouldn't you?”), intensifiers (e.g., “it is extremely important that…”), and rounders (e.g., “you should feel better in about 5 days”). The author conducted a workshop for the RAs to clarify and provide examples for discussion. The RAs initially coded 25% of the cases to assess coding agreement, which was acceptable (Cohen's α = .88). The remaining cases were equally distributed among the RAs. Once coded, tentative language frequency was transformed (total number of tentative words divided by overall word count, and multiplied by 100; see Bradac, Mulac, & Thompson, 1995). The rationale for transforming tentative language frequencies was to account for word count differences in participant simulation length.

Results

On completion of coding for tentative language, SPSS® version 24 software was used for all subsequent analyses, descriptive statistics to evaluate the sample's demographic profile, and ANOVA for the study hypothesis.

The study sample consisted of 183 male nursing students enrolled in nursing programs (Bachelor of Science in Nursing) across the United States and were recruited through purposive sampling techniques. According to Harding (2007), the use of nursing students as a substitution strategy for RNs is a commonly used recruitment strategy for nursing-focused research. As this study was exploratory in nature, no further attempts were made to recruit students based on age, race, or amount of time in their respective nursing program. See the Table for a complete demographic profile of the study sample. Heeding the call from Taylor and Spurlock (2018), G*Power 3.1.9.3 software (Faul, Erdfelder, Buchner, & Lang, 2009) was used to determine the power of the current study sample size, operating with a moderate effect size (f = .30) and a significance level of .05 across six groups. The current sample demonstrated an ANOVA power analysis output of .81.

Demographic Profile of the Study Sample (N = 183)

Table:

Demographic Profile of the Study Sample (N = 183)

The performance effects predicted by the study hypothesis were tested in a 2 × 3 ANOVA: patient gender and diagnostic frame served as independent variables, tentative language as the dependent variable. The omnibus test did not reveal a significant difference for patient gender (F [1, 177] = .74, p = .39) or diagnostic frame (F [2, 180] = .27, p = .77).

However, controlling for the patient gender and diagnostic frame interaction, participants in the empathy frame with a male patient (M = 6.00, SD = 4.27) were significantly more tentative than participants in the patient management frame with a male patient (M = 4.61, SD = 2.94) and participants with a man patient in the control frame (M = 4.60, SD = 2.91; F [2, 87] = 3.03, p = .05, ηp2 = .03). Thus, the study hypothesis only received partial support.

Discussion

Given the prevailing socio-cultural stereotypes that portray men as less empathic than women (Flannery, 2000) and nursing as a career focused on empathy (Davies, 1995), men appear to be susceptible to the pernicious effects of stereotype threat. However, despite these prevailing sociocultural stereotypes, the study results varied.

Four unique explanations are offered for the partial support of the study hypothesis: two with pedagogical implications discussed within this section, and two that offer post hoc clarification of study limitations. The first pedagogical implication surrounds the potential dissipation of social stereotypes. The famous Princeton Trilogy study on social stereotypes (Karlins, Coffman, & Walters, 1969; Katz & Braly, 1933) provides support for this notion, as theses cited authors validated the reduction in race-based stereotypes over time. Further, it is possible that although stereotypes persist, proper support structures are in place for male nurses. This is especially optimistic within education, where increased efforts to recruit men continue (O'Lynn & Tranbarger, 2007). These provide an opportunity to forearm men in nursing on how to address encountered gender-based barriers and stereotypes. Forearming holds merit as it looks to reduce perceptions of threat susceptibility to the effect of stereotypes (McGlone & Aronson, 2006). This positive script substitution could follow this line of thought in the classroom:

You are a male nurse and here are specific barriers and stereotypes that you might encounter…. You have the ability to be an outstanding nurse and here are some response options when faced with such barriers and stereotypes….

The second pedagogical explanation focuses on the opportunity for targeted simulation training. Results from this study point to a small stereotype threat interaction effect—male patients in the empathy frame. Patient management aligns with masculine attributes of authority and control (Flannery, 2000) and thus may not have served as a threat when engaging male patients. On the other hand, being subjected to the empathy frame could have prompted participants to attempt to increase empathic levels, which in turn serves as a threat to one's masculine identity. This is further supported in the lack of an observed effect with female patients. According to LaRoche and Livneh (1983), women are more accepting of male nurses than are men. Results from this study provide a level of support to this claim, but only when nursing was outlined as an empathic profession and the patient was male. This unique patient gender and framing effect is an opportunity for targeted nurse simulations and forearming training.

Limitations

The two post hoc explanations (frame subtlety and domain-identification) take a different approach by addressing study limitations and how these lead to future research opportunities. The first centers on frame subtlety, as it is possible that participants did not identify with the constructs of patient management and empathy—especially with the stereotype that men are seemingly lacking in empathic potential relative to women. If participants did not identify with the attributes within which threat was being elicited, there is a potential they would not experience the disruptive effects of stereotype threat. This could begin to explain the small gender × frame interaction. Second, it is possible that participants did not strongly identify with the domain of nursing. Domain-identification requires that an individual perceives the selected domain (e.g., nursing) as attractive, important, and having favorable outcomes (Steele, 1997). As indicated by Crocker, Major, and Steele (1998), individuals that strongly identify or are highly invested in a stereotyped domain are most likely to be influenced by the effects of stereotype threat. The study sample comprised Bachelor of Science in Nursing students, with a median time of 10 months within their respective nursing programs. Thus, it is possible that participants in this study did not identify as strongly as someone who is either further along in their education or practicing in the field.

Recommendations for Future Research

In looking to continue this line of research, future studies should begin by looking at the opportunities surrounding the current study limitations of frame subtlety and domain identification. Further, researchers should consider alternative data collection methodology (in-person versus online and use of a confederate as the patient). This opens up the opportunity to gain further insights into unedited communicative practices and can extend beyond tentative language to consider disfluent speech patterns (McGlone & Pfiester, 2015). Moving forward, findings from this study will be used to frame a secondary investigation that is inclusive of both male and female nurses. This investigation will also look to sample practicing nurses, as they engage with patients daily and represent a different population than nursing students.

Conclusion

Findings from this study offer encouragement that male nurse stereotypes have limited impact on communicative ability. It is also plausible that gender stereotypes surrounding male nurses are shifting. These results and discussion point to the potential of forearming approaches (McGlone & Aronson, 2006) in preparing male nurses to effectively manage gender-based barriers and stereotypes. Finally, there are opportunities for targeted training that not only controls for patient gender, but place nurses under various stereotype-based threat conditions. The objective of this research is to help ensure that nurses are excelling interpersonally, regardless of gender, and the findings of this study should serve as a call to continue this line of investigation.

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Demographic Profile of the Study Sample (N = 183)

VariableFrequency (n)Valid (%)
Gender
  Male183100
Race/ethnicity
  African American/Black1710.1
  American Indian53
  Asian/Pacific Islander105.9
  Hispanic/Latino(a)127.1
  Middle Eastern10.6
  Multiracial84.7
  White/Caucasian10964.5
  Other74.1
  Did not disclose14
Regional locationa
  Northeast4124.1
  Midwest4526.5
  South6337.1
  West2112.4
  Did not disclose13
Nurse in immediate family
  Yes4224.1
  No13275.9
  Did not disclose9
Prior experience in medical field
  Yes5329
  No13071
RangeMean (SD)Median
Age (years)18 to 4925.69 (6.08)25
Times as a nursing student (months)1 to 4811.79 (9.28)10
Authors

Dr. Tollison is Assistant Professor of Communication, Department of Communication and Media, Merrimack College, North Andover, Massachusetts.

The author has disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Andrew C. Tollison, PhD, Assistant Professor of Communication, Department of Communication and Media, Merrimack College, 315 Turnpike Street, North Andover, MA 01845; e-mail: tollisona@merrimack.edu.

Received: March 06, 2018
Accepted: June 21, 2018

10.3928/01484834-20180921-08

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