University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care SCHOOL OF NURSING AND MIDWIFERY COLLEGE OF HEALTH SCIENCES UNIVERSITY OF GHANA, LEGON PATIENTS’ PREFERENCE FOR NURSES’ GENDER IN NURSING CARE AT THE KOMFO ANOKYE TEACHING HOSPITAL, KUMASI. BY AKUA OWUSUA ASANTE (10552217) THIS THESIS IS SUBMITTED TO THE UNIVERSITY OF GHANA, LEGON IN PARTIAL FULFILMENT OF THE REQUIREMENT FOR THE AWARD OF MASTER OF PHILOSOPHY NURSING DEGREE JULY, 2017 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care DECLARATION I, Akua Owusua Asante hereby declare that the work presented in this thesis is produced out of my own research. This work has never been presented to this university or any institution for the award of any degree with the exception of the work of other research works that have been duly acknowledged in the reference section. ---------------------------------- --------------------------------- Akua Owusua Asante Date (Student-10552217) This thesis has been presented for examination with our approval as supervisors. --------------------------------------- ------------------------------ Dr. Kwadwo Ameyaw Korsah Date (Lead Supervisor) ------------------------------------------- ----------------------------- Ms. Patricia Avadu Date (Co-Supervisor) i University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care DEDICATION To my entire family especially my late father, Mr. Kwabena Asante, my dear mother, Ms. Margaret Ofosuah Omari, my siblings, my husband and my lovely children: Awurakumiwaa, Maamefosuah and Miracle for their immense support throughout the programme. ii University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care ACKNOWLEDGEMENT I am grateful to God for His grace and mercies in my entire life. Indeed, His love for me has been marvellous. I am filled with gratitude for my supervisors, lecturers, colleagues, family and friends who supported me as I made my way on this educational journey. First, I thank my Lead Supervisor, Dr. Kwadwo Ameyaw Korsah and my Co-supervisor, Ms. Patricia Avadu for their support and guidance throughout the research work. My next gratitude goes to all my lecturers at the School of Nursing for their academic guidance and tutoring that had enabled me to complete the coursework and the thesis. I wish the department a very bright future. I am grateful to my colleagues at the school of nursing (MPhil, year group 2015) for their excellent inputs with regard to the content and structuring of this thesis. My next appreciation goes to my family. I want to acknowledge my grandmother , Obaapayin Mary Anyei Omari for praying tirelessly towards my academic success. My mother, Ms. Margaret Ofosuah Omari, who instilled in me the value of higher education. She supported me throughout this process, willingly sacrificed her all for me over the past two years so that I could dedicate time to my studies. She was patient, kind, and encouraged me all through. My dear husband, Mr. Frank Denkyira Dampare who has always shown me that he believed in me and who never doubted that I would succeed. I would also like to acknowledge my siblings: Ms. Adwoa Korang asante, Ms. Afua Seiwaa Asante and Mr. Kwadwo Asante who taught me that blood is thicker than water, and who are an infinite well of love and support. I would like to recognize the contributions of Dr. Clifford Amoako of the department of planning, KNUST, who read through the manuscript and provided useful feedback to improve the quality of the thesis. He taught me to think deeply about this work, and always had iii University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care encouraging words to keep me moving forward. I also want to show appreciation to all who in diverse ways have contributed to the success of this work. These include special people such as Mr. and Mrs. Wilson Kwabena Osei, Mr. and Mrs. Samuel Kwaku Frimpong Ms. Phyllita Nyanful and Mr. Richard Makae for their invaluable contribution towards this achievement. I am grateful to all patients admitted to the medical and surgical wards of the KATH during the period of the research work for their input especially those who participated in the study. My appreciation also goes to the staff of KATH for their assistance and good reception during the data collection. Finally, to the authors and publishers whose journals, articles and books were used as references in this work, I will always cherish your ideas and wisdom. God bless you all. iv University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care TABLE OF CONTENTS Content Page DECLARATION ........................................................................................................................................... i DEDICATION .............................................................................................................................................. ii ACKNOWLEDGEMENT ........................................................................................................................... iii TABLE OF CONTENTS .............................................................................................................................. v LIST OF ABBREVIATIONS ..................................................................................................................... xii ABSTRACT ................................................................................................................................................xiii CHAPTER ONE ........................................................................................................................................... 1 1.0 Introduction ................................................................................................................................... 1 1.1 Background to the Study ..................................................................................................................... 1 1.2 Statement of the problem .................................................................................................................... 7 1.3 Purpose of the study ............................................................................................................................ 9 1.4 Objectives of the study ........................................................................................................................ 9 1.5 Research questions .............................................................................................................................. 9 1.6 Significance of the study ..................................................................................................................... 9 1.7 Operational Definitions ..................................................................................................................... 11 CHAPTER TWO ........................................................................................................................................ 12 LITERATURE REVIEW ........................................................................................................................... 12 2.0 Introduction ....................................................................................................................................... 12 2.1 Rational Choice Theory (RCT) and Preferences .............................................................................. 13 Figure 2.1: Diagrammatic Representation of Key Themes in the RCT .................................................. 15 2.2 The Most Preferred Gender of a Nurse in Nursing Care. ................................................................. 18 2.3 Determinants of Patients‘ Gender Preferences in Nursing Care. ...................................................... 21 2.4 Effect of the gender preference of a nurse on the patient. ................................................................ 30 2.5 Barriers associated with gender preference in nursing care .............................................................. 33 2.6 Perceptions of Patients on certain issues in Nursing Care. ............................................................... 36 2.7 Summary critique of the literature review ........................................................................................ 41 CHAPTER THREE .................................................................................................................................... 43 METHODS ................................................................................................................................................. 43 v University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care 3.0 Introduction ....................................................................................................................................... 43 3.1 Research Design ................................................................................................................................ 43 3.2 Research Setting ................................................................................................................................ 44 3.3 Target population .............................................................................................................................. 45 3. 4 Inclusion criteria .............................................................................................................................. 45 3. 5 Exclusion criteria ............................................................................................................................. 45 3.6 Sample size and sampling technique ................................................................................................ 45 3.7 Data collection tool and procedure ................................................................................................... 47 3.8 Pre-testing of Data Collection Instrument ........................................................................................ 48 3.9 Data Analysis .................................................................................................................................... 49 3.10 Methodological Rigour ................................................................................................................... 50 3. 11 Ethical Considerations ................................................................................................................... 51 3.12 Data Storage and Management ....................................................................................................... 52 CHAPTER FOUR ....................................................................................................................................... 54 PRESENTATION OF FINDINGS ............................................................................................................. 54 4.0 Introduction ....................................................................................................................................... 54 4.1 Demographic Characteristics of Participants .................................................................................... 54 4.2 Most Preferred Gender in Nursing Care. .......................................................................................... 55 4.2.1 Patients‘ Preference for Male Nurses in Nursing Care. ............................................................. 56 4.2.2 Patients‘ Preference for Female Nurses in Nursing Care. .......................................................... 57 4.2.2.1 Patients’ Preference for Elderly Female Nurse in Nursing Care ......................................... 57 4.2.2.2 Preference of Young and Beautiful Nurses in Nursing Care .............................................. 57 4.2.3 Patients with no Preference for a Particular Gender of a Nurse in Nursing Care. ..................... 58 4.3 Patients‘ Reasons for the Preference or No Preference for Nurses‘ Gender in Nursing Care. ......... 59 4.3.1 Patients‘ Gender as a Reason for the Preference of the Gender of a Nurse in Nursing Care. .................................................................................................................................................... 60 4.3.1.1 Patients‘ Reasons for Preference of the same Gender in Nursing Care .............................. 60 4.3.1.2 Participants‘ Reasons for Preference of the Opposite Gender in Nursing Care. ................. 62 4.3.2 Patients‘ Preference based on Past Experiences ........................................................................ 63 4.3.2.1 Patients‘ Preference based on Experience with Sickness. (―Recovery from illness matters and not choice of gender of nurses‖)............................................................................................... 63 4.3.2.2 Patients‘ Preference based on Past Experiences with Nurses ............................................. 65 vi University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care 4.3.3 Situation as a Determinant for Patients‘ Preference for Nurses‘ Gender ................................... 66 4.3.3.1 Condition of the patient as a determinant for Patients‘ Preference for Nurses‘ Gender ..... 67 4.3.3.2 Type of Procedure as a Determinant for Patients‘ Preference for Nurses‘ Gender ............ 68 4.3.4 Qualities of the Nurse not Gender as a Determinant for Patients‘ Preference in Nursing Care ..................................................................................................................................................... 73 4.3.5 Personal Interest as a Determinant for Patients‘ Preference for nurses‘ Gender in Nursing Care. ...................................................................................................................................... 73 4.3.6 Religion as a Factor in patients‘ preference for Nurses Gender ................................................ 75 4.3.7 Cultural Factors as a Determinant for the Preference of a Nurses‘ Gender in Nursing Care ..................................................................................................................................................... 76 4.4 Effect of the Preference for Nurses‘ Gender in Nursing Care. ......................................................... 78 4.4.1 Effect of Asking for a Preferred Gender of a Nurse in Nursing Care. ....................................... 78 4.4.2 Effect of Not Getting a Preferred Gender of a Nurse in Nursing Care. ..................................... 79 4.4.2.1 Psychological Effect Associated with Not Getting a Preferred Gender of a Nurse in Nursing Care ................................................................................................................................... 79 4.4.2.2 Physical Effect Associated with Not Getting a Preferred Gender of a Nurse in Nursing Care ................................................................................................................................................. 80 4.4.2.3. No Effect for Not Getting a Preferred Gender of a Nurse in Nursing Care ....................... 81 4.4.3 Benefits of Getting a Preferred Gender of a Nurse in Nursing Care .......................................... 82 4.4.3.1 Psychological Benefits Associated with Getting a Preferred Gender of a Nurse in Nursing Care ................................................................................................................................................. 82 4.4.3.2 Physical Benefits Associated with Getting a Preferred Gender of a Nurse in Nursing Care ........................................................................................................................................................ 83 4.5 Barriers to Patient‘s Preference of a Nurse‘s Gender in Nursing Care ............................................. 83 4.5.1 Attitude of Nurses as a Barrier for not getting a Preferred Gender of a Nurse in Nursing Care. .................................................................................................................................................... 84 4.5.2 Hospital Policy as a Barrier for not getting a Preferred Gender of a Nurse in Nursing Care. .................................................................................................................................................... 84 4.5.3 Inadequate Male Nurses as a Barrier for not getting a Preferred Gender of a Nurse in Nursing Care. ...................................................................................................................................... 86 4.5.4 Patient‘s Attitude as a Barrier for Not Getting a Preferred Gender of a Nurse in Nursing Care. ...................................................................................................................................... 87 4.6 Perspectives of Participants on Certain Issues in Nursing. ............................................................... 89 4.6.1 Qualities of a preferred nurse, perspective of participant .......................................................... 89 4.6.1.1 Communication of a preferred nurse................................................................................... 90 vii University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care 4.6.1.2 Professional competence of a preferred nurse .................................................................... 90 4.6.1.3 Appearance of a preferred nurse ......................................................................................... 91 4.6.1.4 Virtues of a preferred nurse ................................................................................................ 92 4.6.2 Attitude of a bad nurse, participant‘s perspective. ..................................................................... 92 4.6.2.1 Nurses Neglecting Patients in their Care ............................................................................ 92 4.6.2.2 Nurses seeking monetary gains before rendering care to patients ...................................... 93 4.6.2.3 Nurses ignoring patients‘ needs and complaints ................................................................. 93 4.6.2.4. Nurses raining insults on patients ...................................................................................... 94 4.6.3 Stereotypes associated with nurses in Ghana ............................................................................. 94 4.6.3.1 Stereotypes associated with Male Nurses in Ghana ............................................................ 95 4.6.3.2 Stereotypes associated with Female Nurses in Ghana ........................................................ 96 4.6.4 The need to Increase the number of male nurses in the nursing profession ............................... 96 4.7 Summary of Findings ........................................................................................................................ 97 DISCUSSION OF FINDINGS ................................................................................................................... 99 5.0 Introduction ....................................................................................................................................... 99 5.1 Most Preferred gender in nursing care ............................................................................................ 100 5.1.1 Patients‘ Preference for Male Nurses in Nursing Care ............................................................ 100 5.1.2 Patient‘s Preference for Female Nurses in Nursing Care ......................................................... 101 5.1.3 Patients with no Preference for a Particular Gender of a Nurse in Nursing Care. ................... 102 5.2 Patients‘ Reason for the preference or no Preference for Nurses‘ Gender in nursing care. ............ 104 5.2.1 Patients‘ Gender as a Reason for the Preference of the Gender of a Nurse in Nursing Care. .................................................................................................................................................. 104 5.2.2 Patients‘ Preference based on Past Experiences ...................................................................... 106 5.2.3 Situation as a Determinant for Patients‘ Preference for Nurses‘ Gender ................................. 108 5.2.4 Qualities of the Nurse not Gender as a Determinant for Patients‘ Preference in Nursing Care. .................................................................................................................................................. 112 5 .2.5 Personal Interests as a Determinant for Patients‘ Preference for Nurses‘ Gender in Nursing Care. .................................................................................................................................... 113 5.2.6 Religion as a Factor in Patients‘ Preference for Nurses Gender. ............................................. 113 5.2.7 Cultural Factors as a Determinant for the Preference of a Nurses‘ Gender for Nursing Care. .................................................................................................................................................. 115 5.3 Effect of the Preference for Nurses‘ Gender in Nursing Care. ....................................................... 116 5.3.1 Effect of asking for a preferred gender of a nurse in Nursing Care. ........................................ 116 viii University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care 5.3.2 Effect of not getting a Preferred Gender of a Nurse in Nursing Care. ..................................... 117 5.3.3 Benefit of Getting a Preferred Gender of a Nurse in Nursing Care ......................................... 118 5.4 Barriers to Patient‘s Preference of a Nurse‘s Gender in Nursing Care. .......................................... 119 5.4.1 Attitude of Nurses as a Barrier for not getting a Preferred Gender of a Nurse in Nursing Care. .................................................................................................................................................. 119 5.4.2 Hospital Policy as a Barrier for not getting a Preferred Gender of a Nurse in Nursing Care. .................................................................................................................................................. 120 5.4.3 Inadequate male nurses as a barrier for not getting a preferred gender of a nurse in Nursing Care. .................................................................................................................................... 121 5.4.4 Patients‘ Attitude as a Barrier for not getting a Preferred Gender of a Nurse in Nursing Care. .................................................................................................................................................. 122 5.5 Perspectives of Participants on certain issues in Nursing. .............................................................. 123 5.5.1 Qualities of a preferred nurse, perspective of participants. ...................................................... 123 5.5.2 Attitude of a bad nurse, participant‘s perspectives. ................................................................. 125 5.5.3 Stereotypes associated with nurses in Ghana. .......................................................................... 127 5.5.4 The need to increase the number of male nurses in the nursing profession. ............................ 129 5.6 Evaluation of the Rational Choice Theory. ..................................................................................... 130 SUMMARY, IMPLICATIONS FOR NURSING, LIMITATION, CONCLUSION AND RECOMMENDATIONS .......................................................................................................................... 134 6.0 Introduction ..................................................................................................................................... 134 6.1 Summary of the study ..................................................................................................................... 134 6.2 Implications for Nursing ................................................................................................................. 136 6.2.1 Implications for Nursing Practice ............................................................................................ 136 6.2.2. Implications for Nursing Education ........................................................................................ 137 6.2.3 Implications for Nursing Administration .......................................................................... 139 6.2.4 Implications for Nursing Research .......................................................................................... 139 6.3 Limitations of the study .................................................................................................................. 140 6.4 Researcher‘s Reflections on the study ............................................................................................ 141 6.5 The influence of the study on the researcher .................................................................................. 141 6.6 Conclusion ...................................................................................................................................... 142 6.7 Recommendations ........................................................................................................................... 143 6.7.1. To Management of the Komfo Anokye Teaching hospital ..................................................... 143 6.7.2 To The Ministry Of Health (MOH), Ghana ............................................................................. 143 ix University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care REFERENCES ......................................................................................................................................... 145 APPENDIX A: BACKGROUND INFORMATION FORM ....................................................................... 1 APPENDIX B: SEMI-STRUCTURED INTERVIEW GUIDE ................................................................... 2 APPENDIX C: INDIVIDUAL CONSENT FORM ...................................................................................... 3 APPENDIX D: GENERAL PROFILE OF PARTICIPANTS ...................................................................... 8 APPENDIX E: SUMMARY OF THEMES AND SUB-THEMES .............................................................. 9 APPENDIX F: INTRODUCTRY LETTER TO UNIVERSITY OF GHANA HOSPITAL. ..................... 11 APPENDIX G: ETHICAL APPROVAL FROM NOGUCHI MEMORIAL INSTITUTE OF MEDICAL RESEARCH ............................................................................................................................ 12 APPENDIX H: INTRODUCTORY LETTER FROM SCHOOL OF NURSING AND MIDWIFERY. ............................................................................................................................................ 13 APPENDIX I: CERTIFICATE OF REGISTRATION FROM KATH ...................................................... 14 APPENDIX J: ETHICAL APPROVAL FROM KATH ............................................................................. 15 x University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care LIST OF FIGURE Figure 2.1: Theoretical Framework ......................................................................15 xi University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care LIST OF ABBREVIATIONS BP _ Blood Pressure BSc. _ Bachelor of Science FGDs _ Focus Group Discussion GP _ General Practitioner IM _ Intramuscular IMO _ Institutional Medical Organization JSS _ Junior Secondary School KATH _ Komfo Anokye Teaching Hospital KNUST _ Kwame Nkrumah University of Science and Technology MOH _ Ministry of Health MPHIL _ Master of Philosophy NMC _ Nursing and Midwifery Council of Ghana PCC – Patient Centred Care PCP _ Primary Care Physician PSI _ Patient Satisfaction Index Score RCT _ Rational Choice Theory SSS _ Senior Secondary School WHO _ World Health Organization xii University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care ABSTRACT Accommodating patients‘ preference for nurses‘ gender in health care is vital in the provision of patient centred care and ensuring patient satisfaction and better health outcome. The study aimed at exploring patients‘ preference for nurses‘ gender in nursing care at the Komfo Anokye Teaching Hospital, Kumasi. Rooted in the Rational Choice Theory, the study adopted and used the qualitative exploratory descriptive design. Participants were recruited using purposive sampling technique. A semi-structured interview guide was used to elicit information from 14 participants. The data were analyzed using thematic content analysis and five main themes emerged. The study noted that: patients had a varying preference for nurses but gender was not particularly significant in patients‘ preferences for nurses. It was rather found that patients‘ preferences were determined by their wellbeing, disease condition, type of care, religion, the attitude of nurses and hospital policy. However, nurses of the same gender were preferred for intimate procedures to ensure privacy and satisfaction. The additional result that emerged outside the constructs of RCT revealed that: the majority of nurses had a bad attitude towards patients, male nurses were labelled as unsuitable for nursing. However, participants indicated the need to increase male nurses in the nursing profession. It was recommended that it would be ideal to match patients with the preferred nurses to ensure patient satisfaction, though most health care systems do not have adequate capacity to satisfy patients‘ preference and have not factored patients‘ preference into health care policies. Therefore, it may be essential that health policy makers factor patients‘ preferences into health policy. Future research has been recommended to centre on the preference of women for the gender of their midwives in Ghana to inform the continued training of male midwives or otherwise since the training of male midwives in Ghana has come to a halt. xiii University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care CHAPTER ONE 1.0 Introduction This chapter focuses on the background to the study of patients‘ preference for nurses‘ gender in nursing care, the statement of the problem, the purpose of the study, aim and objectives, research questions, the significance of the study, and operational definitions of keywords used in the study. 1.1 Background to the Study Nursing as a profession has been dominated by females over the years (Best, 2003). Even though the number of male nurses is increasing, there are still more female nurses than male nurses worldwide (Saritas, Karadag, & Yildirim, 2009). Statistics for male and female nurses working with the Ministry of Health in Ghana is estimated to be 4,984 (13.5%) and 31,943 (86.5%) respectively. Moreover, the number of male midwives in Ghana is found to be insignificant (Integrated personnel pay roll data, Ministry of Health (MOH), Ghana 2016). A 2010 statistics put the midwife-patient ratio is 1 : 7,200. Also, according to the 2012 annual Report on the Ghana Shared Growth and Development Agenda (2010 - 2013), the nurse patient ratio revealed one nurse to 1,251 patients (National Development Planning Commission, 2010). In addition, the national average of the nurse to population ratio in Ghana, however, almost reached the World Health Organization (WHO) target of 1 (one) nurse per 1,000 citizens (Dickson, Darteh & Kumi-Kyereme, 2017). Patients‘ preference for the gender of their nurses and the possible impact of nurses‘ gender on patients‘ health is not well defined. Several studies investigated patients‘ preference for their physicians‘ gender (Kwak et al., 2017; McKee et al., 2017), women‘s choice for the 1 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care gender of their gynaecologists- obstetricians (Amer-Alshiek et al., 2015; Amir, Tibi, Groutz, Amit, & Azem, 2012), or gastroenterologists (Consedine, Reddig, Ladwig, & Broadbent, 2011; Shah, Karasek, Gerkin, Ramirez, & Young, 2011), and indicated preference for same-gender physicians. 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 (Laurent, 2000). As human beings, they have diverse beliefs, desires, values, needs, and preferences. To satisfy the needs of a patient and render proper nursing care one need to know the preferences of patients and treat them as individuals. The nursing profession also lays emphasis on providing holistic care and ensuring that patient values guide all clinical decisions (Marchetti, Piredda, & Marinis, 2016). Moreover, the Institute of Medicine (IOM) has presented a policy for improving the quality of healthcare delivery system in the 21st century and one of the major areas identified for improvement was the need for patient centred care (Baker, 2001). This was described as health care that is respectful and responsive to individual patient needs, values, and preferences and encourages shared clinical decision making. Patient-centred care (PCC) is known to significantly influence the process of care and its outcomes (Bertakis & Azari, 2012). Again, Bertakis and Azari (2012) have proven that patient and physician gender and gender concordance, impact the provision of Patient centeredness and influence the process of medical care. A patient‘s preferences for nurses‘ gender is a situation whereby a person receiving medical or nursing care is interested in a particular gender of a nurse giving the care than the other gender. Patients‘ preference is gradually emerging and becoming an essential requirement in decision-making in health (Llewellyn-Thomas & Crump, 2013; Rubrichi et al., 2015; Sacchi 2 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care et al., 2015). In the past three decades, the number of patients asking, and willing, to be involved in clinical decisions during encounters with their care providers has been constantly increasing (Chewning et al., 2012). This changing attitude does not only include the call for information but also the need to consider personal preference as an essential part of therapeutic intervention (Saha & Beach, 2011). Nurses are expected to perform many intimate procedures that require constant contact with the patient no matter the body part involved to promote the recovery process (Fisher, 2009). Harding, North, and Perkins (2008) define intimate physical touch as touch involving inspection of, and possibly physical contact with, those parts of the body whose exposure can cause embarrassment to either the patient or the nurse. O'Lynn and Krautscheid (2011) expanded this definition and defined intimate touch as task-oriented touch to areas of patients‘ bodies that might produce feelings of discomfort, anxiety, and fear or might be misinterpreted as having a sexual purpose. Such areas of the body include, but are not limited to, the genitalia, buttocks, perineum, inner thighs, lower abdomen and breasts (O'Lynn, Cooper, & Blackwell, 2016). These procedures include: examining the cervix for dilation, shaving of the perineum, circumcision, examination of the breast, giving an enema, changing pads, inserting urinary catheters, bandaging the scrotum, and sterilizing the vaginal area (Sarfraz & Hamid, 2014). Furthermore, procedures that require intimate touch can cause feelings of embarrassment, discomfort, anxiety, and fear for both the nurse and the patient (Clair, 2014; Eswi & El Sayed, 2011; Keogh & Gleeson, 2006). Vanderbilt University Medical Centre emphasized 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 (Ikizler et al., 2013). Nursing and Midwifery code of professional conduct also indicates that nurses must recognize and 3 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care respect the role of patients as partners in their care. Therefore, a request for any gender of a nurse should be acted upon but only as far as professional practice or resources would allow (Spouse, Cook, & Cox, 2008). In addition, the American Medical Association in 2010 recommended that an authorized health professional should serve as a chaperone whenever possible to protect both patients and staff to safeguard against formal complaints of inappropriate behaviour or allegations (Alvarez-Erviti et al., 2010) Gender has been shown to have an influence on the provider-patient interaction. Moreover, it is important to understanding the impact of patient and the care providers‘ gender because what transpires during the medical encounter considerably affect patient health (Choi, Park, & Jung, 2017; Schoenthaler, Allegrante, Chaplin, & Ogedegbe, 2012). A study by Kristiansen et al. (2010) proved that patients consider emotional support essential in the provision of care. Therefore, it is not all about the diagnosis and treatment of the condition, but that understanding the patients‘ needs and preferences, the human concern, support and comfort also matter to the sick patient (Govender & Penn-Kekana, 2008). Moreover, the provider‘s relationship with the patient is central to patient centred care (PCC) and this empowers the patient to some extent resulting in satisfaction with the care received (Lee & Lin, 2010). A research conducted in Spain indicated that the gender of care providers at the maternity wards has a direct impact on parents‘ willingness to share personal information (Newham & Alderdice, 2017). Secondly, the gender of the health care worker affects patients‘ ability to understand, believe or trust the provider and adhere to prescribed treatment (Hardeman et al., 2015). Researches done indicate that all over the world patients have a varying preference when it comes to the gender of a nurse (Fisher, 2009; MacWilliams, Schmidt, & Bleich, 2013). A study in Jordan by Ahmad and Alasad (2007) indicates that gender preferences are stronger 4 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care 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. 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 orthopaedic surgeons or endoscopists (Abghari et al., 2014; Amir et al., 2016; Lahat, Assouline-Dayan, Katz, & Fidder, 2013). A study by Chur-Hansen in 1984 and replicated in 2002 found consistent results and indicated that the level of intimacy in a clinical situation was found to predict same-gender preferences (Chur‐ Hansen, 2002). Several reasons abound for the preference of the gender of nurses (O'lynn & Krautscheid, 2011).There are several societal and cultural factors which prevent men from providing care, including the general perception that men are less suited than women for nursing and the negative way male nurses are described in the media and labelled as ―He-Man‖, causing trouble, effeminate or gay. Again, some social, cultural and religious norms and practices restrict physical and social contact between males and females (Rizk, El‐Zubeir, Al‐Dhaheri, Al‐ Mansouri, & Al‐Jenaibi, 2005). Men caring touch are perceived by some societies as sexualized (Bartfay, Bartfay, Clow, & Wu, 2010; Coleman, 2008; Meadus & Twomey, 2011; Weaver, Ferguson, Wilbourn, & Salamonson, 2014). Others say men may express caring differently with the use of humour and gentleness (Pullen & Simpson, 2009). In Africa, many women and men experience gender-related socio-cultural, physical, and religious barriers that limit their ability to seek care. Some religion and culture look down on women and perceive civilized women as 5 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care unclean and rude. Therefore, they find it difficult and unwilling to be cared for by female nurses. Again in some cultures, women may be reluctant to receive care from male providers, or husbands may object to having their wives see male providers, so a shortage of female providers may limit women's access to services (Creel, Sass, & Yinger, 2002). Past experience with a particular gender may require the preference of the same gender or different gender Leach et al. (2017). Some procedures are embarrassing and intimate and require a preferred gender to ensure privacy (Keogh & Gleeson, 2006). However, patients are insulted, discriminated and ignored as a result of making their preference for nurses‘ gender known (Eriksson & Svedlund, 2007). Some patients feel embarrassed, distressed and uncomfortable especially during intimate nursing care and all these affect patients‘ health negatively (Eriksson & Svedlund, 2007; Moores, Metcalfe & Pring, 2010). Others may decide inwardly not to visit the hospital for health care but will not complain to us. There is evidence from a number of studies that patients may avoid seeking care, refuse or delay treatment because of the gender of the health care workers and this can lead to complications and death (Haron & Ibrahim, 2012). There seem to be limited published studies in Ghana regarding patient‘s preferences for nurses‘ gender. Throughout my literature search, I did not come across any published work in Ghana on nurses‘ gender preference in nursing care. Therefore, whether there is the same gender preference, the opposite gender preference or there is no gender preference among patients in Ghana, it is yet to be established. This study will, therefore, address patients‘ preference for nurses‘ gender in nursing care at the Komfo Anokye Teaching Hospital in Kumasi -Ghana. The underpinning model for the study would be Rational Choice Theory founded by sociologist George Homans in 1961 (Homans, 1987). 6 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care 1.2 Statement of the problem Generally, in Ghana, both female and male patients could encounter a nurse of either sex, even though female nurses are encountered more often than male nurses and due to the fact that nursing is dominated by females. Presently, health care providers are educated to provide their services equally to all patients no matter their gender. However, patients are not trained to accept or receive care provided by both genders of nurses. Moreover, patients are not required to choose and they are not asked about their preferred nurses‘ gender and it is not factored into the nursing procedures. However, the Code of Ethics for the Ghana Health Service indicates that all service personnel in the sector shall deliver a comprehensive equitable and patient centred care for the benefit of patients/clients and society as a whole (Yeboah, Ansong, Appau-Yeboah, Asante Antwi, & Yiranbon, 2014). Besides, the health sector is mandated to recognize the needs and preferences as well as the rights of patients and offer them accordingly to improve health and enhance satisfaction in health care (Brazier & Cave, 2016). From my seven years‘ experience as a practice nurse, I have observed that more often than not in our hospitals, patients of all kinds both out patients and in patients who require specific attention and care tend to be selective when it comes to the sex of the health provider especially the nurses. Some go to the point of refusing to take injections or receive other required services solely because they were not comfortable with the gender of the nursing staff to deliver the service. Again as a practicing nurse, I have come across many women of all faiths who do not like personal care carried out by male nurses. Besides, some male patients also preferred female nurses while others preferred male nurses. Again, in my years of practice experience, I have also noted that most female patients preferred female nurses whiles some preferred male nurses and others were indifferent. Yet, some nurses, as well as other health workers, sometimes 7 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care ignore patients who insist on being taken care of by a particular gender of a nurse and do not understand why the gender of a nurse should be of importance when the goal of the patient is to recover without complications. Similar to these observations, Amoakohene 2004, Ampofo, Beoku-Betts, Njambi, and Osirim, 2004 reported that nursing in Ghana is structured around power and control, and patients are often expected to keep quiet and comply with instructions while their personal needs are ignored. In addition, some nurses go further to the extent of calling patients names (eg. ‗‗truller‘‘ meaning, ‗‗too known‘‘ and ‗‗cocosomic‘‘ meaning, ‗‗troublesome‘‘) and refuse to get the patient the requested gender to give the nursing care. From my interactions with student nurses as a clinical instructor, I have also noticed that quite a number of student nurses encounter similar situations. Most student nurses report that some patients do request and insist on being cared for by a particular gender of a nurse, especially in situations that involve touching during clinical experience. Colleague nurses at different hospitals in Ghana have also confirmed to the occurrence of similar phenomena in their various hospitals. They added that although the situation is not so alarming it is gradually evolving. Therefore, it may be important to shed more light on patient gender preference in nursing care, identify patients‘ preference and offer them accordingly to ensure better health outcome. Understanding the factors that determine patients preference, the effect of getting or not getting a preferred nurse and the barriers that prevent a patient from getting a preferred nurse in nursing care will enable nurses to give quality care and also satisfy our clients who are considered central in nurse-patient relationship and interaction in general. When patients are supported psychologically and their values respected they would be more likely to feel relieved of their condition and other stressors (Haywood et al., 2014; Street, Gordon, & Haidet, 2007). Therefore it is necessary to get insight into gender preferences in nursing care in Ghana. 8 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care 1.3 Purpose of the study The purpose of the research was to investigate gender as a determinant in patients‘ choice of a nurse to provide care and how significant that factor is to patients in their selection of a preferred nurse at the Komfo Anokye Teaching Hospital. 1.4 Objectives of the study 1. To explore the gender of a nurse that is preferred for nursing care by patients. 2. To identify the reasons for the gender preference of a nurse in nursing care. 3. To explore the effect of the gender preference of a nurse on the patient. 4. To identify the barriers associated with patients‘ preference for nurses‘ gender. 1.5 Research questions 1. Which gender of a nurse do patients prefer for nursing care, male or female? 2. What determines the reasons for preferring a particular gender of a nurse in nursing care? 3. Of what effect is gender preference of a nurse to a patient? 4. What barriers are associated with gender preference in nursing care? 1.6 Significance of the study It is hoped that the findings of the study will be useful in improving health policy, health delivery, nursing education, administration, and research. Specifically, the result of the study would help to know and understand the cultural, religious, social and psychological needs of patients and how these factors influence a patient preference for the gender of a nurse for nursing care. This understanding will help improve the knowledge base of health workers especially the nursing staff and guide health professionals in providing quality care to meet the needs of patients to ensure patients‘ satisfaction. 9 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care This study will also help to educate our national leaders and health policy implementers to understand the needs and preferences of patients and improve our health policy so that every patient would have to choose the gender of a care giver if resources would allow, as a result seeking health care at the health facility would be attractive to patients. Hospital employment policies would be based on giving patients a choice of gender so that an adequate number of male and female nurses would be on duty at every shift. This will help to ensure that the required numbers of male and female nurses are enrolled in the nursing training schools. The study will help to reveal the culture, values, and beliefs of patients and this will go a long way to reduce potential conflicts that may occur at the health system as a result of a patient‘s culture. The findings will facilitate a better understanding of patients‘ needs. This may help health providers during patients‘ education and counselling and while planning health services for specific communities. Specifically, considering the focus on global health in health care delivery, the results presented may offer insights to health care providers. This is particularly important while developing and organizing new ways of providing efficient health-care services. 10 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care 1.7 Operational Definitions Adult: a person who by virtue of attaining full growth or maturity, normally eighteen years and above. Hospital: a place where the sick and the well visit for health advice or treatment. Modest: Correct moral behaviour in appearance, speech or conduct. Nurse: a health worker who focuses on the care of patients and family throughout their stay at the hospital. Nursing care: providing physical, mental and social support for patients to enhance their wellbeing. Preference: wanting or liking someone more than the other. Patient: An adult who is physically, mentally, socially or psychologically not sound and visits a hospital for treatment. Rational: purposeful and goal-oriented behaviour. Seriously ill: being ill to the extent that engaging in minor daily actitities like conversation, movement, etc. would be stressful. 11 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care CHAPTER TWO LITERATURE REVIEW 2.0 Introduction A literature review is a critical, analytical account of the existing research on a particular topic. This chapter of the study includes the review of the literature on patients‘ preference for nurses‘ gender and has been discussed under six (6) sections. The first section highlighted on the theoretical framework; the Rational choice theory that guided the study. The second section reviewed the literature on the most preferred gender of a nurse in nursing care by patients. The third section reviewed literature on the reasons for the preference of a nurse‘s gender in nursing care, the fourth section highlighted on the effects of patients‘ preference for nurses‘ gender in nursing care on patients, the fifth section reviews the barriers and challenges associated with patients‘ preference for nurses‘ gender, while the six section reviewed the perceptions of patients on certain issues in nursing care (the additional finding from participants‘ responses through content analysis. Sources for literature search included the following databases: Google Scholar, PUBMED, Science Direct, Wiley, Sage, EBSCOhost, and Medline. Key words used for the search included patients, preference, choice, nurses‘ gender, nursing care, patient‘s preference, male nurses, female nurses. A wide range of books, journals, papers and the internet were consulted for the appropriate information. Below is an extensive overview of the rational choice theory (the conceptual framework to guide the study). 12 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care 2.1 Rational Choice Theory (RCT) and Preferences The study adopted rational choice theory as a guiding framework to shape and understand the phenomenon under study. In a search for conceptual framework to underpin the study, the researcher considered using several models such as the Bayesian statistical decision model, revealed preference theory, and the rational choice theory but settled on the rational choice theory. The Bayesian statistical decision model states that what an individual does on any given occasion is completely determined by his/her beliefs and desires or values. The major constructs of the model are: the Data, Model, Likelihood, Posterior, Prior, Utility and Decision (Pettigrew, 2016). The revealed preference theory, pioneered by American economist Paul Samuelson, is a method of analyzing choices made by individuals, mostly used for comparing the influence of policies on consumer behaviour (Bochenek, 2016). The rational choice theory was chosen because it was more appropriate for the study and the constructs in the theory guided the researcher to elicit responses that answered the research questions from the study participants and thus addressed the research objectives. Rational choice in the standard view is defined as the process of determining what options are available and then choosing the most preferred one according to some consistent criterion (Levin & Milgrom, 2004). The rational choice theory was founded by sociologist George Homans in 1961, he laid the basic framework for exchange theory and drew his assumptions from behavioural psychology (Homans, 1987). RCT has basically changed the paradigm of rationality, Down‘s definition of man‘s rationality refers to an individual who strives to achieve its objectives in a way that causes the greatest satisfaction (Downs, 1957 p.5). The concept of rationality used in rational choice theory is different from the colloquial and most philosophical use of the word which means sensible, predictable or thoughtful. The theory uses a narrower 13 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care definition of rationality at its basic level to imply that behaviour is rational if it is goal-oriented, reflective, and consistent across time and different choice situations (Ogu, 2013). The model states that every individual has preferences among available alternatives that enable them to state which option they prefer most. The preferences of individuals are determined by the past information, personal interest, beliefs and values on the options available (Levin & Milgrom, 2004). The theory assumes that people make choices based on a thoughtful and purposeful action depending on a perceived outcome of benefit or importance to arrive at maximizing personal happiness, satisfaction, and utility (Adanali, 2016). In addition, an individual is assumed to make a choice according to constrains or barriers facing them (Burns & Roszkowska, 2016). The theory is appropriate for the study because it offers a rich collection of techniques and procedures to aid the researcher to reveal which choice a typical patient will choose among a male and a female nurse, which factors will determine such a choice, what the outcomes of choosing or preferring a male or a female nurse would be, and lastly whether health facilities are designed to offer such choices to patients as well as clients. The graphical representation of the model of RCT is shown on the next page. 14 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care Figure 2.1: Diagrammatic Representation of Key Themes in the RCT Source: Adopted from Elster (2010) Figure 2.1 represents the explanatory or causal version of the theory (Elster, 2010). The heavily drawn lines represent both causal relations and optimality relations. The action, for instance, is optimal in the light of the desires and beliefs that cause it. The lightly drawn lines represent causal relations that are not also optimality relations. Thus, the line from desires to beliefs represents wishful thinking and other forms of motivated belief formation. The line from beliefs to desires or preferences represents mechanisms such as adaptive preference formation. 15 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care Although aligning one's beliefs on one's desires is basically irrational, it does embody a form of short-term optimizing. Believing that the world is as you would like it to provide some kind of immediate satisfaction, or at least removes the discontent that is produced when beliefs and desires diverge. Aligning desires on beliefs is neither rational nor irrational. There are no rationality criteria for processes of preference formation or for the outcome of such processes, except for the requirement that preferences be logically consistent. At the same time, the outcome of adaptive preference formation or of dissonance reduction can be seen as a form of optimizing, as they make the agent better off. The alignments of desires and preferences on one another tend to improve the welfare of the agent, at least in the short run. Some processes of belief adjustment or preference adjustment seem, however, to make the agent worse off, not better. As indicated in the diagram, rational choice is defined in terms of the relations among action, desires, beliefs, and information. Applying the model to this current study, rational choice theory tells how best a patient‘s desires and beliefs inform the choice for a male or a female nurse in nursing care. In other words, the interest or desires of a patient directly inform the preference. Secondly, the trust and believes in the options are influenced by the cultural, societal and religious information received about the options. Furthermore, the desires and the beliefs of the individual have influence in the type of information he will seek and obtain on the alternatives. It is also based on total knowledge and information on what is available and the implications of choosing anyone of them. Needless to say, a belief may be rational and yet false. We see that belief rationality can be shaped by the agent‘s desires, not directly (as in wishful thinking), but indirectly through the process of information acquisition. The optimal investment in information acquisition also depends, as shown by the loop, on the information acquired previously and the past experience with the choices to be selected from. 16 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care The theory has had a wide range of applications: among others, microeconomic models and analyses, political science, sociology and philosophy epidemiological and medical research, operations research, decision engineering, game theory and criminology, deterrence theory, and international relations. Specifically, it has been applied in personal choices about marriage, child-bearing, crime, education; personal and household choices about food consumption and savings, public policy and public choice about whom to vote for during election of leaders (Burns & Roszkowska, 2016; Krstić, 2013). Not always are preferences chosen based on a consistent criterion. Preference may change according to a condition, a situation, or an additional knowledge or information on the available alternatives. A common main criticism is that real decision-makers are not strict rationally calculating and self-interested. They are constrained by institutions, cultural influences, and psychological limitations that make the assumption of rationality problematic. Rational choice agents operate outside of social systems. The agents are social atoms, rationally calculating to further their own self-interests, wholly free from social encumbrances and cultural constraints. This is in contrast to social embeddness approaches to human action. There is overwhelming evidence that factors other than self-interest such as concern for others in interpersonal relations, institutionalized roles, values, and culture, how situations and problems are framed generally are central to much human judgment and action. The rational choice theory provides little insight and explanation about much social behaviour, since humans as social beings are embedded in social relations and institutional and sociocultural arrangements of family, work, and community. Another criticism of the rational choice model is that real-world choices often appear to be highly situational or context-dependent. The way in which a choice is posed, the social context of the decision, the emotional state of the decision-maker, the addition of seemingly extraneous 17 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care items to the choice set, and a host of other environmental factors appear to influence choice behaviour (Burns & Roszkowska, 2016). In RCT norms and ethical considerations are not part of the conception of the human actor. The individual has subjectively based self-interest and concerns herself only with consequences for herself. Also, rational choice is improperly extended to circumstances characterized by uncertainty where the agents do not know the probabilities or even all the possible outcomes of their choices. Some processes of belief adjustment or preference adjustment seem, however, to make the agent worse off, not better (Adanali, 2016). The current study adopted the RCT to investigate the preference of patients for their nurses‘ gender in nursing care at the Komfo Anokye Teaching Hospital, Kumasi. The literature is reviewed based on the constructs and assumptions of the rational choice theory which defines the objectives of this study. The first part revealed literature on the most preferred gender of a nurse in nursing care. 2.2 The Most Preferred Gender of a Nurse in Nursing Care. A quantitative study with 100 adult patients to determine if patients view male and female doctors differently, and the factors that influence these views in six medical specialties in the University of Benin Teaching Hospital Nigeria found that 53% of the patients were interested in the gender of the attending doctor, 42 % preferred male doctors and11% preferred female doctors (Adudu & Adudu, 2007). Another research on male nurses‘ experiences of gender barriers: Irish and American perspectives showed that male nurses were most preferred among the gender of nurses (Keogh & O'lynn, 2007). However, Howell, Gardiner, and Concato (2002) investigated the gender preference for obstetricians in a hospital setting and examined its relationship to patient satisfaction. A 18 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care qualitative method of analysis was used and they interviewed 67 obstetric patients during their postpartum hospital stay. The overall results showed that 58% of patients had no preference for physician gender, 34% preferred female physicians, and 7% preferred male physicians. Although most patients do not mind being cared for by either male or female nurses, the majority of patients 34% preferred a female nurse if given the chance to choose. In contrast, 7% of patients preferred a male obstetrician in another study (Rao, Peters, & Bandeen-Roche, 2006). These bring about the need to research into the gender preference in nursing care in the Ghanaian context. A similar study by O'Lynn and Krautscheid (2011) investigated patients' preferences for how nurses should perform procedures involving touch, especially intimate touch involving private and anxiety-provoking areas of patients' bodies. A purposive maximum-variation sample of adults in an urban region of the western United State was recruited from a Catholic church and a Protestant church. A sample of 24 adults was selected and semi-structured interviews were conducted in four focus groups found that participants had varied preferences for their nurse's gender but in all, female nurses were most preferred. The participants in this study lived in a metropolitan area and may not represent the attitudes of rural residents. Secondly, the recruitment from faith-based institutions may have limited the range of responses. Further, research on touch on the perspective of patient‘s with diverse background is advocated. Rizk et al. (2005) also conducted a research on determinants of women's choice of their obstetrician and gynaecologist in the United Arab Emirates. The objective of this study was to evaluate women's priorities and preferences in selecting their obstetrician and gynaecologist in a non-Western society. A sample of 508 patients attending the obstetric and gynaecologic services of AL-Ain Hospital within 4 months was recruited. Participants were interviewed by using a structured 26- item questionnaire administered by means of face-to-face interview within 24 hours of admission 19 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care to the ward or before consultation in the outpatient clinic. The results showed that 86.4% of the participants preferred female physicians, 12% had no preference and 1.6% preferred male physicians. This study had enough questionnaires to gather adequate information for the research, yet the timing of the interview, that is 24 hours of being on admission in the ward or before consultation in the outpatient clinic is questionable. This is because the first 24 hours is when the patients‘ problems (chief complaint) need to be addressed. The patients may be distracted as they will expect to have solutions to their chief complaint before having time and sound mind answering the questionnaire. Secondly, participants may also be biased as they would be anxious and wouldn‘t know how their response will be affecting their treatment at the ward or at the clinic because they might not be familiar with the environment yet. A quantitative study by Ahmad and Alasad (2007) sampled 484 (53%) male patients and 435 female patients from seven hospitals representing private, public and educational hospitals in Jordan. Forty-three percent (43%) of the participants were indifference on preference for nurses‘ gender, 38% prefer female nurses and only 19% prefer male nurses. Furthermore, 69% of female patients prefer female nurses, and only 3% prefer male nurses. In contrast, 33.9% of male patients preferred male nurses, and only 9.7% preferred female nurses. Therefore, 90% of male patients either prefer or do not mind to be cared for by male nurses; however, 66% of male patients also would allow female nurses to care for them. Moreover, 97% of female patients would either prefer or do not mind female nurses to care for them. Equally, Johnson, Schnatz, Kelsey, and Ohannessian (2005) conducted a study to determine whether men should be encouraged to enter the medical specialty of obstetrics and gynaecology. A self-administered survey was distributed to patients (N=264) in 13 obstetrics and gynaecology waiting rooms in Connecticut, a state of the northeast United State. The survey was used to determine whether 20 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care there were any patient preferences with regard to the gender of physicians providing obstetric and gynaecologic care. The study found that majority of patients (66.6%) had no gender preference when selecting an obstetrician-gynaecologist (Johnson et al., 2005). The setting of this study being waiting rooms could be distracting and respondents‘ privacy is questionable therefore this can influence the result of the study. In addition, Makam, Mallappa Saroja, and Edwards (2010) conducted a study on gender and patient preference related to ethnicity. Data were collected using questionnaires from 500 women attending gynaecology and antenatal clinic of a single hospital. The study resulted that 51.7% of participants had no preference, 44.6% preferred females and 3.7% preferred male doctors. The findings of this study may not be generalizable, the sample of the study was only limited to patients in a single Hospital. Therefore, a replication of the study is recommended using several hospitals in order to justify statistical connection. 2.3 Determinants of Patients’ Gender Preferences in Nursing Care. This section includes a review of the literature on patients‘ reasons for the preference or no preference of a nurse‘s gender in nursing care. The literature is reviewed under nine main areas and they have been discussed in paragraphs accordingly. These comprise: patients‘ gender as a reason for the preference of the gender of a nurse in nursing care, patients‘ preference based on past experiences, situation as a determinant for patients‘ preference for nurses‘ gender, qualities of nurses not gender as a determinant for patients‘ preference in nursing care, personal interest as a determinant for patients‘ preference for nurses‘ gender in nursing care, religion as a factor in patients‘ preference for nurses gender, sociocultural factors as a determinant for the preference of a nurses‘ gender for nursing care, race as a determinant of a patient preference of a nurse‘s gender and lastly, age as a determinant of a patient preference of a nurse‘s gender. 21 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care A quantitative study on 218 Emirati Muslim women about their preferred physician (in terms of gender, religion, and nationality) for three personal clinical scenarios was studied by McLean et al. (2012). The findings showed that female was almost exclusively preferred for the gynaecological (96.8%) and stomach (94.5%) scenarios, while 46% of the women also preferred a female physician for the facial allergy scenario. This reveals that Muslim women have a preference for same gender physicians and the gender of patient influences the preference of a provider‘s gender. This indicates a gap for further studies on the perspective of the gender of midwives in Ghana to inform the continued training of male midwives or otherwise since the training of male midwives started some time ago but currently not in existence. Another research on sex preferences for colonoscopists and gastrointestinal physicians among patients and health care professionals resulted that women had a stronger sex preference for an office visit with a gastroenterologist (44.3%) and for a colonoscopist (53%) than men (23% and 27.8% respectively) (Deepa, Shah, Karasek, Gerkin, Ramirez, & Young, 2011). Amir et al. (2016) assessed provider gender preference among urology patients. Of the 119 patients, most patients (97%) preferred a same-gender urologist rather than physician‘s characteristics such as being more sympathetic, more patience because they felt less embarrassed. In addition, a research by Bishop, Smith and Lewith (2013) on patients‘ choice of therapist to treat low back pain found that, participants demonstrated a small but significant preference for female practitioners over male practitioners, but this effect differed by participant gender: female participants had a statistically significant preference for female practitioners to male practitioners, but male participants were not influenced by practitioner gender. A study was done to assess sexual attraction, depression, self-harm, suicidality and help-seeking behaviour in New Zealand secondary school students. Results indicated that 92% of students were attracted to the opposite 22 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care sex, 1% to the same sex, 3% to both sexes, 2% were not sure and 2% were attracted to neither sex. The study concluded that students who paid more attention to the opposite gender were found to have less psychological and social problems. This suggests that opposite gender nurse may reduce psychological and social problems of patients (Lucassen et al., 2011). Another study on the effects of visual exposure to the opposite sex: cognitive aspects of mate attraction in human males. Twenty-six male University of Chicago students were recruited and completed the experiment. The study revealed that males are attracted by sight and touch to the opposite gender and gain some comfort during their interactions (Roney, 2003). Therefore opposite gender may influence the preference of a male or a female nurse in nursing care. Janssen and Lagro-Janssen (2012) reported about women seeking gynaecological or obstetrical care and physician‘s gender in relation to patient preferences, differences in communication style and patient satisfaction in their studies. Most patients preferred a female rather than a male gynaecologist–obstetrician. Patient-centred communication style, experience and clinical competence used by female gynaecologists–obstetricians were important factors in choosing a gynaecologist–obstetrician. Haron and Ibrahim (2012) researched into Patients‘ Preference for Doctors: Perceptions of Patients at a Hematology Clinic suggested that patients were comfortable with doctors who were quick to respond, caring, experienced, good communicators, with a good reputation and also of the same ethnic group as the patient. A study using data from the 2014 Association of American Medical Colleges Consumer survey of health care access identified themes in open text responses to reasons for respondents‘ provider type preference using a qualitative analysis. Both groups of respondents in this study equally mentioned previous experience with their provider type as a reason for their preference for a preferred physician (Leach et al., 2017). The aim of this study was to examine the international 23 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care research relating to registered and student nurses‘ attitudes towards older people and the potential underpinning variables. Three studies found that male nurses had more positive attitudes than female nurses towards patients and this past experience informed their choice of a male nurse during care (Liu, Norman, & While, 2013). It has been proved that a history of sexual assaults or homophobia may also account for the preference of the gender of a care provider, according to Sherman (2010). He emphasized that a patient who has been sexually assaulted in the past by a particular gender may be frightened when receiving care from a provider of the same gender. The mind of the patient may reflect back to the incidence and may go through post- traumatic stress disorder which could be distressful. The severity and types of illnesses determine the level of participation of a patient in his care. A seriously ill patient may not be able to communicate their concerns to health workers (Vahdat, Hamzehgardeshi, Hessam, & Hamzehgardeshi, 2014). In addition, a study concluded that 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 (Street, Gordon, Ward, Krupat, & Kravitz, 2005). Several studies have shown that the type of care provided for a patient determines the preferred gender of a nurse. According to Janssen & Lagro-Janssen (2012), all articles studies and reviewed found that women preferred a female rather than a male gynaecologist–obstetrician. Patient‘s preference for a female gynaecologist–obstetrician increased when physical examination was required, compared to a consultation without a physical examination. A study by Ahmad and Alasad (2007) in addition reported that female patients prefer female nurses. 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. Another study was 24 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care to investigate the perception and attitude of male and female Chinese patients to the presence of a chaperone during an intimate physical examination at a public teaching hospital in Hong Kong using a convenient sampling method. The result showed that over 90% of the participants considered the presence of a chaperone appropriate during intimate physical examination, and 84% felt that doctors, irrespective of gender, should always request the presence of a chaperone. The most commonly cited reasons included the availability of an objective account should any legal issue arise, protection against sexual harassment, and provide psychological support. The participants preferred same gender nurse when procedures were intimate (Fan et al., 2017). The convenient sampling method adopted by the study may result in systematic bias, skewed results, and potentially suboptimal generalizability of the findings, particularly outside the public hospital setting. Adudu and Adudu (2007) also found that male surgeons were preferred for greater technical capability and the suitability of their greater physical strength. Also, female obstetricians and gynaecologists were preferred for gender sensitivity and less social embarrassment during clinical examinations. There was an association between patient gender and specialty preferences of the gender of doctors with male and female respondents preferring male doctors generally, especially in surgery. A study by O'Lynn & Krautscheid (2011) revealed that participants believe nurses irrespective of the gender have gone through training and would perform the work professionally, competently, and in a way that conveys respect so the gender does not make a difference. Nurses both male and female have the qualities needed to provide care, nurses specialty and good qualities are preferred not gender. Moreover, provider qualifications and qualities are cited as key reasons for preferring all provider types by the participants of this study (Chen, Zou, & Shuster, 2017). Additionally, physicians were more preferred by patients for their 25 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care qualifications and technical skills and not the gender (Leach et al., 2017). Piper, Shvarts, and Lurie (2008) also researched into Israel women's preferences for their gynaecologist or obstetrician and the objective was to evaluate women‘s preferences in selecting their gynaecologist or obstetrician. Most women (60.3%) reported that the gender of their gynaecologist or obstetrician was not an important consideration when choosing a gynaecologist or an obstetrician. The major determinants in their choice of a gynaecologist or an obstetrician included: professionalism (45.3%), courtesy (25.8%), board certification (10.8%), availability (10.1%), comprehension (6.5%) and communication (1.5%) A research to assess patients' preference for a migraine preventive therapy engaged in analysis of preventive treatment scenarios. The study found that patients were more likely to choose treatments with higher efficacy rates, fewer adverse events, and a less frequent dosing schedule. However, patients indicated that they preferred the treatment options with higher efficacy rates even if side effects were present and a more frequent dosing schedule was necessary to enhance their immediate comfort and happiness. Their concern was to improve fast (Peres et al., 2007). Reuben and Tinetti (2012) emphasized that patient welfare may be an important factor in goal setting and achievement of satisfaction and the outcome of patient‘s health. In addition, the relative priority and personal interest were also needed in patient care for the better outcome. Another survey of migraineurs indicated that an overwhelming majority of patients consider complete relief of head as the most important determinant of treatment preference. Most of the patients preferred the treatment option that will give them a rapid response and did not base their choice on the doctors‘ recommendation. The patients valued their personal interest and priority of getting the rapid onset of complete pain relief from the head pain as more important than the doctor‘s advice (Lipton, Hamelsky, & Dayno, 2002). 26 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care Modesty is very important in Islam. Muslim men and women may be shy about being naked and very reluctant to expose their bodies to a stranger. Some Muslim patients may not wish to have physical contact with or expose their bodies to, the opposite sex. Muslims (both men and women) may be accustomed to being examined by a health care provider of their own gender, and if possible, this should be arranged. Women may be especially reluctant to be examined by a male health care provider for sexual or reproductive health matter because of the religion (Health Care Providers‘ Handbook on Muslim Patients, 2010 pg 10). A related study about Muslim women choice for the gender of obstetricians and gynaecologist in Turkey aimed to investigate the gender preference of Turkish Muslim women regarding obstetric/gynaecological, and identify other features that affect their choice. Surprisingly, only 5% women responded that the religious orders are important in their preference. However, the religious impacts on female obstetric/gynaecological preference in this study were found to be much less than the cultural effects (Bal, Yılmaz, Beji, & Uludağ, 2014). This suggests the need to research to know whether Ghanaian women preferred male or female nurses to inform decisions about training more male midwives. Another study explores the various religious practices and considerations for cancer treatment of Christian, Jewish, Islamic, and Buddhist individuals, and how health care providers can best care for these divers. It was found that when caring for a Buddhist cancer patient, it is suggested that the doctors and nurses caring for the patient be of the same gender, if possible to ensure comfort and satisfaction (Moore, 2014). This study investigated the various religions that people affiliate with and the beliefs and practices of such religions towards various health issues. It was shown that although the Christian religion is of much concern about the issue of modesty and decency, there is no religious objection about being nursed by a male or a female nurse. Therefore, the Christian religion does not influence the 27 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care choice of a nurses‘ gender in nursing care (Rumun, 2014). This also suggests the need to research to know whether the preference of patients in Ghana for male or female nurses is influenced by their religion to inform decision of practicing transcultural nursing in Ghana. Modesty has been described as one of the five pillars of the Islamic faith and includes restrictions on dress, privacy, and mention of anything related to bodily functions or direct body and eye contact with the opposite gender (Rashidi & Rajaram 2000). Within the Chinese culture, there are specific gender congruent norms in health care, such as women should be attended by women only. In addition, a Chinese American woman described modesty as a cultural value which prevents women from obtaining breast examinations and mammography. As a result, Chinese women are not comfortable being naked before a male provider. Orthodox Jewish women also have problems with being alone with the opposite gender (Andrews, 2011). Future research to explore modesty and relationships to health care is recommended in Ghana. The findings of a qualitative study by Norouzinia et al. 2016 showed that Iran is a multicultural country with recognized cultural pluralism. In Iranian religious context, nurses are not allowed to gaze or touch patients of the opposite-sex, except in emergency cases. It is considered as unethical. The reference of patients in Iran would be for same gender nurse because of the cultural norm. Another quantitative study by Bartfay, Bartfay, Chow, and Wu (2010) surveyed 149 male and female nursing and non-nursing students to investigate societal attitudes and perceptions towards men in nursing education revealed that there is a general perception in Canadian society that female nurses are more caring and compassionate in nature. Moreover, there are societal perceptions and stereotypes towards male nurses indicating that male nurses are gay, effeminate, less compassionate and caring than females. The above reasons may affect male nurses‘ interaction and relationship with patients and influence the choice of patients for their 28 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care nurse's gender in Canada (Stanley, 2012). Here, it may not be appropriate to generalize this finding to the other parts of the world since Canadian societal perceptions may defer from other societies in other parts of the world. Therefore, there is the need for a study in Ghana to know the perception of patients in Ghana on male and female nurses. Additionally, a research on attitudes of patients towards being cared for by male nurses in a Jamaican hospital by Adeyemi- Adelanwa, Barton-Gooden, Dawkins and Lindo (2016) using a descriptive, quantitative cross sectional study resulted that male nurses were perceived negatively by 51% of respondents as not suitable to provide intimate care and being effeminate and possibly gay. Although most participants reported positive interactions with the male nurses, there were reservations among 67% of participants in performing procedural bowel preparation with 80% of the male and 54% of female patients reporting that they would not allow a male nurse to give them an enema because it is not appropriate for a male nurse to provide such a care. However, only 10% had a negative perception of the care they received from male nurses. This indicates that patients generally had placed negative labels on male nurses without basis because Jamaica is an overwhelmingly homophobic society and this influence the preference of a male or a female nurse in Jamaica. A research is recommended to investigate the influence of Ghanaian cultural on patients‘ preference for their nurses. The purpose of a study by LaVeist & Carroll (2002) was to examine predictors of physician-patient race concordance and the effect of race concordance on patients' satisfaction with their primary physicians. More than 21% of African American patients reported having a preference for their physicians‘ gender than other races. They concluded that the race of a patient has much influence in the choice of a physician and the level of satisfaction. Janssen et al. (2012) 29 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care reported similarly that, nonwhite patients prefer a female gynaecologist–obstetrician more often compared to white patients. In a subgroup analysis of patient age and race as well as income and education levels by Johnson et al. (2005), there was no significant effect on patient gender preference. Patients‘ age, however, was significantly associated with patients' perceived levels of comfort during pelvic examinations. In addition, respondents who specified no gender preference for their obstetrician- gynaecologists while they were undergoing pelvic examinations were significantly older than respondents preferring female physicians. A quantitative study to compare gender, humanistic qualities or technical competence and age when an obstetrician-gynaecologist is selected was conducted by Schnatz, Murphy, O‘Sullivan, and Sorosky (2007). The study found that older patients were less likely to prefer a female gynaecologist as compared to younger patients. Preference towards the gender of the nurses was influenced by age, as younger women also preferred care from female nurses while those above 40 years of age had no preference for nurses based on their sex. Lastly, in another study, health and education agencies collaborated in a hospital‘s special school to ask children about intimate care, the boys generally expressed a preference for male carers and this was related to age. Older children were less comfortable. For younger children, female nurses were like mums to them (Randall & Hill, 2012). Research on patients‘ preference for nurses‘ gender relating to age is recommended in Ghana. 2.4 Effect of the gender preference of a nurse on the patient. A research exploring rural Ghanaian women‘s experiences of seeking reproductive health care aimed to describe rural women‘s perspectives on their experiences in seeking reproductive care from professional nurses. Findings indicated that many women recalled experiences in 30 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care which they were scolded for not seeking care earlier, for not practising birth control, or for asking questions. They were also threatened with treatment withdrawal or denial if they did not comply with instructions from nurses, and were treated ‗like children‘, ignored, and disrespected. The researchers noted that field observations confirmed participants‘ stories of nurses ignoring their preferences as well as their individual medical needs. This poor treatment occurred when women requested for their needs or demanded to be treated better (Yakong, Rush, Bassett-Smith, Bottorff, & Robinson, 2010). Another study by Moyer, Adongo, Aborigo, Hodgson and Engmann ( 2014) explored community and health-care providers‘ attitudes towards maltreatment during delivery in rural northern Ghana. Maltreatment was spontaneously described by all types of interview respondents in this community, suggesting that the problem is common and may dissuade some women from seeking facility delivery. Respondents reported that midwives and nurses shouted at women, insulted them, and spoke harshly to them when client demand for their rights. Respondents described labouring or recently delivered women being left alone or ignored. The health care providers also confirmed maltreatment during labour and delivery. Lack of accommodation of patients‘ religious and cultural beliefs as well as their preference for a nurse‘s gender can contribute to their reluctance in seeking care. In many cases, this means that patients will avoid seeing a healthcare provider until advanced stages of the disease, ultimately resulting in poorer outcomes and higher costs (Hasnain, Connell, Menon, & Tranmer, 2011). In addition, a study by Umar, Mandalazi, Jere, and Muula (2013) in Malawi explored the acceptability, by male clients, of female clinicians taking part in the circumcision procedure. Six focus group discussions were conducted, with a total of 47 newly circumcised men from non-circumcising ethnic groups in Malawi. The men had been circumcised at three health facilities in Lilongwe district in 2010. The majority of participants in the FGDs indicated 31 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care that they were not happy with female clinicians being part of the circumcising group. While few mentioned that they were not totally against female health providers‘ participation, arguing that their involvement was similar to male clinicians‘ involvement in child delivery. The participants‘ objections were based on two main reasons: (1) a potential negative outcome of the circumcision process due to a female nurse‘s presence leading to client distress, embarrassment and sexual undertone (2) the risk of female providers exposing client to their colleague females as men who had been circumcised and the consequent stigma they could suffer in the community. According to Sherman (2010), patients nursed by the opposite gender during intimate care and procedures become dissatisfied and uncomfortable, and as such may decide to avoid medical treatment. Secondly, most patients accept opposite gender intimate care without complaining, but that does not mean that they are not embarrassed. They do not complain because of fear of being victimized (Sherman, 2010). Additionally, patients who do not get their preferred nurse do encounter some dissatisfaction with health care (Schoenthaler, Allegrante, Chaplin, & Ogedegbe, 2012). Previous research work on children‘s perspectives on community children‘s nursing found that children may feel embarrassed at receiving care from a nurse of the opposite sex (Randall 2010). However, Johnson et al. (2005) revealed that 80.8% of their respondents felt that physician gender does not influence a patient preference and quality of care. Moreover, there was no statistical difference in patient satisfaction based on physician‘s gender. Janssen and Lagro-Janssen (2012) reported that after reviewing studies published in a period of 10 years about women seeking gynaecological/obstetrical care and physician‘s gender in relation to patient preferences, differences in communication style and patient satisfaction, the results were similar. Participants became more comfortable and relaxed when care was provided by a preferred gender of a provider. Another study done in the emergency department by Derose, 32 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care Hays, McCaffrey, and Baker (2001) concluded that women preferred female physicians more compared to male physicians and were more comfortable and satisfied when seen by a gender of a physician that is preferred. 2.5 Barriers associated with gender preference in nursing care This section reviews the literature on barriers associated with gender preference in nursing care. The literature is reviewed under four main topics and they have been discussed in paragraphs accordingly. These include: attitude of nurses as a barrier to a preferred nurses‘ gender in nursing care, hospital policy as a barrier to the preference of a nurses‘ gender, inadequate male nurses as a barrier to patients‘ preference for nurses‘ gender, and attitude of patients as a barrier to patients‘ preference for nurses‘ gender. A research that investigated the challenges for primary care in the age of the autonomous patient found that sometimes patients cannot make informed treatment choices because professional bias puts pressure on them. They might not want to interfere with the treatment, give reasons for their decision to their general Practitioner (GP), and fears they might have a conflict with them. Patients added that it feels like coercion and it seems health professionals use their power to influence patient choice and make a decision on behalf of the patients (Blennerhassett, 2007). Another research intends to promote the exchange of ideas and creative partnerships to ensure that right decision are made in preparing competent, adaptable and resourceful nurses who can contribute to health for all in the 21st century. They indicated that nurses are believed to have the notion that the patients are ignorant about their health problem and the cure needed. Additionally, the patient should be submissive and cooperative to the health provider. Moreover, some nurses trample upon patients‘ rights and treat them badly with the use of verbal abuse, foul language, violent and aggressive behaviour, unfriendly attitudes and 33 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care showing no empathy for the sick. The study showed that most patients are not able to communicate their problems and ask of their needs (Donkor & Andrews, 2011). Similarly, a cross-sectional study to determine the prevalence and pattern of disrespectful and abusive care during facility-based childbirth in Enugu, southeastern Nigeria revealed that 98.% of respondents reported at least one form of disrespectful and abusive care during their last childbirth. Non-consented services and physical abuse were the most common types of disrespectful and abusive care during facility-based childbirth, affecting 243 (54.5%) and 159 (35.7%) respondents, respectively. Non-dignified care was reported by 132 (29.6%) women, abandonment/neglect during childbirth by 130 (29.1%), non-confidential care by 116 (26.0%), detention in the health facility by 98 (22.0%), and discrimination by 89 (20.0%). The study concluded that disrespect and abuse during childbirth are highly prevalent in Enugu (Okafor, Ugwu, & Obi, 2015). A research on Nurses‘ stories about their interactions with patients at the Holy Family Hospital, Techiman, Ghana by Korsah (2011) indicated that most Ghanaians complain bitterly about the bad attitude of nurses during interactions with their clients and this remains a serious problem in Ghana. He further indicated that he has personally observed nurses who verbally abuse and intentionally neglect clients and their relatives in the hospital and this attitude affect nurse-patient interaction negatively therefore, perpetrators should be punished. Johnson et al. (2005) revealed in their study that 40.8% of patients stated that they usually do not have a choice as to the gender of their obstetrician-gynaecologists because all the physicians in the obstetric-gynaecologic units are of the same gender and also patients are randomly assigned to the next available physician. Among the 91 patients who reported usually not having a choice in selecting the gender of their obstetrician-gynaecologist, 73 responded to the follow-up question asking if they would like to have a choice. Of the 73 participants 34 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care responding to this follow-up question, 38 (52.1%) answered yes and 35 (47.9%) answered no. This necessitates the need to research into the reason why patients do not have a choice or are not given the chance to select the gender of their caregivers since the majority of the patients would like to have a choice. Another study examined patient preferences for doctors by using a set of questionnaire adapted from Kenyan patient‘s attitude regarding doctor ethnicity and doctor- patient ethnic discordance. It was found that patients who are less participatory during clinical consultations may have issues that needed to be addressed but are not because patients are not asked about their concerns. Moreover, there is also some issue about the lack of patient‘s right to choose the doctor they prefer at the facility (Haron & Brahim, 2012). Hasnain et al (2011) also emphasised that health service providers‘ lack the accommodation of cultural beliefs: especially modesty needs, for example, male provider performing intimate examinations without a female nurse or staff member present or making the patient sit in a revealing hospital gown for x-ray examination in open waiting area with male patients. Ghana experiences inadequate male nurses in the health sector as such patients who prefer a male nurse may not get one in nursing care (Aranda, Castillo-Mayén, & Montes-Berges, 2015). Moreover, according to Sherman (2010), there are situations where male nurses are not available to take care of intimate health issues confronting male patients as well as females who preferred male nurses. A study to explore issues surrounding recruitment, retention, and work life satisfaction for male nurses working in acute care settings resulted that men are underrepresented in nursing, accounting for less than 6% of Canadian nurses (Rajacich, Kane, Williston, & Cameron, 2013). The participants in this study indicated the imbalance between the number of men and women in nursing and how this affected the ability to provide intimate care. Participants acutely confirmed that there are few male nurses as compared with the female nurses in nursing 35 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care and that the reality of same gender nurse patient care delivery was impractical (Crossan & Mathew, 2013). Additionally, a study indicated that Intensive care unit, operating room, and emergency departments were seen as proper places for males to work after graduation by both genders. On the other hand, maternity and paediatric clinics were not seen as fit places for males to work. For that reason, male nurses were stationed to work in places like emergency departments, intensive care units and psychiatry and female nurses at the maternity and paediatric clinics. Therefore pregnant women and children who preferred male nurses may not get their preference when seeking care (Akansel, 2008). A study presents the findings of doctors‘ communication style and its implications on patients‘ participation at a Hematology Clinic in a General Hospital in Malaysia. From the analysis, it is evident that patients do interject their beliefs, preferences and perspectives during consultations and this is when assertion happens. The study found that being assertive was most difficult for patients as it appears to be in direct opposition to the sick role. Older patients in this study were also found to be particularly unassertive. The researchers concluded that older patients may still hold a conventional view of the doctor–patient relationship in which doctors are viewed as the experts and thus more knowledgeable (Harona & Ibrahima, 2013). 2.6 Perceptions of Patients on certain issues in Nursing Care. This section reviews the literature on perceptions of patients on certain issues in nursing care, an additional literature based on the other findings outside the construct of the model used in this study. The literature is reviewed under four topics and they have been discussed in paragraphs accordingly. These include qualities of a preferred nurse, perspective of patients; attitude of a bad nurse, participant‘s perspectives; stereotypes associated with nurses in Ghana and lastly, the need to increase the number of male nurses in the nursing profession. 36 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care An article by Brady (2009) presented findings from a qualitative study that explored views of the good nurse from the perspective of hospitalized children. Five themes relating to children‘s views of the good nurse emerged from the analysis: communication; professional competence; safety; professional appearance; and virtues. Health and education agencies collaborated in a hospital‘s special school to ask children what made a ‗good‘ nurse. Eleven children aged between 11 and 14 years took part and described the ‗good‘ nurse as: having a professional persona and the ability to connect with them, effective care and being respectful of children‘s dignity, trustworthy, look clean and smart, delivered timely, informed care in a humane, good sense of humour, laugh with them, talk to them, understands them, lets them be private, makes the bad stuff seem better, kind and thoughtful, cares about them and professional looking (Randall & Hill, 2012). Another study discusses findings from a mixed method literature review that investigated cancer patients‘ perceptions of what constitutes a good nurse. According to the patients, good nurses were shown to be characterized by specific but interrelated attitudes, skills, and knowledge; they engage in person-to-person relationships, respect the uniqueness of patients, and provide support. Professional and trained skills, as well as broad and specific nursing and non-nursing knowledge, are important. The analysis revealed that these characteristics nurtured patient well-being, which manifests as optimism, trust, hope, support, confirmation, safety, and comfort (Rchaidia, de Casterlé, De Blaeser & Gastmans, 2009). The aim of this qualitative research by de Araujo Sartorio & Pavone Zoboli (2010) with 18 nursing tutors at a university nursing school in Brazil was to identify the ethical image of nursing. In a semi structured interviews, the participants were asked to choose one of the several pictures, to justify their choice and explain what they meant by an ethical nurse. Five different perspectives were revealed: good nurses fulfil their duties correctly; they are proactive patient advocates; they 37 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care are prepared and available to welcome others as persons; they are talented, competent, and carry out professional duties excellently; and they combine authority with power sharing in patient care. Govender and Penn-Kekana (2008) emphasized that patient-provider interface has often been described by clients as discriminatory, marginalising, abusive and mirroring the social stratifications of society at large. The participants confirmed that this occurs in both developed and developing countries. The aim of the study by Haskins, Phakathi, Grant, and Horwood (2014) was to explore the attitudes of nurses towards patient care at a district hospital in KwaZulu-Natal, South Africa. The study adopted an exploratory, qualitative research paradigm. Purposive sampling was used to identify participants from two target populations; selection of nurses and patients. FGDs were used and transcribed verbatim. Both nurses and patients reported incidences of poor patient care and even willful neglect of patients‘ basic care, poor nursing care when patients were not helped to the toilet or being fed. The patient‘s food is normally placed on his table for the relatives to come and feed the patient. The participants described the behaviour of such nurses as terrible. A qualitative study was carried out and data were collected from May to July 2012 at a small Catholic hospital in the Central Region of Ghana. A total of ten women and seven midwives were interviewed. All participants were Ghanaian including seven midwives and ten women. At the end of the study, all the participants acknowledged the common practice of maltreatment during labor and delivery. Types of maltreatment described included midwives yelling, screaming, hitting, slapping, humiliating, and neglecting women all the participants indicated that these were common practice experience in Ghanaian hospitals during delivery and were described by participants as bad behaviour (Yakubu, Benyas, Emil, Amekah, Adanu, & Moyer, 2014). 38 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care In a research by Achora (2016) participants revealed that male nurses had a positive experience of being preferred over their female counterparts as providers of unique, quality nursing care by patients and other health professionals. Male nurses were reported as being approachable and trustworthy. The participants felt that they were capable of providing quality nursing care dismissing the stereotype that men cannot be nurses. However, it reflected in this study that the majority of patients and public in Uganda treated or referred to male nurses as doctors. This made some of them assume the doctor‘s position in health care delivery (Achora, 2016). In this study, ―has the traditional social perception on nurses changed? Attribution of stereotypes and gender roles‖ aimed to analyze gender stereotype and gender role assignment to male and female nurses. Results showed that the gender stereotypes assignment to male and female nurses displayed some similarities in Spain; therefore a less stereotypical perception was observed comparing with other recent research. Moreover, participants low in social dominance orientation indicated a preference to traditional gender roles. Considering the group they found a traditional assignment of gender stereotypes over female and male nurses, even among nursing students. They noted that, nursing in Spain has always been conditioned by a strong influence of the gender role division (Aranda, Castillo-Mayén, & Montes-Berges, 2015). Benalte- Marti (2015) also found that the relationship between nursing and women is so strong that there are even professionals in this sector who identify medicine with male stereotypes and nursing with female ones. Stanley et al. (2016) established a profile of men in nursing in Western Australia and explore the perception of men in nursing from the perspective of male and female nurses. The findings indicated that common misperceptions of men in nursing included: most male 39 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care nurses are gay; men are not suited to nursing and men are less caring and compassionate than women. In addition, nursing profession was performed exclusively by women and was considered an extension of their caregiver role, both circumstances make nursing a feminized profession. Kouta and Kaite (2011) aimed to reviewed articles to examine gender stereotypes in relation to men in nursing, discuss gender discrimination cases in nursing, and explore methods used for promoting equal educational opportunities during nursing studies. The literature reviewed showed that gender stereotypes still exist within the nursing profession that men are not suitable for the profession. The aim of this study was to determine what female and male undergraduate nursing students think of males in nursing in Turkey. Female nursing students agreed that by recruiting males into nursing profession; the quality of patient care will increase (31%) and negative perceptions of health care team about nursing will decrease (7 %). On the other hand, some of the male students (47.8 %) see physical power as solution for better patient care and 30.4% of the male students also reported that men will also improve negative perceptions of health care teams about nursing because men are typically seen as better leaders than women (Akansel, 2008). Another study found that positive action is needed to close the gender gap in nursing. He emphasized the need to re-educate high school counselors and students about the nursing profession and speak against the numerous stereotypes that have been placed on nurses (Meadus, 2000). The objective of this work was to describe the perceived or real barriers to men seeking a career in nursing and to suggest strategies for ameliorating barriers. The findings showed that there is the need to increase male nurses in nursing by exposing male students at a younger age to the diversity, and autonomy that nurse practitioners and clinical nurse specialists have achieved also help in recruitment targeting and generate interest in the work they perform 40 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care (Coleman, 2008). In addition, a comparative study was undertaken to assess the level of satisfaction with nursing care given by female and male staff nurses among the patients admitted in a selected hospital of New Delhi. The findings of the study revealed that the patients were highly satisfied with the nursing care component of the male staff nurses whereas the patients were highly satisfied with the nursing behavior component of the female staff nurses. The researcher concluded that male nurses, as well as female nurses, are doing their part toward the same goal of providing quality patient care, therefore, the need to increase the number of male nurses in nursing (James & Merlin, 2016). 2.7 Summary critique of the literature review The preference of patients for nurses‘ gender has been evaluated by qualitative and quantitative researchers, with varying preferences identified. Reasons leading to the gender preference for nurses identified by various studies pointed out that participants preferred same gender nurse for sensitive and intimate care procedures, male or female nurse not solely on physician gender but on physician attributes and qualities. For the benefits associated with the preference mainly highlighted on satisfaction with health outcome and the consequences being an embarrassment and lastly, barriers associated with the preference centred on the fact that patients are not asked for their preference when seeking care as well as the bad attitude of nurses that deter patients from requesting. Also, literature on the emerging themes identified that stereotypes associated with male nurses still exist in nursing, the good attitude of nurses improves patients‘ outcome of health and finally there are still a lot of bad nurses in the nursing profession. 41 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care In all the studies reviewed, most studies are from the western world, few from Sub- Saharan Africa. Secondly, it is interesting to know that it looks like there has not been any study in Ghana on the patient‘s preferences concerning nurses‘ gender though the widespread need for patient‘s satisfaction with health care is acknowledged. This indicates a gap and therefore the need to do this research work specifically, at the KATH, Ghana using a qualitative research approach. Filling this gap will be necessary to add to previous knowledge on the patient‘s preference for their nurses‘ gender and at length satisfy the needs of patients. Another gap in the literature exists regarding experiences of nurses on intimate care procedures, experiences of male nurses in the nursing profession and patients‘ perspective of a good nurse. The next chapter focuses on the methods used in this study. 42 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care CHAPTER THREE METHODS 3.0 Introduction This section of the thesis talks about how the study was conducted. It explains the research design and methods used to conduct the study. This included: research design, research setting, target population, sample size and technique, the procedure for data collection, data gathering tool, data analysis and data management. The chapter concludes with a presentation on methodological rigour and ethical considerations. 3.1 Research Design Research designs are defined as ‗‗types of designs of enquiry within qualitative, quantitative, and mixed methods approach that provide specific direction for procedures in a research design‘‘ (Creswell, 2014 p.12). In quantitative research designs, the researcher test a theory by specifying narrow hypothesis and the collection of data to support or refute the hypothesis and the information is analysed using statistical procedures and hypothesis testing. Qualitative research is a research approach for exploring and understanding the meaning individual or group ascribed to a social or a human problem and relies on the fact that knowledge about humans cannot be possible without describing the human experience as it is lived and defined by the actors themselves (Polit, Beck, & Hungler, 2001). This study employed and used an exploratory descriptive design to qualitative research. This design was appropriate for the study because patients have daily interactions with male and female nurses and therefore as individuals, they may have a preference for a particular gender of a nurse in nursing care. As such the use of an exploratory descriptive design to qualitative research enabled the researcher to explore understand and describe patient‘s preferences for nurses‘ gender in nursing care. 43 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care 3.2 Research Setting Participant recruitment and data collection took place at the Komfo Anokye Teaching Hospital (KATH) in Kumasi, Ghana. It is the second largest hospital in the country and the only tertiary health institution in the Ashanti Region. KATH is also known as Gee by the public and it is one of the autonomous and self-funded referral centre within the northern sector of Ghana which consists of the Ashanti, Northern, Brong Ahafo, Upper West and Upper East Regions. The hospital was built in 1954 as was known as Kumasi Central Hospital. It was later named Komfo Anokye Hospital after Okomfo Anokye, a legendary fetish priest of the Ashantis. It was converted into a teaching hospital in 1975 and was affiliated with the medical school of the Kwame Nkrumah University of Science and Technology. The hospital is also accredited for postgraduate training by the West African College of Surgeons in surgery, obstetrics and gynaecology, ophthalmology and radiology. The hospital currently has about 1000 beds, up from the initial 500 when it was first built. It caters for public cases only for people in the confines of Kumasi and also from other hospital in the confines of the northern sector in Ghana for further management. The hospital has clinical and non-clinical directorates which includes: Anaesthesia and Intensive Care Unit, Child Health, Dental, Eye, Ear, Nose and Throat, Diagnostics, Medical- Surgical blocks, Obstetrics &health care which could move the health system performance curve upwards. The setting was chosen because Kumasi metropolis is the most populous and most commercialised district in the Ashante Region. Also, the centrality of Kumasi as a nodal city with major arterial routes linking it to other parts of the country attracts high migrant number. Besides, the Ashante 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 patients from other parts of the country. 44 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care 3.3 Target population The target population consisted of all patients 18 years and above admitted to the medical and surgical adult wards of KATH for at least a week from January to March 2017 and before their discharge from the hospital. 3. 4 Inclusion criteria The research included both male and female patients admitted at the adult medical and surgical wards of KATH, not bed ridden or seriously ill and nursed by both female and male nurses. This ensured that only patients who have had much encounter with both female and male nurses and who could go through the interview without much stress on their health were recruited for the study. All participants were able to communicate in English or ―Twi‖. This is because the researcher speaks fluently in English and ―Twi‖. 3. 5 Exclusion criteria The research excluded patient aged below 18 and patients who did not consent to participate in the study. Also, seriously ill patients and patients unable to communicate in English or ―Twi‖ languages were excluded. 3.6 Sample size and sampling technique Sampling refers to the selection of a part of a group with the aim of collecting information and the part that represents the whole (Grove, Burn, & Grey, 2012). There are two main forms of sampling techniques namely probability and non- probability sampling. The non- probability sampling techniques include convenience, purposive, and quota (Smith, 2015). The purposive sampling technique was used to select the participants for this study. In this type of sampling technique the researcher intentionally draws a sample from the population that has the 45 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care qualities that is expected in the study and therefore members of the population do not have equal chance of being selected. Therefore the researcher selected the participants out of the different category of patients seeking care at the hospital. Since qualitative research does not aim for a statistically representative sample, the selected technique was deemed appropriate for the study. The purposive sampling technique was used because the participants selected were considered to have the characteristics believed appropriate for the study and from whom the needed data could be obtained. The researcher was introduced to the target population by the nurse managers of the various wards. She then made contact with the patients to gain their confident and trust, informed them about the study and consent sought from those willing to participate. The background and purpose of the study was explained, checked that the person met the inclusion criteria. Through this process, the researcher selected the participants by seeking their consent to participate in the study. Those who met the inclusion criteria and agreed to participate were provided with an information sheet and consent form to sign or thumbprint (Appendix C). The sampling size for the study depended on the data saturation when there was no new information forth coming during interviews with research participants. The data was saturated at the 14th participant. Seven (7) participants were interviewed from each of the wards before saturation was reached. In th th qualitative data, at the 12 to 15 respondent the researcher is believed to reach saturation (Latham, 2014). According to Fusch and Ness (2015), data saturation is reached when there is enough information to replicate the study and that sampling more data will not lead to more information related to the research questions. This is when almost all the research participants are saying the same thing. 46 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care 3.7 Data collection tool and procedure A semi-structured interview guide (Appendix B) was used to conduct a face to face interview to explore patients‘ preference for nurses‘ gender. Interviews are established method of data where the interviewer sits face to face with the participants and records the responses and able to check cross-check doubts with the participants (Seidman, 2013). A semi-structured interview was more appropriate for this study because it gave opportunity for participants to freely express their views about the phenomenon and also enabled the researcher to divert from the interview guide to seek for clarifications by using probes. The construction of a semi-structured interview was guided by the research objectives. Section A (Appendix A) of the background information form consisted of demographic information about participants while Section B consisted of interview guide with open ended questions and probes. The date, time and venue for the interview were decided according to the choice of the participants. Most of the interviews were conducted in a meeting room or 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. The participants were presented with the consent form to read, clarify any misunderstanding, and sign before the interview started. In addition, the researcher sought permission and recorded the interview with a digital recorder. The interview lasted for at most an hour and the questions focused on the most preferred gender of a nurse, the reason for the gender preference, the benefit to patient as a result of the preference, the challenges a patient face when a patient is not nursed by a preferred nurse and the barriers associated with gender preference in nursing care. All interviews were administered verbally in English 47 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care and / or ―Twi‖ languages as the researcher could fluently speak English and ―Twi‖. The interviews were later transcribed verbatim in English. There was no right or wrong answers and the researcher used probes to clarify, and summarize the comments and expressions of the participants.. The researcher also kept a field note. This was taken on context and behaviour of the researcher and the respondents, and included detailed information about the environment, gestures, the researcher‘s thoughts, feelings, moment of confusion, biases and interpretations. The respondents did not receive monetary compensation for their participation. However, all participants were offered a complimentary meal and beverage in the hospital cafeteria upon completion of the interview which served as a token to show appreciation for their time and contribution and the meals were not contraindicated to their condition. The respondents were informed that the researcher may return for clarification when the need arises. 3.8 Pre-testing of Data Collection Instrument Piloting of a research instrument helps in ensuring the efficacy of the instrument to collect the expected responses and also helps in modifying the instrument before it is administered to the respondents (Dawson, 2009). The semi-structured interview guide was pre- tested at the University of Ghana Hospital, Legon (Appendix F). This hospital was chosen for the pilot study because it has a medical and surgical ward and share similar characteristics as KATH wards. It also served as grounds for the researcher to develop her interviewing skills since she was employing this technique for the first time. All guiding interview questions were pretested using two participants and analysis of their responses were used to effect changes in the interview guide before it was administered to the main participants. Moreover, it was realized that the researcher used few probes, therefore, participants‘ information was scanty. The 48 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care researcher learned how to probe further in order to solicit information from participants after the pre-test. 3.9 Data Analysis Qualitative analysis refers to data analysis methods that use non numerical examination and interpretations of observations, for the purpose of discovering underlying meanings and patterns of relationships ((Babbie, 2005)). The data collection and the data analysis were done concurrently. The data were analysed using thematic content analysis, Braun, and Clarke (2006) approach. This approach involves a six-phase process namely: Familiarizing with the data, Generating initial codes, Searching for themes, Reviewing themes, Defining and naming themes, and Producing the report. The recorded interview was transcribed verbatim. The researcher familiarized herself with the data by reading over and over for several times and paid attention to details that captured her attention. Notes were made from the transcripts to identify phrases and sentences which captured the attention of the researcher. 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 then brought together during this process. Initial codes were generated by organizing the data into meaningful units. The generated codes were combined to form themes (Appendix E). 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. 49 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care 3.10 Methodological Rigour In qualitative research, the rigour of the study can be established by the trustworthiness of the study, that is the ability to infer that the conclusions drawn by the researcher is the true representation of the responses given by the respondents. Credibility, transferability, dependability, and confirmability have been identified as the major criteria for establishing trustworthiness in qualitative research (Lincoln & Guba, 1986). 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 first two interviews were coded independently by the researcher and the supervisor in order to identify similarities and disparities in order to make amends in the interview guide. The participants were assured of the confidentiality and anonymity of information provided therefore each participant was given a pseudonym. This made participants talk freely without fear because they believed their real names were not used for them to be identified. Transferability in a qualitative study is when the results could justifiably be applied to similar settings, group, or context (Plummer-D'Amato, 2008). To achieve transferability, the study sample must be adequate in size and sufficiently varied (Plummer-D'Amato, 2008). To ensure adequacy of sample size for the research study, the 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 appendix D). Also, vivid description of the 50 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care setting that is the medical and surgical ward of the KATH 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. Dependability determines whether the study can or cannot be replicated by another researcher (Long, 2014). 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. Also, the researcher identified correctly the themes and subthemes from the data. Confirmability is to ensure that the meanings of the data collected are not changed by the prejudices, knowledge, and experiences of the researcher (Gast & Ledford, 2014). Therefore, the researcher 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 researcher bracketed her thoughts and values on the study. Also, the participants‘ responses were recorded, transcribed verbatim and the themes that emerged were supported with direct quotations from the participants. 3. 11 Ethical Considerations Ethical clearance was sought and obtained from the Noguchi Memorial Institute for Medical Research (Appendix G) and Komfo Anokye Teaching Hospital Review Board (Appendices I and J) before data collection. An introductory letter was taken from the school of Nursing and Midwifery to KATH to seek permission to conduct the research. Also, permission was obtained from the ward in-charges of the medical and surgical wards of the KATH where participants were recruited. The purpose of the study was explained to the participants and their consents were obtained before they were recruited. The benefits and risks were explained to the 51 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care participants. It was further explained that the participants in the study were not exposed to any harm; however, if during the interview a participant becames emotional, the researcher would give the person a break to relax and put himself together before continuing with the interview. Moreover, the researcher would assist a participant to the ward for prompt medical or nursing care when the need arises in the course of the interview as the venue for the interviews were close to the ward and the nurses were mindful of such activity. Those who voluntarily accepted to participate were given the consent form to read and sign. The respondents were reminded that participation was not obligatory neither would it affect their health care or employment and that they might withdraw their participation at any time. Privacy was ensured during all the interviews as any identifiable information about the participants and the recorded tapes were kept in separate lockers and only the principal investigator and her two supervisors had access to the raw data. Data presented in the findings were anonymized by the use of identification codes and pseudonyms. 3.12 Data Storage and Management Data that is collected during the research is protected in order to maintain the confidentiality of the participants. Each participant was given a code depending on the ward he or she was admitted during recruitment. Pseudonyms were used to replace the codes after the interviews. A folder was created for each participant‘s response comprising of the transcribed interviews and the field notes. Also, the audiotapes, transcripts, and field notes were kept in a safe locker at the supervisors‘ office and separated from the demographic information and consent forms which could be assessed by the researcher and her supervisors only in order to avoid leakages. The raw data was stored in an external hard drive in order to guide against data loss. The data is being kept confidentially for five years until it is discarded. However, if it is 52 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care needed for further analysis, permission will be sought from the Institutional Review Boards of the Nugochi Memorial Institute for Medical Research at the University of Ghana and KATH. The following chapter presents the findings of the analysed data and it is in accordance with the identified themes. 53 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care CHAPTER FOUR PRESENTATION OF FINDINGS 4.0 Introduction This Chapter focuses on the findings of the data gathered from participants in this study. The study aimed to explore Patients‘ Preference for Nurses‘ Gender in Nursing Care at the Komfo Anokye Teaching Hospital, Kumasi. Five (5) main themes emerged from the data with twenty one (21) corresponding sub-themes. The main themes and the sub-themes have been presented and supported with their anonymized verbatim quotations from the participants. Four themes were generated in line with the objectives of the study and one additional theme generated through content analysis. The main themes that emerged were: Most preferred Gender in Nursing Care, Patients‘ Reasons for the Preference or no Preference for Nurses‘ Gender in Nursing Care, Effect of the Preference for Nurses‘ Gender, Barriers Associated with the Preference of a Nurse‘s Gender in Nursing Care and Perspectives of Patients on certain Issues in Nursing. The chapter is first centered on the demographic characteristics of participants in the study and this will be followed by the presentation of the themes identified. 4.1 Demographic Characteristics of Participants Fourteen participants (patients) admitted to the Adult Medical and Surgical Wards of the Komfo Anokye Teaching Hospital between January and March 2017 were sampled. Seven patients were interviewed from each department (Medical and Surgical Ward) 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 Ward. Each patient had spent at least a week on the ward. The ages of the participants ranged from 22 to 79 years: four (4) were between the ages of 22-29 years, another four (4) participants were between the ages of 30- 54 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care 39, two (2) aged between 40-49 years, one (1) participant was 51 years, while two (2) participants were between the ages of 60-69 and lastly, one (1) participant was of age 72. Seven (7) females and seven (7) males participated in the study before saturation was reached. With educational level, almost all the respondents with the exception of two had formal education. Two (2) were primary school leavers, two Junior High School leavers, three Senior High School leavers. One was a middle school leaver, two were degree holders and two masters holders. Seven (7) were Akans, two (2) Ewes, one (1) Ga, one (1) Bulsa, one (1) Dagomba and two (2) from the Kussase tribe. All the participants were Ghanaians. In relation to the religious background, eight (8) out of the fourteen (14) participants were Christians, two (2) were Traditionalist and four (4) were Muslims. Eight (8) out of fourteen (14) were married, five (5) were single, and one (1) was widowed. Saturation was reached at the fourteenth participant. The general profile of the participants had been presented as Appendix D. 4.2 Most Preferred Gender in Nursing Care. This theme focuses on the choice of the gender of a nurse that is preferred by patients during nursing care. To answer the first research question – What gender of a nurse do patients‘ prefer when receiving nursing care? Three 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. 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. 55 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care 4.2.1 Patients’ Preference for Male Nurses in Nursing Care. Three (3) males and one (1) female indicated their preference for a male nurse due to 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 who is energetic, hardworking and skilful in the management of procedures involving machines”- Ekow. A participant added that female nurses often get weaker as they age than male nurses. “I may be indifference but will prefer a male nurse who is smart and hardworking…. They were very, very smart in movement, compared to the women sometimes age and everything tells on them but the men are very healthy” - Dorothy. In a less straight forward 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 (3) of them including the 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” –Agyarko. “I will prefer a male nurse but not in all instances”- Blazu. 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. 56 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care 4.2.2 Patients’ Preference for Female Nurses in Nursing Care. Three (3) females and two (2) males out of the fourteen (14) participants boldly indicated that they preferred elderly female nurses and young beautiful nurses to take care of them when ill. 4.2.2.1 Patients’ Preference for Elderly Female Nurse in Nursing Care 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…” - John 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” – Comfort. “I prefer the female nurse especially the elderly once, they are more respectful…For me I take the elderly female nurse as my mother because they also have children” – Kweku. From participants‘ voices, elderly female nurses have the natural tendency to render proper nursing care to patients because of the care given role of elderly females in the society. 4.2.2.2 Preference of Young and Beautiful Nurses in Nursing Care However, a male participant revealed that he always preferred a female nurse who is young and attractive. He said that with smiles on his face. “I prefer young, beautiful nurses…I would like to see beautiful ladies with nice faces and converse with them” - Ekow. 57 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care According to the participant, it appears that being nursed by a young good- looking female nurse makes him relaxed and relieved of his illness. 4.2.3 Patients with no Preference for a Particular Gender of a Nurse in Nursing Care. This subtheme 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 (5) participants firmly indicated that no matter the situation they were indifference. Firstly, they disclosed that the gender of a nurse does not determine the attitude of a nurse that is, whether a nurse will be good to you or not. They preferred any gender of a nurse with the characteristics such as ‗nice and good‟. “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” –Obeng.‘ “It will be difficult to have a preferred gender …because some female nurses are good and others are bad and the same goes for male nurses. But I only want a good nurse” – Comfort. Likewise, a participant said this with full of confidence: “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 it is a radiologist or a nurse or a doctor if they are nice they are nice, if they are not nice they are not nice” – Nanama. Secondly, other participants indicated that when a nurse is assigned to take care of patients it shows the nurse is a professional, capable 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. 58 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care “When the nurse is a professional the gender will not be considered, she will be able to render proper care”- Comfort. “As long as both male and female nurses have been trained they will be able to render proper care to patients”_ Kweku. “I will not have a problem with any gender of a nurse if the person has been trained and have the license as a nurse” - Aseda. However, two (2) other male participants also confirmed that they did not care about the gender of a nurse who takes care of them but had an alternate preference of a male nurse when asked to choose or when the procedure involves exposure of privacy. Moreover, one (1) participant preferred different gender for different procedures. Two of the participants had this to say: “I will prefer a male nurse when the procedure is intimate but will be indifferent with other procedures” – Aboagye. “I have a preference for female nurses for the care activities and male nurses for energetic procedures such as lifting”- Aseda. It appears that the gender of a nurse is not so much important to most patients but rather most patients look out for qualities of nurses to determine their preference of a nurse only when procedures are intimate. 4.3 Patients’ Reasons for the Preference or No Preference for Nurses’ Gender in Nursing Care. One of the major themes identified is the reason for the preference of a gender of a nurse for a nursing care. To answer the research question, what determines the reasons for preferring a particular gender of a nurse in nursing care? As many as seven (7) sub-themes emerged from this theme. These included: Patients‘ Gender as a Reason for the preference of the gender of a nurse in nursing care, Patients‘ Patients‘ Preference based on Past Experiences, Situation as a determinant for Patients‘ Preference for Nurses‘ Gender, Qualities of a nurse not Gender as a 59 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care determinant for Patients‘ Preference in Nursing Care, Personal interest as a determinant for Patients‘ Preference for nurses‘ Gender in Nursing care, Religion as a factor in patients‘ preference for Nurses Gender and Cultural factors as a determinant for the preference of a Nurses‘ Gender for Nursing Care. 4.3.1 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. 4.3.1.1 Patients’ Reasons for Preference of the same Gender in Nursing Care First, 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 also ask questions because they understand them better than the opposite gender. “It feels more comfortable …It is easier to talk to them about several things than the opposite gender. Like, say menstrual cramps. It feels like they understand you better because they also experience it” - Linda. “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, they understand my emotions … I will find it difficult to ask male nurses questions” - Augusta. A male participant in the similar vein narrated it this way: “You can communicate effectively with the same gender than the opposite gender. And he will understand you better and will be able to educate you better than a female nurse so that gives you a lot of satisfaction” - Agyarko. 60 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care In a whole, most participants feel at ease and delighted to be nursed by a nurse with the same gender because they naturally identify with them. Secondly, some of them indicated that they preferred a nurse of the same gender because there was little or no shyness with the same gender. They were relaxed during procedures requiring them to talk about sensitive issues or expose the nakedness of the body when the same gender was providing the care. One of them stated: “Because he is of the same gender, you feel relaxed and comfortable and there will be no embarrassment during intimate procedures” - Kweku. Another man had this to say: “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” - Obeng. Generally, sensitive issues and intimate touches may require the gender of a nurse same as the patient to ensure privacy and reduce embarrassment as well as shyness. 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 is nervous in 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 loose and remove. But the male nurse took his time to clean around the scrotum and the penis and bandaged them properly” - Agyarko. The view of the participant seems to suggest that nurses may feel embarrassed when providing care that requires exposing of the genitalia of patients of the opposite gender. 61 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care 4.3.1.2 Participants’ Reasons for Preference of the Opposite Gender in Nursing Care. Participants who preferred the opposite gender for nursing care were all males. One indicated that by the nature of his work he hardly comes in contact with 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 my nature of work, I come in touch with women very few times…I would like to see beautiful ladies with nice faces converse with them and go home. Also when female nurses touch you or hold any part of your body it serves as a massaging point communicating with your body and sending chemical messages, positive once so that it can enhance the healing of the body” –Ekow. According to the participant, it appears that some male patients derive satisfaction from female nurses because of opposite gender attraction. Also, the reason for preferring the opposite gender according to another patient was that the 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…” -John. 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. In response to a question posed to male participants who preferred the opposite gender about whether they do not feel shy before the nurse of the opposite gender, this was an expression from one of them: “The female nurse is a woman and therefore a mother. My mother and my sisters take care of me when I am not well, they assist me to do everything that I need to 62 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care do so when I come to the hospital I see the female nurses as my sisters and my mother” – John. Male participants mostly do not feel shy before the opposite gender when naked because they see the female nurses as their mothers and sisters. However, a female participant shared her experience that relating to the opposite gender was not easy due to opposite gender attraction because you cannot tell the psychological impact of your 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” - Augusta. This seems to imply that it would be difficult to relate to the opposite gender, there may be tension on the part of both the nurse and the patient. 4.3.2 Patients’ Preference based on Past Experiences This section looks at experiences that participants have learnt, observed and known about nurses, sickness, hospitals, and life before and during the present admission. They specifically noted that the experience with sickness and nurses are the reasons for preferring a particular gender of a nurse than the other. 4.3.2.1 Patients’ Preference based on Experience with Sickness. (“Recovery from illness matters and not choice of gender of nurses”) It was identified that those who had so much experience with sickness and hospital do not have a preference for nurses gender in nursing care but what matters to them was getting a good care from any gender of a nurse in order to recover. They have battled with sickness and moving from one hospital to another so much that getting healed was what was most important to them 63 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care and not the gender of a nurse. They have also been handled by both genders of nurses so many times that they have become familiar with them. Additionally, they were never worried about what they will go through or how they were being taken care of, what concerned them was the ultimate of getting better. A participant expressed her emotions below: “I am indifferent to whoever takes care of me. Because I have gone through the hands of a lot of doctors and there have been situations that I have been so sick that even if someone saw me naked I really wasn‟t bothered. The only thing that mattered was being taken care of so for me I don‟t think I would mind so far as you are giving me a good care that would be ok” -Dorothy. Another participant sadly emphasized that he had battled so much with his condition and had been going to different places in search for healing. So he was not bothered with the gender of the nurse to takes care of him or the kind of medication being given to him, even if it was obnoxious to taste and will make him recover he would take it, all he wanted was to get healed. “I have been to so many places because I have a chronic condition. I have taken a lot of concoctions, some taste nauseating like blood, others like faeces, some smell like urine and others are tasteless but I had to drink in order to get cured. But all these medications didn‟t help me. When I visited the hospital my prayer was that I will get well. Any drug that will make me recover I will take it even if it is sand or faeces and will make me get better I will not hesitate to take it. The gender of a nurse is not important to me” – Agyarko. Furthermore, a participant who had moved from hospital to hospital because of his condition lamented that even if it was an inanimate object providing the nursing care he would not complain because all he wanted was his healing. “When my condition started, I was taken to several hospitals ... three of them but the doctors said my condition was beyond them before referring me to this hospital. Getting a bed at this hospital was difficult, it took me two days. I am here to get healed so if it is a machine, a robot, a white woman or whoever is taking care of me I don‟t care my aim is to get healed and that is what concerns me” – Comfort. 64 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care The above explanation seems to imply that the health of most participants is their priority not the gender of a nurse. They could easily adjust to their preference for nurses‘ gender in their care. Moreover, their expressions depict that they were like beggars who had no rights or power to request or complain about their needs because they have suffered a lot with sickness. In addition, suffering makes one humble and tolerating and subsequently appeals for quality care. 4.3.2.2 Patients’ Preference based on Past Experiences with Nurses Some participants noted that from their past experience with an attitude of nurses, female nurses were more patience and had time for patients especially the elderly ones. They also treat patients with respect and sympathy, unlike the male nurses who do not have time for patients. Two participants had this to say: “The female nurses have more patience than the male nurses, especially the old women they have respect for patients. You will be in your room and they will come and knock asking, please are you calling me?” – Comfort. “Secondly the females are tender in their care, they take their time during procedures. They do the work from their heart and not as the men” - Ekow. A male participant added that when his wife went to the hospital for delivery the female nurses were attentive and empathetic with her. This is what he said: “The female nurses have patience and time to find out what is wrong with you and attend to your needs. However, the male nurses do not have enough time for you. When my wife went to the hospital to deliver the nurses had so much time for her and treated her with respect and compassion” - John. Moreover, a female indicated that apart from the fact that the male patients do not give much attention to patients they always look serious and hastens during procedures. She noted: “That is not the only reason o. the female nurses also have time for me, the male nurses are always serious and in a hurry to finish procedures” - Happy. 65 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care From participants‘ opinion, it seems female nurses are recognized as better nurses than male nurses because they are more patients and attentive during nursing procedures. However, a participant established that both genders of nurses are equally good and can help patients get better. It depends on the persons‘ qualities and capabilities, not the gender. “Both male and female nurses when they take care of me I will get my healing and be happy. I am able to communicate well with them and they also assist me when I am in need” - Kweku. A participant expanded on the above expressions as follows: “I have experienced both male and female nurses and almost in all situations, it depends on the person‟s behaviour and not the gender” - Dorothy. A participant revealed that as much as he has observed that gender does not determine a good nurse and a bad nurse he has also observed that human character is unstable, it depends on the sentiment of the person at the time of interaction. Someone can be good to you today and be bad to you the next moment so there is no need to prefer any gender in nursing care. “A nurse can be good to you today because she is in a good mood but the next day his mood will 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” - Comfort. 4.3.3 Situation as a Determinant for Patients’ Preference for Nurses’ Gender The situation as a determinant for Patients‘ Preference for Nurses‘ Gender was also a sub theme found under the theme, Reason for the preference of the gender of a nurse in nursing care. Participants pointed out that the reason behind their choice of a preferred nurse was due to the condition on admission and the type of procedure they were receiving at the hospital. 66 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care 4.3.3.1 Condition of the patient as a determinant for Patients’ Preference for Nurses’ Gender 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 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?” –Kweku. 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” - Comfort. “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” - Aboagye. 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 and not the choice of nurses gender in nursing care. 67 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care 4.3.3.2 Type of Procedure as a Determinant for Patients’ Preference for Nurses’ Gender Procedures that expose the private parts and discussions about sensitive issues were considered by participants as what needed privacy. Generally, participants indicated that it unethical to give care that involves touching of sensitive parts of the body and exposing of the nakedness of the body to the opposite gender. However, males seemed not to have many problems with that as compared to the female. Patients indicated that they will not feel comfortable for the opposite gender to provide intimate care for them. Secondly, they revealed that they will feel shy being naked before the opposite gender. Participants, however, confirmed that they will be indifferent with the gender of a nurse when procedures are non-intimate like administration of tablets and education of a patient on condition. An elderly woman and a young man expressed their feelings below: “I will not feel comfortable for a male nurse to change my pampers, I will feel shy. I will have no problem with procedures like serving of tablets” -Aseda. “In terms of privacy, I would prefer a male nurse because I will feel shy before a female nurse when I am naked. When procedures are not too close, any gender will be accepted” -Agyarko. A participant added that she will feel shy to discuss issues pertaining to the private parts with the opposite gender. “I will feel very, very shy for a male nurse to remove my cloths and give me a bed bath. Procedures like Intra muscular injection if a female nurse is available they should allow her to do it and not a male nurse. I cannot tell them… things that pertain to the private parts and also like menstrual problems” – Happy. According to the participants, issues of privacy may be very paramount to every individual and it is to be respected. 68 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care In contrast, some participants reported that although they were careful and would not like to expose the nakedness to other people, it was different when they were seeking medical care. They would not mind being attended by the opposite gender of a nurse because their wellbeing and recovery were most important to them than any other thing at the moment of illness. This is what a lady said: “…If only you are not sick but if you are sick you are sick and you shouldn‟t be thinking about who is watching whatever on your body. You should be concern about getting well that should be the ultimate so I believe if the nurse is touching you somewhere that in the normal case it would have been an excitement that excitement shouldn‟t be there when you are sick‟‟ – Dorothy. Another female patient boldly said that: “I don‟t mind being naked. I see it that in a situation where you need medical help being picky wouldn‟t help especially where you are in a situation that only male nurses are available it wouldn‟t be of benefit to you” – Nanama. Moreover, it is not wrong for nurses to provide 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 but 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‖ – Nanama. Another participant established that it will be appropriate if the patient is unconscious or unable to help himself. “If the patient is helpless there should be no problem but if the person is able procedures that are intimate should be done by the gender of a nurse same as the patient” – Obeng. 69 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care From the above, every individual may have his or her preference concerning the nurses‘ gender. Some people may adjust easily to situations while others may not. Some participants worriedly narrated that it is not a best practice for male nurses to be involved in procedures that expose the nakedness of female patients. It is bad and can lead male nurses to immorality. “That is very bad. I think procedures that will expose the female patients should be done by female nurses. That can lead the male nurses to sinful acts” – Obeng. “Since it‟s a guy opposite sex has tendencies of attracting so by seeing or by touching it sparks up little fire”- Augusta. A participant further indicated that it is forbidden for a male to do toileting for a female patient. “It is not advisable for a man to clean the private part of a woman, it is non- ethical and it should not happen at all. A male is sexually weak and may not be able to control himself” - Agyarko. In the same way, two participants told their stories and requested that there should be a chaperone to serve as a witness. “Also it is advisable to have a third person to serve as a witness because some people are seriously uncomfortable especially the Muslim women. My sister was advised to see a gynaecologist last two years. She has not been able to receive treatment because anytime she goes to the hospital the gynaecologist is a male” – Comfort. “This leads to a situation where the male nurses chase women (patients) and use them anyhow. You know men are weak when it comes to sexual feeling, most men are not able to control themselves. If anything at all there should be a female assistant to witness” – John. A male participant aggressively said that he would not take it lightly for a male nurse to provide intimate care for the wife or the sister. 70 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care “It is not good for a male nurse to provide intimate care for a woman (he said that whiles shaking his head). I will not be happy for another man to see the nakedness of my wife or even my sister who is not married. I believe a woman should keep herself for her husband” -John. Another participant suggested that a law should be passed to prevent against male nurses providing intimate care for females. “I suggest that there should be a law in every hospital that no male should provide intimate care for a female patient and no female nurse should also provide intimate care for a male patient unless there is no same gender nurse available‖ – Happy. From participants‘ responses, it looks like most participants would be comfortable to be nursed by the same gender nurse when procedures involve intimate care. A number of the patients, however, indicated that it is not wrong for a female nurse to care for male patients because the female nurse is like a mother to the male patients. “It will not be shyness for me because I was born by a female, and the same female raised me up so if I am not well and this same female will have to take care of me there is nothing wrong with it. For me I take the female nurses as my mother so I don‟t feel shy before them.” -Kweku. “There is nothing wrong with that. The female nurse is a woman and therefore a mother so I don‟t see anything wrong with them providing intimate care for me” - John. One participant added that it would be right to ask patients of their preference, though it is not bad to be nursed by both genders of nurses. “It is not bad in my case but I think it will be nice to ask patients about their preferred gender of a nurse especially in certain procedures like injections, catheters, and bedpans‖ –Nanama. A female participant ironically added that naturally, the majority of males prefer female nurses for intimate procedures because they gain satisfaction from them. 71 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care “Males in general prefer women taking care of them and wouldn‟t mine especially if the female nurse is beautiful they wouldn‟t mine at all. That is natural, males are attracted to females. So I think it is ok” – Aseda. Another participant explained that female nurses providing intimate care procedures for male patients can also lead to sexual undertone. “You have reminded me of what happened here yesterday. The male patient at the extreme end of the left side was very aggressive insisting he will sleep with a female nurse after giving him a bed bath”-Obeng. The above stories give the impression that male patients‘ preference for same gender nurses for intimate care procedures is not as strong as that of female patients. In addition to the above, some participants indicated that when the procedure involves much energy and technical competency they would prefer a male nurse and a female nurse would be preferred for the caring activities. “If the procedure involves lifting, turning and pushing or the use of a machine I will prefer a male nurse but I prefer a female nurse for the other nursing activities” – Aseda. Similarly, a male participant had this to say: “I prefer a female nurse, but the advantage with the male nurse is that assuming you are unconscious and you need to be turned or lifted they can do that easily. The male nurses should be engaged in physical movement and lifting heavy patients whereas the female nurses should be engaged in caring activities” - Ekow. Nursing profession will be best with both male and female nurses to ensure proper and effective service to our patients since patients have preference for both male and female nurses in diverse situations. 72 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care 4.3.4 Qualities of the Nurse not Gender as a Determinant for Patients’ Preference 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 qualities of a nurse because that differentiate a good nurse from a bad 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” - Dorothy. Additionally, the participants noted that a nurse with good qualities exhibit characteristics such as caring, attentive, patience, encourage patients, have a cheerful face and shows concern for patients. “The things that I will look out for in a good nurse are not gender based. …Someone who is tolerance, 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” – Nanama. A male patient also added his opinion that: “That is the main thing I look for (qualities of a nurse) other than the gender. I prefer a nurse who smiles, have time for me and encourages me all the time to give me hope in life” - Obeng. 4.3.5 Personal Interest as a Determinant for Patients’ Preference for nurses’ Gender in Nursing Care. Firstly, participants disclosed that their preference for a gender of a nurse was influenced by their personal interest and attitude. Their personality and attitude towards life events determined the choices they make in life. 73 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care The participants emphasized that their preference for a nurse‘s gender were mainly due to individual preference, their likes, and dislikes and their way of living. What will help them recover and not due to the collective decision. Below is a response from a Christian participant: “It is about my personal interest and not my Religion, I want to get well and go home”- Linda. A patient belonging to the traditional Religion had this to say: “Though my Culture says that I should be modest I am happy when I am nursed by a female nurse. They are more caring”- John. They further explained that they normally accept whatever comes their way without complaining and were not demanding as well. This has been narrated below by three participants: “I was brought up to accept whatever I am given and not complain because it can turn out to be good” – Agyarko. “In my personal life, I am not that demanding, I mostly accept situations as they come and adjust to them” – Comfort. “My personality, I accept whatever comes my way” – Obeng. In addition, they revealed that their principles, life focus and their concept about life influenced their preference for a nurses‘ gender. “My life focus, my focus is always on my health” – Aboagye. “My principles and my values in life have influenced my choice” - Kweku. One participant confidently expressed herself as follows: “…my personality and my concept about life, I have always wanted my health back and I feel my life is the most important thing. So if you are given it to me no matter the situation I just want it so I wouldn‟t trade my health for gender. No way (she said it boldly)” – Dorothy. 74 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care 4.3.6 Religion as a Factor in patients’ preference for Nurses Gender When participants were asked about their religious influence on their preference for a nurse‘s gender in nursing care the Muslims emphasized that although the Muslim religion does not encourage males to touch or look at a female‘s body and vice versa, they were not restricted when it comes to nursing care because it would not be intentional it would be because they were ill and seeking medical care so God will understand and forgive them. However, all the Muslims indicated that they would have preferred the same gender if they were given the chance to choose because of occasional guilt feelings and religious conflict though they knew God will forgive them. This is explained by a female Muslim: “The Quran does not allow that (being naked before the opposite gender) but no. if you are sick you should accept whoever comes to give you help and you shouldn‟t reject a male or a female nurse” -Comfort. Another Muslim narrated that: “ok being a Muslim the Quran says that if you are a female you shouldn‟t allow a male to see your nakedness …when I am admitted to a hospital and I have no option it is not a sin because God knows it is not my making ”- Happy. This Muslim had this to add: “Even the religion does not allow males to shake hands with the female. The female skin is soft and is like a magnet it can attract you to sin. So it would have been better for you to put your hands into fire than to greet or touch a woman, she will lead you to sin … So you should accept every gender available to help you and when you recover and go home you ask for forgiveness. God knows it is not your fault and will forgive you‖ - Blazu. The Muslim participants did not allow their religious obligations to empower their self-interest. They made a decision about a preferred gender of a nurse based on their personal interest and welfare. 75 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care Some Christians and Muslims among the participants also expressed that they were not worried because it was sinful or restricted by their religion on the preference of a male or female nurse for nursing care but they are expected to keep their body and not supposed to expose it to people who are not their partner. Therefore, the reason for their preference was mainly due to their personal interest, comfort, and wellbeing. That is, what will help them recover and not due to the religious or collective decision. Three of them had this to say: “I am not worried that it is a sin but for me feeling shy and uncomfortable is my problem” - Happy. “It is just about how comfortable I feel. My religion doesn‟t come in. I don‟t know but just because the person is a male I feel bad because it is not supposed to happen that way. The person is not my husband and the bible teaches us to preserve our bodies as the temple of God. In addition, the breast is one of the sensitive parts of the body” – Linda. I believe every nurse assigned to me is knowledgeable... no…I concentrate on what will make me get better and not my religion” Comfort. In addition, a participant with the traditional religion faith indicated: “No, my religion does not restrict a male or a female nurse from taking care of me. It is not all diseases that you take to the gods or the fetish priests, it is only spiritual diseases like curses that are handled by the gods” – John. Most of the participants were not influenced by their Religion but were influenced by their own interest and desire in the gender of the nurse or the outcome of their preference. 4.3.7 Cultural Factors as a Determinant for the Preference of a Nurses’ Gender in Nursing Care Participants indicated that their preference for nurses‘ gender was as a result of their cultural background. The Ghanaian African culture does not allow people (male and female) to see the nakedness of the opposite gender because of issues of morality. It is unethical, especially for a 76 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care male to see the nakedness of a female she is not married to in the Ghanaian culture and it does not show respect and sanity. “It is not respectful and polite to see the nakedness of an elderly woman who can be your mother. There is some part of a woman that is, her breast and perineum when she is not your wife our Ghanaian culture does not permit you to see” - Aboagye. “My culture (Ghanaian culture) does not allow me to easily expose myself before a female so I am careful …” -Ekow. A participant explained that since patients have not been given the chance to be choosing their preferred nurses‘ it wouldn‘t make a difference to have a male or a female nurse to provide nursing care. In addition, having choices have not been part of the practice of patients as such it is not so important for patients to worry about. They have been tolerant for a very long time and so were indifferent. Furthermore, some people in the Ghanaian setting have been brought up not to have choices, they accept whatever is given to them without complaining. Moreover, there used to be elderly nurses so the elderly patients will not be comfortable with the young nurses. “I have always lived in a setting where we have not had choices of male or female nurses so why am I now going to be worried about it. And why should it be a problem now? In our homes, some people have not been brought up to have choices so whatever they put on the table for you, you eat so far as it won‟t kill you. So why now I am sick and I say I want this gender of a nurse. No”-Comfort. A participant further indicated that she feels the elderly men will have trouble with nurses‘ gender as well as young nurses and young doctors because they were used to old nurses and doctors even she herself and do not feel secure in their hands though some of them are doing well. “I think the elderly ones especially the old men will have a problem. You know in the olden days we have always had adult nurses. It is just recently we see very, very young nurses, young doctors and they really don‟t like it even I really don‟t 77 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care like very young doctors. I don‟t feel very safe in their hands. I hear some of them are very good but I prefer an old one with some gray hair taken care of me than a very small, young doctor. No, she laughed” - Dorothy. Preference of patients for nurses‘ gender may be influenced by preconceived mind on the nurses‘ gender because of cultural norms and obligations that abound in our society. 4.4 Effect of the Preference for Nurses’ Gender in Nursing Care. This theme evaluates the consequences of taking possible actions, the benefits, or mainly the effect of preferring a particular gender of a nurse or any gender of a nurse. To answer the research question, of what effect is gender preference of a nurse to a patient? Three (3) subthemes emerged. They were: effect of asking for a preferred gender of a nurse for nursing care, the effect of not getting a preferred gender of a nurse for nursing care and benefit of getting a preferred gender of a nurse for nursing care. 4.4.1 Effect of Asking for a Preferred Gender of a Nurse in Nursing Care. The experience of patients at the hospital on the outcome of asking for their preferred gender of a nurse has been narrated by participants below. Some narrated that in Ghana, patients do not have choices and the hospital does not accept patients‘ choices as such if they request for a particular gender of a nurse, they will be treated badly. This was what a participant said: “If you insist on your preference you may be ignored, neglected or embarrassed by the nurses” – Aboagye. A participant strongly added that you cannot talk about the preference of patients in Ghana because no one will listen to you. “Yes in Ghana you don‟t have a choice if you are a patient. Preference for patients in Ghana? Oh stop and don‟t even mention it. They will insult you…” – Comfort. 78 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care In addition, the nurses will tell you not to protest and accept any gender if you want your condition to improve. “The hospital will not accept your suggestion. The nurses will ask you „‟Asomasi, ( man) did you come to the hospital because you are sick and want your healing‟‟? you will respond yes and they will continue if you want to recover then go to your bed and allow us to help you. Whoever comes to nurse you accept him/her, don‟t complain” – Kweku. It looks like the rights of the patient are being violated because patients‘ are denied their right of choice in the hospital. 4.4.2 Effect of Not Getting a Preferred Gender of a Nurse in Nursing Care. Participants expressed that they do have a negative outcome (psychological and physical effect) when they do not get a preferred gender of a nurse in nursing care. Others, however, indicated that they were not affected in any way by the gender of a nurse who provided care for them. 4.4.2.1 Psychological Effect Associated with Not Getting a Preferred Gender of a Nurse in Nursing Care The psychological effect associated with not getting a preferred gender of a nurse to care for patients were: „not feeling happy and satisfied, feeling shy and uncomfortable, and feeling angry and guilty‟. This is how two participants verbalized it: I mostly feel shy and uncomfortable before a female nurse” -Blazu. “I became shy and occasionally angry and feels guilty” – Aboagye. A male participant angrily had this to add: I didn‟t feel happy and satisfied as the other day when a male nurse dressed my wound… it wasn‟t well done” – Agyarko. 79 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care A young female lamented her story about the checking of her blood pressure: “Sometimes it feels uncomfortable when they (male nurses) are checking your BP, the persons‟ hand might hit your breast. But you cannot complain about it... Yeah, I feel so bad about it so sometimes I try to raise my hand higher and in a situation that I forget the persons‟ hand hit my breast and I feel uncomfortable” - Linda. From the views of participants, getting a preferred gender in nursing care helps them achieve quality nursing care because they derive maximum satisfaction from it emotionally. 4.4.2.2 Physical Effect Associated with Not Getting a Preferred Gender of a Nurse in Nursing Care According to participants, the physical effects associated with not getting a preferred gender of a nurse in nursing care included: ‗forcing discharge, refusing treatment, go to another hospital, prolong stay at the hospital, increase in hospital bills, refusing to seek medical treatment and not able to ask questions‘ A participant expressed her opinion that: “It has some physical effect on the person. You just want to leave the hospital even though you are not well. If the person is not comfortable he might refuse treatment or maybe go to another hospital. Or request to be discharged to go home”- Linda. This participant was upset and lamented that her prolong stay at the hospital was associated with the fact that he did not get the preferred nurse to dress her wound, as a result, he incurred a lot of costs associated with prolonging hospital stay. He narrated it below: “It is that male nurse who caused the problem of the secondary suturing and my prolong stay at the hospital which was also associated with cost” – John. Furthermore, a Muslim revealed that her sister refused to seek medical care when she could not find a female dermatologist because she had previously been seduced by a male dermatologist. 80 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care “I will not be able to express myself much and I will not ask questions even if I have a question to ask…My sister then refused to seek medical treatment and resulted to herbal medicine which didn‟t help her because the male dermatologist attempted to seduce her and she didn‟t get a female afterwards” – Happy. The above shows that the effect of not getting a preferred gender of a nurse could be unfavourable to patients as such patients‘ nurses‘ gender preference should be considered to make patients feel satisfied with health care. 4.4.2.3. No Effect for Not Getting a Preferred Gender of a Nurse in Nursing Care Other participants also disclosed that they really do not encounter any bad consequence such as dissatisfaction when they are not nursed by a preferred gender. This is what two of them have to say: “The gender of a nurse will not add anything to my satisfaction with nursing care.” – Dorothy. I don‟t have a problem with that. I feel indifferent. The gender does not make any difference” – Comfort. This patient included that he was able to adjust to any sex of a nurse for nursing care. “There is no dissatisfaction because you want to be healed, I can adjust to any gender of a nurse” -Kweku. Some participants indicated that they will not refuse the nurse that is not preferred but will allow him or her to provide the care. They added that if you are ill you should not be concerned about nurses‘ gender because you want to get well even though you have your preference. “I will not stop him, I will allow him because I want to get well” –Aseda. “But as for me I am always tolerating, I will not refuse any gender though I have my preference” -Aboagye. 81 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care A participant added that because she does not want to die, she would accept any gender for nursing care. “I believe if you don‟t get your preference and a different sex is available you should allow him to care for you, you adjust to other sex that is available. When you are sick you shouldn‟t be fascinating, otherwise you will die”- Dorothy. Most patients are not able to complain though they may not be comfortable with a particular gender of a nurse. However, a participant expressed that she will refuse a male nurse from giving her Intramuscular injection. “...Like taking injection on my buttocks. If it is a male nurse I will not agree, I will refuse” – Linda” 4.4.3 Benefits of Getting a Preferred Gender of a Nurse in Nursing Care Participants expressed that there were some advantages in getting a preferred gender of a nurse to nurse them. These have been grouped under psychological and physical benefit. 4.4.3.1 Psychological Benefits Associated with Getting a Preferred Gender of a Nurse in Nursing Care The participants mentioned some of the psychological benefits as ‗feels comfortable, make them relaxed, feels cared for, gives hope, feels ok, become satisfied, takes off burden and no embarrassment‟ Two participants narrated it in this way: “It will take your mind off your sickness for sometime before it comes back to reality that you are sick. First you feel comfortable that you are going to be cared for to get some touches and some tender loving care from the female nurses. As soon as you see a female coming you are sure that you are going to get a good nurse” – Ekow. 82 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care “It makes me comfortable and relaxed. I am not worried when I am going to be well or when I am going home. I feel cared for, even if I have pains this female nurse is going to assure me and give me the progress of my condition and that gives me hope and satisfaction” – Augusta. Two other participants indicated their feelings that: “I become happy, relaxed and hopeful about the outcome of my condition” - Happy. “I feel comfortable and relaxed, there is no embarrassment” – Blazu. 4.4.3.2 Physical Benefits Associated with Getting a Preferred Gender of a Nurse in Nursing Care Patients had good interactions with a preferred gender of a nurse as such they were able to communicate their concern and got solution to their problems. This is how some participants narrated their feelings: “I become very happy because of the good interactions they have with me. They normally ask what I need and they get them for me, they sometimes buy me food with their own money” – John. “I feel good, I feel like I can talk about anything, and tell them what is exactly wrong with me. I feel like the person understands me. Yes you really become satisfied because you will be comfortable to talk about your problems and get solutions to them” –Linda. The responses indicate that when a patient gets a preferred gender of a nurse he may be relieved of his psychological and physical burdens and that will enhance his recovery. 4.5 Barriers to Patient’s Preference of a Nurse’s Gender in Nursing Care Barriers to the preference were considered as one of the main themes of the study. To answer the research question, what are the barriers associated with gender preference in nursing care? Four (4) subthemes were obtained namely: attitude of nurses as a barrier for not getting a preferred gender of a nurse, hospital policy as a barrier for not getting a preferred gender of a 83 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care nurse, inadequate male nurses as a barrier for not getting a preferred gender of a nurse and attitude of patients as a barrier for not getting a preferred gender of a nurse. These were identified by participants as policies, behaviour or obstacles that made it difficult for them to have their preferred nurse‘s gender during nursing care. 4.5.1 Attitude of Nurses as a Barrier for not getting a Preferred Gender of a Nurse in Nursing Care. It was identified that participants considered some attitudes of nurses as bad and at the same time these bad attitudes prevent participants from getting their preference. As a result of the bad attitude of nurses, patients were not able to request for their preference and keep quiet on it. Secondly, nurses become angry, insult them and ignore their choices and do not offer them their request. “They (nurses) will insult you” – Comfort. “He will be angry and ask me if I think he doesn‟t know his job and I think he is incompetent” – John. Another participant lamented: “If you insist on your preference you may be ignored, neglected or embarrassed by the nurses” – Aboagye. 4.5.2 Hospital Policy as a Barrier for not getting a Preferred Gender of a Nurse in Nursing Care. When patients were asked to express what prevent them from having their preferred nurse to provide nursing care they responded that they were not asked and were not given the chance to choose though most of them had preference and wish they were asked. One participant added that unless they protest they will not be given their preference. 84 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care “We are not asked so I could not tell the nurses my preference” – Augusta. A participant had this to say: “Never, patients are not given the chance to choose a preferred nurses‟ gender in our hospitals. Mmmm... I wish when I came to this hospital they asked which nurse would you like to attend to you then I will have choices” – Dorothy. This woman added that if you do not complain, you will not be considered. “No. Patients are not given the chance to choose. But then if you don‟t protest no one will really mind you” -Nanama. Secondly, nurses attended to patients at random without the knowledge of the patients so patients do not have the chance to choose. “No, patients are not asked to choose. We are not allowed to choose our preference, if we are to choose I will always choose a male nurse. The nurses attend to the patients randomly” - Agyarko. “The person just comes and say „‟I want to check your BP‟‟ they don‟t give you the chance to choose” – Linda. “They assign nurses for different procedures so if my preferred nurse is not doing dressing today it will indicate that I will not get my preferred nurse. Patients are not asked about their preference” -John. Thirdly, patients indicated that the hospital has no policy that gives them the chance to choose a preferred gender of a nurse for nursing care and will not factor their religious norms into their policy therefore, it will not be necessarily to request for their preference. Two participants had this to say: “They don‟t ask. You cannot bring your house or religious policy to the hospital, the authorities will not accept that and use it” – Kweku. “The laws of the nation will not favour that (her religious obligations). No, nobody has asked me before so I don‟t bother to let my preference known” – Happy. 85 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care A participant added that although he has a preference for nurses‘ gender, he does not reject the nurse that is given to him: “The hospital law does not allow patients to choose. Because the hospital does not give patients the chance to request for our preferred gender of a nurse we just accept what is given to us without complaining” – Blazu. Hospitals have failed to notice the needs and preferences of patients treating every patient as not having a preference for nurses‘ gender which is not true. Moreover, others identified that some hospitals and some departments for the nature of the care they render do not allow male or female nurses to work in those units such as the maternity and orthopaedic so patients may not get their preferred gender of a nurse when admitted to these units. “The type of sickness and the department you are receiving care can prevent you from getting your preferred gender. You can hardly get a male midwife in Ghana” - Ekow. “The institution or the department that you are receiving care in can become a barrier. For instance, in the maternity you will find more female nurses than the male nurses and in the orthopaedic unit you will find more males than females” - Nanama. 4.5.3 Inadequate Male Nurses as a Barrier for not getting a Preferred Gender of a Nurse in Nursing Care. From Participants observation, there have been inadequate male nurses in the Ghanaian setting. There were more female nurses than male nurses in our hospitals. As a result, patients who prefer male nurses would not get their choice so some patient do not bother themselves to make their preference known. This is how two participants expressed it: “Sometimes there are only females. Today no male has come here so in a situation where a patient might need a male nurse there will be no male nurse to take care of the patient and the patient will not be satisfied” – Linda. 86 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care “Over here I am not seeing more of the male nurses so it looks like you don‟t really have a choice. I think the first and foremost one can be the non availability. Also, looking at the patient nurse ratio it is going to also be a barrier” – Dorothy. Another participant complained that: “There are not really a lot of male nurses in Ghana. For instance here I see two regular male nurses as compared to ten female nurses so if they come on shift and you prefer a male nurse it would be very difficult to have one. So I do not bother to make my preference known” – Nanama. A lot of male nurses should be trained to match the number of female nurses for every patient to get access to his preference when needed. 4.5.4 Patient’s Attitude as a Barrier for Not Getting a Preferred Gender of a Nurse in Nursing Care. This subtheme describes the attitude (behaviour) of patients that make it difficult for them to have their preferred nurse in nursing care, when it comes to expressing their preference for nurses‘ gender. Patients identified that in general they are not able to ask for their needs. Some patients feel shy and not able to express themselves in front of health workers so they keep quiet and accept anything whether good or bad though they were mostly not comfortable. Three participants had this to say: “It is not all patients who are able to ask questions. Some patients feel shy to ask what they need. Others too are not able to express themselves in front of health workers because of fear of intimidation” – Happy. “Most of the female patients feel shy when nursed by male nurses but do not complain because they fear that they will be insulted” – Aboagye. “We keep quiet accept what is given to us, we want our healing that is more important to us” – Kweku. 87 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care Others indicated that patients were not courageous, they tolerate whatever is given to them without complaining though they were not happy about it. ―I don‟t question, „I don‟t like this, bring this‟ etc. I always tolerate whatever is given to me even though I am not satisfied” – Ekow. “I know the male nurses too are assigned to do the work so I can‟t stand before them to tell them that I want a female nurse, I keep it to myself though I am not happy” – John. A woman boldly included that Ghanaian patients are not outspoken. “In our culture setting we don‟t even know how to ask for things that we want. Over here we are brought up not to be outspoken yes we tolerate everything if a patient is sick and is not comfortable with a male nurse I don‟t see Ghanaian patients, not all coming out to say I am not comfortable” – Dorothy. Another patient lamented that he would accept anything whether good or bad. “I am not bothered at all. If it is good for me I will accept and if it is bad too I will accept, anything goes bad or good” -Agyarko. The stories of the above participants show that patients view the hospital as a place that they cannot ague or complain. Lastly, participants revealed some anticipated challenges that might serve as barriers to their preference for nurses‘ gender during nursing care. Participants further indicated that patients are going to have different preference and the economy cannot sustain that. Some gender of nurses may be ideal and some may be beginners learning from the nurse that is not preferred by the patient. “Male nurses or female nurses will not have work to do in some wards in some instances. Secondly, the male nurses may be learning from the female nurses. So if you are a patient and you prefer a male nurse in that ward then it means you 88 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care are going to suffer he will add more problems to what you brought to the hospital” – Aboagye. “There is going to be challenges with it because we are all going to have different preference” – Augusta. In addition, this is what a participant said: “It will be nice but the economy of the nation cannot cater for it? Looking at the number of patients and the few nurses and you are coming to select”- Ekow. It is likely that there are going to be challenges if every patient is to be offered a preferred gender of a nurse in nursing care. 4.6 Perspectives of Participants on Certain Issues in Nursing. This theme emerged outside the model when participants were asked to comment on the topic under study at the end of the interview. Participants suggested that: Nurses are mainly preferred by their good qualities, some nurses are good but the majority of them had bad attitude towards patients and their relations, male nurses are labelled as unsuitable in the nursing profession especially for the caring activities whiles female nurses are viewed as better nurses and there is the need to increase the number of male nurses in the nursing profession in Ghana to be able to meet the needs of patients who prefer male nurses in nursing care. Four (4) subthemes emerged under this theme, they included: Qualities of a preferred nurse, perspective of participants; attitude of a bad nurse, participant‘s perspective; stereotypes associated with nurses in Ghana and lastly the need to increase the number of male nurses in the nursing profession. 4.6.1 Qualities of a preferred nurse, perspective of participant Participants described the preferred qualities of nurses at the Komfo Anokye teaching hospital based on four (4) characteristics. These were: communication of a preferred nurse, 89 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care professional competence of a preferred nurse, appearance of a preferred nurse and virtues of a preferred nurse. 4.6.1.1 Communication of a preferred nurse The participants in this study reported that the preferred nurse uses terms of endearment when communicating with them and that makes them happy. That is a nurse who uses sweet talks, pampering and humour in her care, for example: do not worry you will be fine; your wound will heel soon. “I like a nurse who will ask how I am doing and converse with me and that will make me happy and facilitate my healing. I want nurses to use humour in their care” -Kweku. One of them expressed that a preferred nurse tells her not to worry because she would improve on her condition. “I prefer a nurse that will not just come and give me injection and go but will part me and tell me it will be fine. Don‟t worry it will be fine”- Dorothy A preferred nurse tells her not to worry because she will recover soon. “I preferred a nurse who will communicate with me and use sweet talks like, have patience the wound will heal soon and that will take away my worry” – Comfort. A participant further explained that joy and laughter makes him recover fast. “Sweet talk and pampering heals. I prefer nurses who use humour and jokes to make patients laugh and that will make us happy. Joy and laughter makes me recover fast”- Blazu. 4.6.1.2 Professional competence of a preferred nurse The favourite nurse was expected to be able to perform nursing skills competently and promptly, be knowledgeable, organized, hardworking and efficient. 90 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care “I watch out for how smart you are. A nurse who knows her job, that is her competency and her promptness to situations”- Dorothy. “I prefer a nurse who is hardworking and does her work with enthusiasm”- Aseda. These two patients added that a patient may die out of the nurses‘ negligence. “I prefer efficient and knowledgeable nurse. I am saying this because when a nurse makes a mistake it mostly cost a patient‟s life…” –Ekow. “My favourite nurse is a nurse who will not sit at the nurses‟ station and wait till medication time before attending to patients. They should frequently check on patients to ask them how they are doing otherwise a patient can die out of the nurses‟ carelessness” – John. 4.6.1.3 Appearance of a preferred nurse Appearance was emphasized by some participants in the data and related to the concern of cross infection, reviving patient and approaching nurses. Being clean and neat in appearance happened to be a common concern for many. The stories of participants are expressed below: “I look out for a very clean nurse. I also look for how you dress up your hair. It is true you are attending to a sick person who you might think is not watching you. But a sick person is emotionally down, sometimes she feels like giving up but you open your eyes and you see a very well dressed nurse looking all cool and you are like oh yeah there is life outside there so I have to quicken myself and get out of bed and go and continue life. It is true, it wakes up patients spirit when a nurse is looking good. You should look attractive and smell nice as a nurse because you are attending to patients, moving about swinging your arms coming close to patients” – Dorothy. A nurse who is cheerful is more approachable. “I like a nurse who is neat in appearance and in everything, this prevents the spread of infection. It is really good to have a nice look on your face, not frowned. If I have a problem and you come around you have frowned your face, it appears like should I tell her or should I not tell her? What am I going to do” – Nanama 91 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care 4.6.1.4 Virtues of a preferred nurse A lot of patients who participated in the study referred to many ethical and social qualities, character traits and virtues of nurses that made them their favourite among other nurses. They specified that their preferred nurses think and act in particular ways. Some of the virtues identified in this study have characteristics such as ‗patience, attentive, helpful, kind, encouraging, polite, cheerful and friendly‟. This was how they expressed their feeling: “I prefer a nurse who is kind, has patience, always available when needed, fear God and understand me as a patient” – Comfort. “I prefer a nurse who smiles, polite, have time for me and encourages me and gives me assurance all the time to give me hope in life.”- Obeng. A young lady also added her voice that: “I look out for a hardworking nurse, kind and compassionate, cheerful, well read, attentive to detail. I prefer someone who is helpful, punctual, friendly and have patience”- Augusta. Most patients preferred a nurse with good qualities rather than a nurse with a particular gender in nursing care. Moreover patients are very sensitive and observe everything that happens around them critically though they are ill. 4.6.2 Attitude of a bad nurse, participant’s perspective. A bad nurse was described to portray attitudes such as: neglecting patients in their care, seeking monitory gains before rendering care, ignoring patients‘ needs and complaints and finally raining insults on patients. 4.6.2.1 Nurses Neglecting Patients in their Care Several participants narrated their experience with bad nurses as overlooking them as human beings during their care thinking they have no contributions to make. 92 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care ―They treat patients as nobody. That is they don‟t involve you in whatever they do, they think all patients are illiterates” –Aboagye. Another participant lamented that even when you are sleeping the nurses go ahead and perform procedures without alerting you. “… Another nurse will come and even when you are sleeping will just prick your finger without telling you anything. I mostly feel bad because it doesn‟t show respect and mostly startles, when I am not informed that action gives me headache because of the pains” -Agyarko. 4.6.2.2 Nurses seeking monetary gains before rendering care to patients A small number of participants plainly stated that they have observed that male nurses take money in the form of bribe from patients before attending to them but the female nurses are exceptional. This is how two participants expressed their observations: I have observed that most of the male nurses want to collect money in the form of bribe before helping patients but the females are not like that” – John. What I have observed is that the females will work on you and finish before you show appreciation by giving them a token but the male will tell you boldly, father do something o. they will approach you first and collect money before trying to help you” – Ekow. 4.6.2.3 Nurses ignoring patients’ needs and complaints Participants bitterly complained about nurses‘ attitude of overlooking their concerns. Some of them narrated that nurses do not respond to their needs, asking them to wait for their relatives or a doctor to come and help them. They sit at the nurses‘ station and only administer routine procedures. “Sometimes you call a nurse and tell her your needs and she will tell you wait for visiting time when your relatives come then you tell them. No, for the nurses they sit at their station and when it is time to give medication, check temperature and blood pressure that is when they come around”- Kweku. 93 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care A patient almost lost his life because he had serious abdominal pains and the nurses refused to attend to him. “When I called the nurses they didn‟t mind me. I nearly died that night, everyone was sleeping and I was the only one awake and having serious abdominal pains. They told me to wait for a doctor to attend to me” -Obeng. These two participants were shouted to keep quite whiles they were in pain. “Well he didn‟t say anything, he just did his work and left. A ward aid shouted at me haiii stop screaming and sleep soundly whiles I was in pain” – Aseda. “I screamed every night but the nurses wouldn‟t mind me. I begged them to get me medicine to relieve the pain but they never mind me. At this ward when you need a nurse and you call him he shouts at you and tells you, you are troublesome, can‟t you see that every patient is sleeping, keep quiet and sleep” - Kweku. 4.6.2.4. Nurses raining insults on patients Patients lamented that some nurses have the habit of insulting patients with the little mistakes they make or even when have not done anything wrong. These have been narrated below: “Anytime he comes to my room he will yell angrily and use abusive words on me while I have done nothing wrong”- Aboagye. “When you make a mistake and it comes to the insults they do not mind, they give it to you straightaway” –Ekow. “There is a situation where you meet a nurse and out of the blues she just doesn‟t like you. And she will tell you nasty words like „‟ you think you are beautiful, I have beautiful daughters in my house” –Dorothy. 4.6.3 Stereotypes associated with nurses in Ghana Some participants revealed that they have noticed some particular behaviour associated with male and female nurses in Ghana and this was revealed in the participants‘ responses. 94 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care 4.6.3.1 Stereotypes associated with Male Nurses in Ghana Patients disclosed some stereotypical ideas placed on male nurses in Ghana, these were: men in nursing are inappropriate because nursing is predominantly a female‘s job, male nurses are effeminate, males should become doctors and females, nurses because males naturally do not possess qualities of a nurse. This is what one of them had to say: “In the Akan and Ghanaian setting…nursing was predominantly like a woman‟s job. Even up till now I think people get a little bit surprised at a male nurse. Yes it has always been women, women, women and now we see the guys also in the trade it‟s like they are out of place. She laughed…so they see male nurses as kojo basia‟s (a man who behaves like a woman) type, like you are taking up a woman‟s profession. Even they start behaving like the women” –Dorothy. A participant added that assisting and caring is an auxiliary job and therefore, a female‘s job. She noted: “There is this stereotype, when you talk about nursing you think of a female. That is the kind of understanding we have in Ghana. At first I didn‟t know there were male nurses until I grew up. Mostly when I see them I don‟t refer to them as nurses, I see them as doctors because they are males. Sometimes I feel assisting and taking care of the sick is an auxiliary job and therefore, a lady‟s job” - Linda. Another patient had this to say: “I think the males should be doctors and nursing should be for only females because male do not have patience” –Happy. Some of the patients insinuated that although male nurses also go through nursing education, they will not be able to provide nursing care naturally as females because only females have the natural ability to care. “You see nursing is generally for females and a man is doing what a female should do. It doesn‟t come naturally no matter what. A female has the natural ability to care” – Nanama. 95 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care This man clearly stated that unless male nurses apply their training consciously the application will not be natural. “…you know a man is a man and physically they (male nurses) will go through the training but the application will not come naturally unless they apply it consciously” –Ekow. It looks like people still have the perception that nursing is for females from the time of Florence Nightingale though men in nursing are gradually increasing and performing well. 4.6.3.2 Stereotypes associated with Female Nurses in Ghana According to patients‘ views female nurses were labelled as having special heart for caring, doing better in terms of caring while male nurses apply a lot of muscles when nursing patients. “The female has a natural caring heart but the men apply a lot of muscles and do not have time for patients” – John. An elderly female participant confidently said that some female nurses may have bad attitude but when it comes to caring for patients females are superior. “Nursing started with Florence Nightingale, women have a special heart when it comes to caring. We may have female nurses who are proud, insolate or arrogant but when it comes to taking care of patients, women do better” –Aseda. It appears that stereotypes still abound in our society that females are better nurses and males are not and this is affecting the image of males in the nursing profession. 4.6.4 The need to Increase the number of male nurses in the nursing profession Some participants wishfully suggested at the end of the interview that more males should be given the chance to enter into nursing to be available for patients who prefer only male nurses. This is what three participants said: 96 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care “I think more males should be encouraged to enter into nursing because in some situations you might want the same gender so I think more males should be encouraged to take up the nursing profession”- Linda. “So then we can make nursing more attractive to men by not making nursing looks like a servant‟s job. Secondly, there should be more slot for men when they apply to the nursing training schools”- Nanama. “We need more men to work as nurses because some of them even do better than the women”- Dorothy. Both males and females could be better nurses and therefore more males should be involved to match the females in nursing profession. 4.7 Summary of Findings This study used four objectives based on the Rational Choice Theory to explore the preference of patients for nurses‘ gender at the Komfo Anokye Teaching Hospital, Kumasi. Fourteen patients agreed and participated in the study after the objectives and the purpose of the study had been explained to them. An interview guide was used to moderate the interviews. The interviews were recorded and transcribed and the principles of thematic content analysis were employed to analyze the data. The findings proved that patient had varying preference for their nurses‘ gender. However, majority of the participants did not have preference for a particular gender of a nurse meaning most of the participants were indifferent. The reasons for the preference were mainly due to the gender of the patient, the past experience of the patient on nurses and sickness, the situation which the patient find himself, the type of care provided for the patient, personal interest of the patient, religion of the patient and lastly the culture of the patient. However some participants specified that they look out for the good qualities in a nurse and not the gender to indicate a preferred nurse. Secondly, their preference was mostly due to their personal interest such as what will make them improve upon their condition or satisfied with the 97 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care care. Moreover, the effect of asking, getting or not getting a particular gender of a nurse in nursing care were shown to be include: beneficial effect such as being comfortable, relaxed and satisfied; no effect for not getting a preferred gender in nursing care, that is not really bothered about who takes care of them and lastly, negative effect such as felling embarrassed, uncomfortable, angry and guilty. In addition to the above, the barriers to patients‘ preference for a particular gender of a nurse in nursing care were identified to be due to the attitude of nurses, inadequate male nurses, hospital policy, condition of patient and attitude of patients. However it was also found that if patients were to get their preferred gender of a nurse some nurses will not get patients to care for them in some situations. Finally, one other result that emerged from the collected data aside the objectives and the theoretical framework was the perspective of participants on issues in nursing. On this, it was revealed that nurses were mainly preferred by their good qualities not gender, some nurses were good but the majority of them had bad attitude towards patients and their relations, male nurses were labelled as unsuitable for the nursing profession especially for the caring activities whiles female nurses were viewed as better nurses in Ghana and finally there is the need to increase the number of male nurses in nursing in Ghana to be able to meet the needs of patients who prefer male nurses in nursing care. The main findings from this study would be discussed in the next chapter. 98 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care CHAPTER FIVE DISCUSSION OF FINDINGS 5.0 Introduction In this chapter the researcher would be discussing the key findings of the research in relation to the existing literature and conclude by evaluating the usefulness of the rational choice theory to the study. The study was intended to explore the preference of patients for nurses‘ gender in nursing care at the Komfo Anokye Teaching Hospital in Kumasi. The study specifically sought to:  Explore the gender of a nurse that is preferred for nursing care by patients.  Identify the reason for the gender preference of a nurse for nursing care.  Explore the effect of the gender preference of a nurse on the patient.  Identify the barriers associated with patients‘ preference for nurses‘ gender. The main themes and their corresponding sub-themes from the study are presented, discuss and analyzed with literature. The findings identified are: The most preferred Gender in Nursing Care, Patients‘ Reasons for the Preference or no Preference for Nurses‘ Gender for Nursing Care, Effect of the Preference for Nurses‘ Gender, Barriers Associated with the Preference of a Nurse‘s Gender in Nursing Care and Perspectives of Patients on Certain Issues in Nursing. Again, the competencies of synthesis and evaluation to develop connections between what is known and what emerges from the research would be further discussed to create new knowledge on the preference of patients for nurses‘ gender in nursing care. The main findings of the study are discussed. 99 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care 5.1 Most Preferred gender in nursing care The three sub themes that emerged from the theme ‗The most preferred gender in nursing care‘ included: Patients‘ Preference for Male Nurses in Nursing Care, Patient Preference for Female Nurses in Nursing Care and Patients with no Preference for either Male or Female Nurse. The result of this theme is consistent with the findings of several literatures which indicate that some patients prefer male care providers, others prefer female care providers, while others do not care about the gender of the providers of health care (Howell et al., 2002; Johnson et al., 2005; McLean et al., 2012). Although the studies were conducted in different geographical location worldwide with different methodology, participants had varying preference as a result of their individual demographic characteristics (Georgieva, Mulder, & Wierdsma, 2012; Laurant et al., 2008). 5.1.1 Patients’ Preference for Male Nurses in Nursing Care In the current study, few participants preferred male nurses. This study findings is similar to the findings of other studies with different health workers which noted that only few participants prefer male nurses, especially in gynecological and obstetric cases (Rizk et al; 2005; Janssen et al; 2012). The findings of Adudu and Adudu (2007) showed that majority of patients prefer male doctors to attend to them and this contradicts with this study‘s findings but also similar with this study that the male participants chose male doctors only when they were asked or pushed to choose their preference for doctors Secondly, this 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 equipments 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 literature (Bishop, Smith, & 100 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care Lewith, 2013; Keogh & O'lynn 2007) which stated that male nurses are suitable for tasks involving physical labor and dealing with violent and irritable patients. Additionally, male nurses are also believed to be perfect in performing job requiring technical skills because men are good at handling machines. To stress on the above, a female participant 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 (Chiu et al., 2007). Moreover, this study found that male nurses had more positive attitudes than female nurses and it supports the findings of Liu et al. (2013) that male nurses have good interpersonal relationship with patients than female nurses. The researcher therefore suggests the need to train more male nurses to cater for patients who prefer male nurses and to improve upon the nursing practice. 5.1.2 Patient’s Preference for Female Nurses in Nursing Care 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 of Howell et al. (2002) 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 when in need of help (Moyer, Adongo, Aborigo, Hodgson, & Engmann, 2014). Secondly, 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 Xiao et al. (2013) younger Chinese student nurses have more positive attitudes towards patients. This is quite different from the findings reported in earlier studies which stated that older student 101 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care nurses had more positive attitudes and this was attributed to more mature views about the reality of ageing (Ayoglu et al., 2013). 5.1.3 Patients with no Preference for a Particular Gender of a Nurse in Nursing Care. 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 (Ahmad & Alasad, 2007; Bal, Yılmaz, Beji, & Uludağ, 2014; Makam et al., 2010), in this current study, 57.1% of participants both men and women had no specific preference regarding the gender of their nurses. They emphasized 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 by Piper, Shvarts and Lurie (2008) 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 (Adudu & Adudu., 2007; Piper et al., 2008). The 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 Bishop et al. (2013). In their research, respondents consistently reported that they considered a practitioner‘s qualifications and technical skills important when choosing either a physiotherapist or a chiropractor whiles the gender of a practitioner was less important to them (Bishop et al., 2013). By comparison it was found that the current study and the study of Bishop et al. (2013) had similar result but uses different words in describing the characteristics of a preferred nurse example professionalism and expertise, good manners and good. The present study additionally found that being nursed by a professional nurse who have the licence to practice nursing gives much confidence and does not make one worry about the 102 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care gender of a nurse. In a study by Calman (2006) participants 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. Similar in other studies there are evidence suggesting that stereotypes of the male identity of being strong, independent and self-reliant make them reluctant in disclosing their preference due to fear of being embarrassed and victimized (Duffy, 2005). This may be the reason for majority of male participants not having preference for a particular gender of a nurse in this present study (57.1%). 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 are much concern with issues of modesty Varadarajulu, Petruff, and Ramsey (2002) and the results disagrees with this current study‘s findings. In this current study, only 42.9% of females were gender biased and this finding corroborate with the findings of Heath (2010) and Johansson et al. (2003). In their study, they found that the female participants did not care about the gender of the health care provider (Heath, 2010; Risberg, Johansson, Westman, & Hamberg, 2003). Therefore, it appears that the current study‘s finding of absent preference for nurse‘s gender was as a result of a 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 (57.1%). Secondly, 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 (de Klerk, Boere, van Lunsen, & Bakker, 2017). Future research on determinant of women preference for their midwives in Ghana is recommended. Subsequent 103 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care discussion centres on discussing the reasons for patients preference of a gender of a nurse in nursing care. 5.2 Patients’ Reason for the preference or no Preference for Nurses’ Gender in nursing care. This theme discusses the reasons for the preference of a gender of a nurse in nursing care. Seven (7) subthemes were identified: Patients‘ Gender as a Reason for the Preference of the Gender of a Nurse in Nursing care, Patients‘ Preference based on Past Experiences, Situation as a determinant for Patients‘ Preference for Nurses‘ Gender, Qualities of nurses not Gender as a determinant for Patients‘ Preference in Nursing Care, Personal interest as a determinant for Patients‘ Preference for nurses‘ Gender in Nursing care, Religion as a factor in patients‘ preference for Nurses Gender and Cultural factors as a determinant for the preference of a Nurses‘ Gender for Nursing Care. The next section looks at the discussion of each of these findings. 5.2.1 Patients’ Gender as a Reason for the Preference of the Gender of a Nurse in Nursing Care. Majority of the participants preferred the same gender of a nurse for nursing care and few of them preferred the opposite gender in nursing care. The participants 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 colonoscopist because they feel less embarrassed with them during treatment (Amir et al., 2016; Shah et al., 2011). 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. In a related study, female patients expressed that a female 104 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care therapist could imagine problems more easily than a male therapist because females identify easily with each other as mother-daughter relations. It is also legal to discuss personal issues, such as reproduction and health matters. Information concerning menarche, menstrual problems and sexuality is often given from mother to daughter (Højgaard & Laursen, 2017). Haron and Ibrahim (2012) proved that as a result of gender difference, the patient may find it hard to share information that they think are personal. On the other hand, male patients revealed less preference for same gender provider for nursing care as compared with female patients in this study. In agreement with Bertakis and Azari (2012), there was no significant relationship for the male patient-male physician concordance. Surprisingly, most of the existing literature that the researcher came across talk about physicians, gynaecologists, urologist and colonoscopist and not nurses (Amir et al., 2016; Bertakis & Azari, 2012; Haron & Ibrahim, 2012; Saha & Beach, 2011; Shah et al., 2011). It is therefore necessary to research into patients‘ preference for nurses‘ gender in all aspect of nursing care to know and understand the needs of patients when seeking nursing care. It was also found in the present study that a same gender nurse was able to perform procedures around the genitals better than the opposite gender because the opposite gender nurse may be uncomfortable and also in hast when handling the sexual organs. This finding reflected the findings of Eswi and El Sayed (2011) which specified that male nurses feel embarrassed and nervous when attending to women at the maternity ward but adopted some measures to cope with the situation. Issue of modesty is considered important for most male and female patients due to cultural and religious demands of some society. As a result, the religious and cultural background of patients should be considered and their values factored into health care to provide gender-concordant care (Padela, Gunter, Killawi, & Heisler, 2012). 105 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care Most individuals frequently prefer the same gender nurse or provider when seeking health interventions, and this preference is reported as being strong enough to delay procedures and to incur personal expense. It is an absolute barrier to both men and women‘s reproductive and sexual health (Okoro & Whitson, 2017). Consequently, interventions must be made to address this issue and to increase the participation of the general population in seeking help when needed. Interestingly, only males cared more about the opposite gender nurse in the current study. They indicated that the opposite gender nurse gives a lot of attention when rendering nursing care and that gives them satisfaction. Similarly, Lucassen et al. (2011) found that 92% of their participants were attracted to the opposite sex, 1% to the same sex, 3% to both sexes, 2% were not sure and 2% were attracted to neither sex. Those attracted to the opposite sex were found to be free from social and psychological problems. Furthermore, the therapeutic touches of a female nurse serve as a massaging point communicating with the body of male patients and sending positive chemical messages which enhances the healing of the body. This agrees with a study using university of Chicago students that males are attracted by sight and touch to their female colleagues and the relationship enhance their well being (Roney, 2003). The findings of this research draw attention to the need to offer patients gender- concordant providers to maximize communication between patients and providers to achieve patients‘ goals (Vu, Azmat, Radejko, & Padela, 2016). 5.2.2 Patients’ Preference based on Past Experiences The findings of this study supported existing evidence on the patients‘ past experiences with nurses as a reason for preferring a male or a female nurse when assessing nursing care. Both 106 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care groups of respondents in the study of Leach et al. (2017) equally mentioned previous experience with their provider type as a reason for their preference for a physician. In the present study, the participants communicated that female nurses have been observed to be more patient and had time for patients especially the elderly ones. They also treat patients with respect and compassion, unlike the male nurses who do not have time for patients. This finding is similar to that of other studies that most patients preferred a female rather than a male care provider because they use more patient-centered communication style (Huang, Yeoh, & Toyota, 2012). On the other hand, this study found that male nurses have more positive attitudes and are able to hide their emotions more than female nurses (Liu et al., 2013). According to participants in the current study, some female nurses are good and some male nurses too are equally upright. So the gender does not tell who is good and who is not good and both can help in their recovery. Moreover, they are able to communicate well with both male and female nurses. These support the findings of Alexander (2016) that both male and female nurses are good no matter the environment they are working, they are able to make a difference in the lives of many. A participant in the current study revealed that as much as he has observed that gender does not determine a good nurse and a bad nurse he has also observed that human character is not static, it depends on the sentiment of the person at the time of interaction. Someone can be good to you today and be bad to you the next moment so there is no need to prefer any gender in nursing care. The study of Robins, Fraley, Roberts, and Trzesniewski (2001) confirmed that personality traits showed consistency, however, can change systematically. This was also agreed by Yilmaz, Unal, Gencer, Aydemir, and Selcuk (2015) that human behaviour is unpredictable. It was also revealed that participants who have battled with sickness for a long time and moving from one hospital to another in search for health have no preference for nurses‘ gender. 107 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care However, getting healed was what was most important to them. Published surveys in the study of Benbassat, Pilpel, and Tidhar (1998) supported the findings of this study that the severity of the patients' conditions are predictors of a preference for the passive role in the doctor-patient relationship. Similarly, in another study, there is a significant statistical correlation between hospitalization frequency and preference for patients' spiritual needs (Ghahramanian, Markani, Davoodi, & Bahrami, 2016). 5.2.3 Situation as a Determinant for Patients’ Preference for Nurses’ Gender 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. Vahdat et al. 2014 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 (Street et al., 2005). Intimate care procedures and discussions about sensitive issues also informed participants‘ choice of the gender of a nurse in this current study. Patients indicated that they will not feel comfortable for the opposite gender to change their diaper, give bed bath and intramuscular injection on the buttocks but will relax during procedures like education on condition and serving of tablets. This reflected in a study of patients seeing a urologist, patients with incontinence had a statistically significant preference for the the gender of their provider but patients with different diagnoses did not demonstrate statistically significant gender preferences due to less frequent changing and exposing of the nakedness (Ficko, Li, & Hyams, 2017). Secondly, participants in the current study revealed that they will feel shy being naked before the 108 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care opposite gender and also will feel shy to discuss issues pertaining to the private parts with the opposite gender. Consistent with other studies Ahmad and Alasad (2007), women have been found to prefer female nurses for matters of reproductive, sexual health and intimate or psychosocial issues, whereas men also demonstrate a a similar trend, but to a lesser degree. Besides, more than half of the male student nurses in a study by Eswi & El Sayed (2011) preferred to care for males rather than female patients at the maternity clinical practice due to frequent exposing of the breast, abdomen, perineum and thighs as well as the vagina at the maternity ward. The students were embarrassed with procedures such as abdominal examination, breast examination and perinea care but were comfortable during procedures such as health talk and counselling (Eswi & El Sayed, 2011). Majority of participants indicated that the reasons for selecting female care providers were embarrassment during intimate examination (Menees, Inadomi, Korsnes, & Elta, 2005). In addition, participants in the current study worriedly narrated that it is not a best practice for male nurses to be involved in procedures that exposes the nakedness of female patients. It is bad, unethical and sparks up some fire. This agrees with the findings of Sirois, Darby, and Tolle (2013) that it is bad to overlook patients‘ modesty and provide intimate care for female patients as such if patient clothing needs to be removed, full discussion prior to treatment is needed and same gender provider should be engaged. Secondly, a male is sexually weak and may not be able to control himself when carrying out procedures that involve exposing of the nakedness of a female and can lead to immorality. This corroborate with the findings that sexual desire provokes if the touch between any man and woman not married to each other goes beyond care given it would be sinful (Padela & Rodriguez del Pozo, 2011). In the same way, some participants in the present study requested that there should be a chaperone to serve as a witness when care is intimate. Similarly, male nurses' insisted on the presence of a 109 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care chaperone during caring interventions or avoiding caring interventions that involve any intimate procedures (Keogh & Gleeson, 2006). The male nursing students felt that a chaperon played an important role in protecting the legal rights of both parties (Chan, Chan, & Tse, 2014). Other studies found that physician gender had a variable impact on female patient‘s preference for a chaperone. Almost all the participants considered the presence of a chaperone appropriate during intimate physical examination (Ong, Garnett, MacFarlane, & Donat, 2010). The most commonly cited reasons included the protection against sexual harassment, and to provide psychological support (Fan et al., 2017). A male participant in this current study aggressively said that he would not take it lightly for a male nurse to provide intimate care for the wife or the sister (Mujallad & Taylor, 2016). A Muslim participant suggested that a law should be passed to prevent against male nurses providing intimate care for females. This supports Iranian religious pluralism. In the context of Iran, nurses are not allowed to gaze or touch patients of the opposite- sex, except in emergency cases (Norouzinia et al; 2016). In contrast, some participants expressed that it is not bad so long as there are no inappropriate things done and the nurse is not providing the care under sexual context, it‘s ok. This is similar to the views of the student nurses (participants) in a study by Crossan and Mathew (2013) that there is no inappropriateness done because nurses have the responsibility to provide care to those in need of care. However, their primary concern was the potential embarrassment for the patient and for themselves. In addition, the students displayed a negative mind-set to male nurses providing intimate care to female patients, in that male nurses should not care for female patients, especially younger women (Crossan & Mathew, 2013). One participant added that it would be right to ask patients of their preferred gender of a nurse especially in procedures like IM injections, catheters and bedpans (Georgieva et al., 2012). 110 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care From participants‘ responses it looks like most participants would be comfortable to be nursed by the same gender nurse when procedures are intimate. Therefore, it may be necessary for patients to request for their preferred nurses‘ gender when the type of care exposes the nakedness of patients and involves sensitive touch. Secondly, education on privacy and dignity should be integrated into nursing practice and nursing curricula (Matiti, Cotrel-Gibbons, & Teasdale, 2007). A number of the male patients in this study indicated that it is not wrong and there is no shyness for a female nurse to care for male patients because the female nurse is like a mother to the male patients. This supports the assertion that mothering has become associated with nursing (Miers, 2000). A female participant ironically added that naturally, the majority of males prefer female nurses for intimate procedures especially if the female nurse is beautiful because naturally males are attracted to females. This confirms that Nonsexual intimate touch is often part of nursing care, but it has been associated with sexual meaning .Young female nurses become objects of sexual desire as they express their caring skills (Harding et al., 2008). Another participant explained that female nurses providing intimate care procedures for male patients can also lead to sexual undertone (Bronner, Peretz, & Ehrenfeld, 2003). The above stories give the impression that male patients‘ preference for same gender nurses for intimate care procedures are not as strong as that of female patients. Further research needs to explore patients‘ understanding of intimacy of being nursed. Moreover, Rajacich et al. (2013) have shown that male surgeons are preferred for greater technical competence as well as the appropriateness of their greater physical strength for surgeries. Also female obstetricians and gynaecologists were preferred for gender sensitivity and less social embarrassment during clinical examinations (Janssen & Lagro-Janssen, 2012). There was association between patient gender and specialty preferences of gender of doctors with male 111 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care and female respondents preferring male doctors generally, especially in surgery. Secondly, males are being called upon for tasks that required physical strength (Adudu & Adudu, 2007; Rajacich et al., 2013). The current study also found similar result that when the procedure involves much energy and technical competency participants would prefer a male nurse and a female nurse for the caring activities. 5.2.4 Qualities of the Nurse not Gender as a Determinant for Patients’ Preference in Nursing Care. This study found that participants‘ preference is not about the gender of a nurse but about the good qualities in a nurse. As a result, the gender of a nurse is not so much important to most patients but rather most patients look for qualities of nurses to determine their preference of a nurse because they believe every nurse will be able to help them recover from their sickness and also a ―good nurse‖ will make them feel comfortable and satisfied. As noted already by Chen, Zou & Shuster (2017) similarly, patient satisfaction regarding health care is associated with physician specialty and good qualities not gender. Similarly O'Lynn and Krautscheid (2011) revealed that participants believe nurses are trained and would perform the work professionally, competently, and in a way that conveys respect so the gender does not make a difference. Additionally, a study indicated that physicians‘ qualifications, affective support and technical skills are key reasons for preferring a physician more often than the gender or the age (Leach et al., 2017; Tang, Soong, & Lim, 2013). Another study also found that the gender and age of a therapist is of less importance for sexological patients. Regarding profession, most patients prefer a physician or a psychologist, but the actual consultation with any professional results in either indifference or a change in preference towards the professional background of their therapist (Højgaard & Laursen, 2017). Similarly, in Ghanaian hospitals empathy exhibited by 112 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care health professionals in a healthcare settings is the strongest predictor and immensely contributes to the overall service quality (Mensah , Yamoah, & Kwame., 2014). 5 .2.5 Personal Interests as a Determinant for Patients’ Preference for Nurses’ Gender in Nursing Care. In this study participants explained that they make the choice of a gender of a nurse based on their personal interest and not by a collective decision. They consider their health and recovery first and base their choice on the nurse who would help them recover fast and become satisfied with the health care. Reuben and Tinetti (2012) supported participants‘ views that priority and personal interest of patients are also needed in patient care for better outcome and satisfaction. In a similar study Peres et al. (2007) found that patients preferred the treatment options with higher efficacy rates even if side effects were present and a more frequent dosing schedule was necessary. Their concern was to improve fast (Peres et al., 2007). To add to that, patients preferred the treatment option that will give them rapid response and did not base their choice on the doctors‘ recommendation. The patients valued their personal interest and priority of getting rapid onset of complete pain relief from head pain as more important than the doctor‘s advice (Lipton et al., 2002). 5.2.6 Religion as a Factor in Patients’ Preference for Nurses Gender. When participants were asked about their religious influence on their preference for a nurse‘s gender for nursing care the Muslims emphasized that although the Muslim religion does not encourage males to touch or look at a female‘s body and vice versa (Lovering, 2012; Mujallad & Taylor, 2016), they were not restricted when it comes to nursing care because it would not be intentional but because they were ill and seeking medical care so God will understand and forgive them (Health Care Providers‘ Handbook on Muslim Patients, 2010 pg 113 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care 10). However, in the current study all the Muslims indicated that they would have preferred the same gender if they were given the chance to choose because of occasional guilt feelings and religious conflict though they knew God will forgive them. This is supported by McLean et al. (2012) that Muslim women exclusively preferred female gynecologist and physician. Again, the Muslim women participants in the United State indicated that they may prefer a female healthcare provider because of modesty concerns or the concept of ‗khalwah‘ (Padela & Curlin, 2013). In contrast, only 5% Turkish Muslim women responded that the religious obligations were important in their preference. This agrees with the findings of this study which indicated that most of the participants were not influenced by their Religion but were influenced by their own interest and desire and the outcome of their preference (Gott, Galena, Hinchliff, & Elford, 2004). However the religious impacts on female obstetric and gynecological preference have been found to be much less than the cultural effects (Bal et al., 2014). In contrast to the above, Hindu women are very reluctant to undress for examination. They prefer same- sex nursing since disregard of modesty can cause extreme distress and they do not compromise with it (Neuhaus, Memeti, Schäffer, Zimmermann, & Schäffer, 2016). Similarly, it was also found that when caring for a Buddhist cancer patient, it is preferred that the doctors and nurses be of the same gender, if possible to ensure comfort and satisfaction (Moore, 2014).Though the Christian religion is of much concern about issue of modesty and decency, there is no religious objection about being nursed by a male or a female nurse (Rumun, 2014). This agrees with the findings of the current study that Christians are expected to keep their bodies sacred and remain chaste and decent but their preference for a gender of a nurse depend on their personal interest. It may be impossible to honor every patient‘s religious needs for modesty when providing health 114 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care care therefore, exceptions should be allowed for emergencies and necessary activities (Padela & Rodriguez del Pozo, 2011). 5.2.7 Cultural Factors as a Determinant for the Preference of a Nurses’ Gender for Nursing Care. The participants of the present study indicated that it is not respectful or polite to see the nakedness of an elderly woman who can be your mother. Furthermore, there are some part of a woman that is, her breast and perineum when she is not your wife the Ghanaian culture does not permit anyone to see. Similarly, Jewish, Chinese and Islamic women have problems with being alone with the opposite gender, being naked with a male provider as well as being touched by a male provider. Such actions are considered immoral in those cultures (Andrews, 2011). In the same vein, Rosario (2010) has proven that woman of Micronesia, an unincorporated territory of the United State in Chamorro culture does not feel comfortable showing or exposing their body outside an acknowledged intimate relationship. To do so is contrary to the Christian moral standard of modesty that is valued highly in Chamorro culture (Rosario, 2010). Furthermore, the participants in the current study revealed that some people in the Ghanaian setting have been brought up not to have choices, they accept whatever is given to them without complaining. This is comparable to a study in China by Cai et al. (2011). They established that in Eastern culture due to modesty people shun the attention of others and do not behave assertively by voicing out their feeling in the name of culture. They added that this patterns of life should be reversed such that violation of the modesty norm via immodest explicit self-praise will lead to implicit self- effacement. A patient‘s satisfaction and quality of care may improve in the health-care setting if the system takes into account peoples' strong feelings about modesty. If there is more focus on 115 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care privacy and respect, patients may feel more valued and respected (Andrews, 2011; Gupta, 2010; Hammoud, White, & Fetters, 2005). These findings may indicate the need to research into the influence of culture on health seeking behaviours among Ghanaian patients with specific focus on patients‘ preference. 5.3 Effect of the Preference for Nurses’ Gender in Nursing Care. Three (3) subthemes emerged. These included: effect of asking for a preferred gender of a nurse for nursing care, effect of not getting a preferred gender of a nurse for nursing care and benefit of getting a preferred gender of a nurse for nursing care. 5.3.1 Effect of asking for a preferred gender of a nurse in Nursing Care. It was found in the present study that patients do not have choices and the hospital does not accept patients‘ choices. Secondly, if you insist on your preference you may be ignored, neglected or embarrassed by the nurses. This agrees with the findings of a study in a similar context from the Talensi-Nabdam district of Northern Ghana indicating that healthcare providers‘ attitude influenced women‘s healthcare-seeking behaviours negatively (Yakong, Rush, Bassett-Smith, Bottorff, & Robinson, 2010). The women in the study of Yakong et al. (2010) further lamented that they were scolded for not seeking care earlier, for not practising birth control, or for asking questions. They were also threatened with treatment withdrawal or denial if they did not comply with instructions from nurses, and were treated ‗like children‘, ignored, and disrespected. In addition, a study by Moyer et al. ( 2014) revealed maltreatment during labour and delivery in rural northern Ghana. The women in this study indicated that they are mostly insulted and neglected especially when they try to ask questions concerning their care. Seeger (2015) also found that patients may avoid making requests for accommodations because of the risk of negative reactions from the healthcare facility. There may also be associated 116 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care frustration of patients from increased waiting time or from the healthcare facility if there is a lack of understanding or ability to accommodate the requests they make (Seeger, 2015). 5.3.2 Effect of not getting a Preferred Gender of a Nurse in Nursing Care. The participants in the current research revealed that they encounter some bad consequences when they are not nursed by a preferred gender. Others however indicated that they were not affected in anyway by the gender of a nurse who provides care for them. The study participants specified the psychological effect associated with not getting a preferred gender of a nurse to care for patients to be feeling of shyness, feeling bad and uncomfortable, feeling of guilt and anger, not feeling happy and satisfied (Schoenthaler, Allegrante, Chaplin, & Ogedegbe, 2012). This reflected the findings of a study in Malawi by Umar et al. (2013) that male client undergoing circumcision suffered distress, sexual undertone and the client and female provider‘s discomfort and embarrassment. Moreover Inoue, Chapman, and Wynaden (2006) found that equally male nurses go through a lot of tension, stress, discomfort and embarrassment when providing care involving touching and exposure of private parts just as the female patient encounter when they do not get their preferred nurse in nursing care (Eswi & El Sayed, 2011; Inoue, Chapman, & Wynaden, 2006). Interestingly, Randall and Hill (2012) showed that children may also feel embarrassed at receiving care from a nurse of the opposite sex. The physical effects associated with a patient not getting a preferred gender of a nurse in nursing care in the current study were found to be forcing discharge against medical advice, refusing treatment, leaving to another hospital, prolong stay at the hospital, increase in hospital bills, seeking medical treatment elsewhere which could be detrimental and not able to ask questions. The findings of (Eriksson & Svedlund, 2007; Hasnain, Connell, Menon, & Tranmer, 2011) support the findings of this present study and proved that when patients‘ needs are not met they become 117 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care dissatisfied with health care and avoid seeking care at a health facility but turn to places that may be detrimental to their health. Additionally, patients may delay until advanced stages of disease, ultimately resulting in poorer outcomes and higher costs. In addition, many American Muslim women reported delays in care seeking due to a perceived lack of female clinicians. Furthermore, women with higher levels of modesty and self-rated religiosity had higher odds of delaying care also due to lack of female providers in the health sectors (Vu, Azmat, Radejko & Padela, 2016). Other participants also disclosed that the gender of a nurse does not really add anything to their satisfaction with nursing care. They really do not encounter any bad consequence such as dissatisfaction when they are not nursed by a preferred gender they can adjust to any gender of a nurse (Johnson et al; 2005). 5.3.3 Benefit of Getting a Preferred Gender of a Nurse in Nursing Care The benefits of getting a preferred gender of a nurse have been grouped under psychological and physical benefit. The study participants mentioned some of the psychological benefits of getting a preferred gender of a nurse in nursing care as, feels comfortable, makes them relaxed, feels cared for, gives hope, feels good, become satisfied, takes off burden and no embarrassment. Similarly, Patients feel satisfied with health care when they are seen by their preferred health provider (Janssen & Lagro-Janssen, 2012; Atingaa, Bawolea, & Nang- Beifubahb, 2015). The findings of Paternotte, van Dulmen, van der Lee, Scherpbier, and Scheele (2015) also corroborate with the findings of this current study that patients had physical benefit when nursed by a preferred gender. In addition, they have good interactions and are able to communicate their concern and get solution to their problems when nursed by the preferred gender (Paternotte et al., 2015). 118 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care 5.4 Barriers to Patient’s Preference of a Nurse’s Gender in Nursing Care. Six (6) subthemes were obtained namely: Attitude of nurses as a barrier for not getting a preferred gender of a nurse, Inadequate male nurses as a barrier for not getting a preferred gender of a nurse, Hospital policy as a barrier for not getting a preferred gender of a nurse and Attitude of patients as a barrier for not getting a preferred gender of a nurse. These are discussed in the subsequent section. 5.4.1 Attitude of Nurses as a Barrier for not getting a Preferred Gender of a Nurse in Nursing Care. The present study found that some attitude of nurses prevents patients from requesting and getting a preferred gender of a nurse. A similar study by Blennerhassett (2007) showed that, it seems nurses use their power to determine patients‘ choices. Secondly, participants in the current research reported that nurses become angry, insult patients and ignore their choices and do not offer them their request. In a similar study in South Africa, 94.9% of participants reported to have observed discriminatory nursing interventions, or had witnessed situations that nurses refused to provide care because of a patient's behaviour of demanding for their right (Khalil, 2009). Another study carried out to determine the prevalence and pattern of disrespectful and abusive care during facility-based childbirth in Enugu, southeastern Nigeria revealed that 98.% of respondents reported at least one form of disrespectful and abusive care during their last childbirth. Non-consented services and physical abuse were the most common types of disrespectful and abusive care during facility-based childbirth, affecting 54.5% and 35.7% respondents, respectively. The study concluded that disrespect and abuse during childbirth are highly prevalent in Enugu (Okafor, Ugwu, & Obi, 2015). 119 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care 5.4.2 Hospital Policy as a Barrier for not getting a Preferred Gender of a Nurse in Nursing Care. Firstly, the participants of the present study indicated that they are not asked and are not given the chance to choose though most of them had preference and wish they were asked. This findings supported the study of Haron and Ibrahim (2012) that patients are not ask to choose the gender of their care providers but wished they were asked. Secondly, they pointed out that nurses attended to patients at random without the knowledge of the patients was a barrier that prevented patients from having the chance to choose and this supports the findings of (Johnson et al; 2005).To add to that, several participants in a study by O'Lynn and Krautscheid (2011) indicated that nurses assumed what patients wanted and needed and did not give them the chance to talk about their preference. The participants showed interest in the involvement in deciding whether intimate touch was necessary and whether there were alternatives for them (O'Lynn & Krautscheid, 2011). Thirdly, patients of the present study indicated that the hospital has no policy that gives them the chance to choose a preferred gender of a nurse for nursing care and will not factor their religious norms into their policy therefore, it will not be necessarily to request for their preference. Interestingly, the results presented here challenge the medicine‘s claim to exemption from prevailing social norms. The law allows hospitals and physicians to accommodate patients' reasonable privacy interest in shielding their nakedness from the opposite sex. Furthermore, justice requires hospitals and physicians to comply with patient requests for a female or male physician or nurse when those requests are based on patient characteristics rather than provider generalizations (Watson & Mahowald, 1999). Similarly, Muslim women in the United state found that health providers‘ lack the accommodation of cultural beliefs, especially modesty needs in their policy and that is against patient‘s right (Hasnain et al., 2011). Haron and 120 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care Ibrahim (2012) equally suggested that hospitals should allow patients to choose their preference because patients normally have issues that need to be addressed but are not able to complain unless they are asked. Moreover, the present study‘s participants identified that some hospitals and some departments for the nature of the care they render do not allow male or female nurses to work in some units such as the maternity and orthopaedic wards. As such patients may not get their preferred gender of a nurse when admitted to these units. Similarly, in a Turkish sample, the students indicated that Intensive Care Unit, operating room and emergency departments are seen as proper places for male nurses to work. On the other hand maternity and paediatric clinics were not seen as fit places for males to work (Akansel, 2008). 5.4.3 Inadequate male nurses as a barrier for not getting a preferred gender of a nurse in Nursing Care. From participants‘ observation, there are inadequate male nurses in the Ghanaian healthcare setting and in instances that a patient prefers a male nurse they may not get their preferred gender. Similarly, the ministry of Health, Ghana presented a Holistic Assessment of the Health Sector Programme of Work 2013, Final version 30th July 2014. One of the identified challenges facing the Nursing and Midwifery Council of Ghana was inadequate nurses to occupy various health facilities in the country (Health., 2014). Secondly the findings of the current research agrees with the data of the Ministry of Health of Ghana report that only 13.5% of nurses are males and male midwifes are insignificant in Ghana (Integrated personel pay roll data of MOH Ghana, 2016) . Similarly, Aranda, Castillo-Mayén, and Montes-Berges (2015) reported that Ghana experiences inadequate male nurses in the health sector. The study of Sherman (2010) is consistent with the findings of the current study that there are situations where male nurses are not available to take care of intimate health issues confronting male patients as well as 121 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care females who preferred male nurses. Besides, some patients of the present study do not bother themselves to make their preference known. This confirms the findings of (Crossan & Mathew, 2013). 5.4.4 Patients’ Attitude as a Barrier for not getting a Preferred Gender of a Nurse in Nursing Care. This subtheme describes the attitude (behaviour) of patients that make it difficult for them to have their preferred nurse, when it comes to expressing their preference for nurses‘ gender because of timidity and fear of being embarrassed. Patients in the current study identified that in general they are not able to ask for their needs. In a related study by Harona & Ibrahim (2013), patients were unassertive because they viewed the doctors as experts and thus more knowledgeable. In a similar way, some patients in the present research feel shy and not able to express themselves in front of health workers so they keep quiet though they are sometimes not comfortable with their nurses‘ gender. Others participants in this study indicated that patients are not courageous, they tolerate whatever is given to them without complaining though they were not happy about it. Lastly, participants in this current study revealed some anticipated challenges that might serve as barriers to their preference for nurses‘ gender during nursing care. Participants further indicated that if they were visiting a hospital for the first time it will not be possible to have a preference because they may not know how the male or female nurse is going to treat you. Additionally, patients are going to have different preference and the economy cannot cater for that. In addition, some gender of nurses may not have work to do and some may be beginners learning from the nurse that is not preferred by a patient. Fan et al. (2017) agreed with the 122 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care findings of this study that challenging situations may arise when there is a shortage of staff or when the patient refuses the gender of the nurse which is offered him. An additional theme emerged from the study when participants were asked to comment and contribute to the research topic. This theme was, Perspectives of Participants on issues in Nursing and is discussed in the next section. 5.5 Perspectives of Participants on certain issues in Nursing. This section focuses on the unexpected findings that participants identified through content analysis. The suggestions are in connection with nurses and nursing care. Four (4) subthemes emerged under this theme, they included: Qualities of a preferred nurse, perspective of participants, Attitude of a bad nurse, participant‘s perspectives, stereotypes associated with nurses in Ghana and lastly the need to increase the number of male nurses in the nursing profession. These subthemes are discussed below accordingly. 5.5.1 Qualities of a preferred nurse, perspective of participants. The participants described the preferred qualities of nurses at the Komfo Anokye teaching hospital based on four (4) characteristics. These incorporated: communication of a preferred nurse, professional competence of a preferred nurse, appearance of a preferred nurse and virtues of a preferred nurse. The findings of these subthemes have been discussed below: The participants in this study reported that the preferred nurse uses terms of endearment when communicating with them and that makes them happy. That is they prefer nurses who use sweet talks, pampering and humour in their care and not just come and carry out her duty for example: do not worry you will be fine; have patience your wound will heel soon, etc. These findings reflected the responses of children at a hospital‘s special school when asked about what 123 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care makes a ‗good‘ nurse. They mentioned that they prefer a nurse who uses humour and sweet talks when providing nursing care (Randall & Hill, 2012). The favourite nurse was expected to be able to perform nursing skills competently and promptly, be knowledgeable, organized, hardworking and efficient and does her work with enthusiasm because when a nurse makes a mistake it mostly cost a patient‘s life. A study supported the result of the current study (Rchaidia, Dierckx de Casterlé, De Blaeser, & Gastmans, 2009). Appearance was emphasized by some participants and was related to the concern of cross infection, reviving patient‘s to continue life and making nurses approachable. Being clean, smelling nice and having a cheerful face appeared to be a common concern for many patients in the study of Brandy (2009). Also the cleanliness of doctors‘ scabs increase the patient‘s confidence (Gherardi, Cameron, West, & Crossley, 2009). Similarly among Japanese outpatients, respondents most preferred the white coat for physician attire. Perceived hygiene and inspiring confidence were important factors for doctor‘s attire (Yamada, Takahashi, Ohde, Deshpande, & Fukui, 2010). A lot of patients who participated in this study referred to many ethical and social qualities, character traits and virtues of nurses that made them their favourite among other nurses. Some of the virtues identified in this study were patience, attentive, helpful, kind, punctual, encouraging, empathetic, polite and friendly. Similarly a research project carried out with 18 nurse teachers at a university nursing school in Brazil to identify the ethical image of nursing revealed similar results: good nurses curry out their duties correctly; they are proactive patient advocates; they are prepared and available to welcome others as persons; they are 124 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care talented, competent, and carry out professional duties excellently; and they combine authority with power sharing in patient care (de Araujo, Zoboli, & Campos, 2010). Patients may prefer a nurse with good qualities rather than the characteristics of a nurse such as age, gender, ethnicity, etc. this calls for future studies on the influence of demographic characteristics on a patient‘s preference for nurses. 5.5.2 Attitude of a bad nurse, participant’s perspectives. A bad nurse was described to portray attitudes such as: neglecting patients in their care, seeking monitory gains before rendering care, ignoring patients‘ needs and complaints and finally raining insults on patients. Several participants narrated their experience with bad nurses as overlooking them as human beings during their care, not involving them in their care, thinking they have no contributions to make. Similarly, Donkor and Andrews (2011) emphasized that nurses are believed to have the notion that the patient is ignorant about his or her health problem and the cure needed and often neglect them. Few participants in this study plainly stated that they have observed that male nurses approach patients first and collect money in the form of bribe before trying to help them but the female nurses are exceptional they will finish working on you before you show appreciation by given a token . Contrary, Williams (2014) reported that there has been a great deal of discussion in recent times about gifts from patients to nurses prompting accusations of preferential treatment. But there is no evidence for this. The researcher insisted that he has not heard or seen any instances where gifts from patients might be seen as an attempt to curry favour or bribe nurses. 125 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care The participants in the present study bitterly complained about nurses‘ attitude of overlooking their concerns. Some of them narrated that nurses do not respond to their needs, asking them to wait for their relatives during visiting time to attend to them or to wait for a doctor to come and review them when seriously in pain. Both assertions are consistent with a study at rural district Hospital in the Kwazulu-Natal province of South Africa by Haskins et al. (2014) which showed that both nurses and patients reported incidences of poor patient care and even wilful neglect of patients‘ basic care. The nurses narrated that in some situations the patient were not helped to the toilet or being fed, the food will come and be placed next to the patient, until the relatives come and feed the patient. Additionally, a research on Nurses‘ stories about their interactions with patients at the Holy Family Hospital, Techiman, Ghana by Korsah (2011) indicated that most people complain bitterly about the bad attitude of nurses during interactions with their clients and this remains a serious problem in Ghana despite criticism and concern raised by the public and health regulatory bodies. He further indicated that he has personally observed nurses who verbally abuse and intentionally neglect clients and their relatives in the hospital. Patients from this study lamented that some nurses have the habit of yelling angrily and using abusive and nasty words on patients with the little mistakes they make or even when they have not done anything wrong. Consistent with this study, Govender and Penn-Kekana (2008) reported that unfortunately, the patient-provider interface has often been described by clients as abusive and discriminatory. Similarly, all participants including ten women and seven midwives sampled from a Catholic hospital in the Central Region of Ghana acknowledged the common practice of maltreatment during labor and delivery. The types of maltreatment described included midwives yelling, screaming, hitting, slapping, humiliating, and neglecting women. All the 126 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care participants indicated that these were common practice experience in Ghanaian hospitals during delivery (Yakubu et al., 2014). Additionally, some nurses trample upon patients‘ rights and treat them with such indignity as verbal abuse, use of foul language, violent and aggressive behaviour, unfriendly attitudes and showing no empathy for the sick and vulnerable people (Donkor & Andrews, 2011). Contrary to the bad attitude of nurses identified by participants in this study, another study has proven that nurses have a neutral attitude towards patients with a history of illicit drug use by showing care and empathy (Chu & Galang, 2013). Nursing involves strenuous physical work, washing patients, lifting them, walking them and generally providing all aspects of care that patients could not perform themselves. These require a special person with a special heart and unique characteristics (Chokwe & Wright, 2011), therefore nursing training institutions must admit and train students who have the potential and what it takes to become better nurses in the future. Policy makers in nursing should institute measures to hold nurses who abuse clients or clients‘ relatives accountable and saction them appropriately to ensure discipline in the nursing profession (Korsah, 2011) 5.5.3 Stereotypes associated with nurses in Ghana. Some participants revealed that they have noticed some particular behaviour associated with male and female nurses in Ghana. This was revealed in participants‘ responses that they have placed some labels on male and female nurses. Patients in this study disclosed that in the Ghanaian healthcare- setting, nursing has always been a female‘s job therefore men in the nursing profession are considered as: inappropriate because nursing is predominantly a female‘s job, effeminate because they end up behaving like females, males should become doctors and females, nurses because males naturally 127 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care do not possess qualities of a nurse and also nursing is like an auxiliary job. Similarly, Bernalte- Martí (2015) found that the relationship between nursing and women is so strong that there are even professionals in this sector who identify medicine with male stereotypes and nursing with female ones. In the same vein, the Canadian society perceives nursing to be a more suitable career choice for women than men (Bartfay et al., 2010). A study added that the common misperceptions of men in nursing included: most male nurses are effeminate and gay; men are not suited to nursing and men are less caring and compassionate than women (Adeyemi- Adelanwa, Barton-Gooden, Dawkins, & Lindo, 2016; Stanley et al., 2016). Consistent with the findings of this study, in Iran, many people think of nurses as simply assistants to physicians (Iranmanesh, Razban, Nejad, & Ghazanfari, 2014). Similarly, the status of the nursing profession is considered low, and the low status deters men from choosing nursing as a career (Liat, Ilana, Pnina, & Orli, 2017). Some of the patients in this study insinuated that although male nurses also go through nursing education, they will not be able to provide nursing care naturally as females unless they apply their training consciously the application will not be natural. In contrast, it has been confirmed that male nurses in Uganda are capable of providing quality nursing care dismissing the stereotype that men cannot be nurses (Achora, 2016). Similarly, participants did not perceive nursing as characteristically feminine role but as a job for both males and females (Liat, Ilana, Pnina, & Orli., 2017). It looks like people still have the perception that nursing is for females although men in nursing are gradually increasing and performing well. These stereotypes may be due to cultural and societal perception on male nurses .Therefore there is the need to clear this idea and stereotypes from the mindset of people by making them aware that male nurses are doing well in 128 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care nursing (Crisp & Watkins, 2017). Further studies need to explore the reasons for males‘ choice of nursing as a career in Ghana in multiple sites. According to patients in this study, female nurses are labelled as having natural and special heart for caring, doing better in terms of caring while male nurses apply a lot of muscles when nursing patients. Stanley (2012) found that nursing is considered an extension of the care- giver role of women. In contrast the gender stereotypes placed on male and female nurses displayed some similarities in terms of their caring ability (Mosqueda-Díaz, Paravic-Klijn, & Valenzuela-Suazo, 2013). The participants of this current study added that most female nurses are proud, insolate and arrogant but when it comes to taking care of patients women do better. Contrary, the findings of a study revealed that the participants were highly satisfied with the nursing care component of the male staff nurses whereas the patients were highly satisfied with the nursing behaviour component of the female staff nurses. The researcher concluded that all nurses no matter the setting, role, ages, gender, are all doing their part toward the same goal of providing quality patient care (James & Merlin, 2016). It appears that stereotypes still abound in our society that females are better nurses and males are not and this is affecting the image of males in the nursing profession. It is therefore recommended to speak against the existing stereotypes that shun young individuals especially males from entering the nursing profession and leaving the profession before retirement (Flinkman, Laine, Leino-Kilpi, Hasselhorn, & Salanterä, 2008). 5.5.4 The need to increase the number of male nurses in the nursing profession. Some participants wishfully suggested at the end of the interview that more males should be encouraged and given the chance to enter into nursing to be available for patients who prefer 129 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care only male nurses. Secondly, nursing should be made attractive by not making it looks like a servant‘s job (Borkowski, Amann, Song, & Weiss, 2007). Likewise, there should be more slot for men who apply to the nursing training schools, some of them even do better than the women (they are able to control their emotions). A study similarly indicated that by exposing male students at a younger age to the diversity, mobility and autonomy that nurse practitioners and clinical nurse specialists have also help in recruitment targeting and generate interest in the work they perform (Coleman, 2008). Similarly, in a study by Meadus (2000) the researcher stressed on the need to increase the recruitment of men in nursing to cater for the shortage of nurses in the health care system. Seventy-three percent of his participant rejected the idea that only women should be nurses, and 77% confirmed that male nurses are strong as well as courageous to carry out responsibilities of nurses (Meadus, 2000). Participants in the current study narrated that both males and females could be better nurses and therefore more males should be involved to match the females in the nursing profession. Akansel (2008) supported the findings of the current study that men entering into the nursing profession will make a difference and improve the nursing profession. The researcher also reported that men will improve negative perceptions of health care teams about nursing and lastly men are typically seen as better leaders than women (Akansel, 2008). Moreover, an increase in male nurses may create a cultural change in the profession, for example less emphasis on task-orientated routines and the creation of a more ethically sensitive and empathic mode of nursing that responds holistically to the wishes and needs of male and female patients (Prideaux, 2010). 5.6 Evaluation of the Rational Choice Theory. The rational choice theory developed by Homans was useful in this study because it assisted the researcher to explore the preferences of patients for nurses‘ gender in nursing care. 130 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care The researcher used the various construct and assumptions of the theory in formulating the research objectives and subsequently came out with an interview guide. The rational choice theory indicates that every individual has preferences among available alternatives that enable him to choose which option he prefers most. The preferences of individuals are determined by the past information, desires, beliefs and values on the options. The theory assumes that people make choices based on a thoughtful and purposeful action depending on a perceived outcome of benefit or importance to arrive at maximizing personal happiness, satisfaction, and utility. In addition, an individual is assumed to make a choice according to constrains or barriers facing them. The theory assisted the researcher to explore the preferred gender of a nurse which came out that most patients are indifferent. Secondly, it helped in eliciting responses from participants to reveal the determinants of their preference and the major determinant was the personal interest as well as the situation that the individual finds himself. Thirdly, the patients considered the effect of the preference such as becoming comfortable, satisfied and quick recovery before making a choice. Also it was found that participants made a choice by taking into account the anticipated insult and neglect from nurses, the availability of the preferred nurse and the accommodation of the patient‘s preference by the hospital before making a choice. All the constructs in the model were useful for the study. The ‗information‘ in the model was modified to be the past experience with nurses, the ‗beliefs‘ as cultural and religious factors, the ‗desires‘ as personal interest and the ‗action‘ as the preferred gender of a nurse to be chosen. Two themes emerged that were congruent with the constructs in the model; the most preferred gender of a nurse in nursing care as action in the model, and patients‘ reasons for the preference or no preference for a nurses‘ gender in nursing care as information, desires and beliefs. Secondly, two other themes were also consistent with the assumptions of the rational decision 131 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care theory; effect of the preference for nurses‘ gender with which the theory assumes that people make choices based on a thoughtful and purposeful action depending on a perceived outcome of benefit or importance to arrive at maximizing personal happiness, satisfaction, and utility, barriers associated with the preference of a nurse‘s gender in nursing care with which the theory assumes that individuals make a choice according to constrains or barriers facing them. The following are other assumptions of the theory that were consistent with the findings of this study:  The preferences of individuals are assumed to be complete (the person can always say which of two alternatives they consider preferable or that neither is preferred to the other). Truly, the participants indicated the preference of a male nurse, a female nurse or had no preference for nurses‘ gender in nursing care.  Another assumption of the rational choice paradigm is that individual preferences are self- determined and self-interested and this reflected in the study that participants considered their wellbeing before making a choice and not a religious or cultural obligation through they were bounded by them.  Individuals choose the best action according to the constraints facing them. In this research, most participant were indifferent because the hospital did not have a policy that enables patients to chose a preferred gender of a nurse and moreover, the perceived attitude of nurses as well as the inadequate male nurses in the facility deterred participants from indicating their preference resulting in no preference.  In addition, the theory assumes that people learn from their past experiences, and that explains their behaviour and this reflected in the study that pasts experience with both genders of nurses determined patients‘ preference for their nurses. 132 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care However, the assumptions below were not useful to the study:  The rational agent is assumed to be well informed about the options available but in this study the participants were not fully informed about the alternatives.  Participants considered the potential costs and benefits in determining preferences but did not act consistently in choosing a preferred nurse because they indicated that the situation (the type of care, the condition and the hospital policy) would determine their preference. The study additionally found the biological characteristics of the individual such as the gender, situational factors, religious and cultural factors as a determinant of patients‘ preference. The researcher suggests that the rational choice model should incorporate situational influence, biological characteristics of the individual, religion and culture into the determinant of preference in the domain of the model and also include the outcome as well as challenges of an individual‘s preference as constructs of the model. 133 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care CHAPTER SIX SUMMARY, IMPLICATIONS FOR NURSING, LIMITATION, CONCLUSION AND RECOMMENDATIONS 6.0 Introduction This final chapter summarized the key findings of the entire research. The implications of the study findings to nursing practice, nursing education, nursing administration nursing and research are also presented accordingly in this chapter followed by limitations of the study and the researcher‘s reflections on the findings as well as conclusion. The chapter ends with recommendations drawn from the findings specifically for the Komfo Anokye Teaching Hospital (KATH) and the Ministry of Health (MOH). 6.1 Summary of the study Researches indicate that patients are individuals who come from a wide variety of religious, social and cultural backgrounds therefore, have varying preference when it comes to the gender of a nurse (Rosario, 2010; Schouten, Meeuwesen, Tromp, & Harmsen, 2007). Over the past years, there have been concerns raised worldwide about patients‘ satisfaction with health care in the health sector (Ademuyiwa, Mosaku, Ogbolu, Oshodi, & Bode, 2017; Quintana et al., 2006). Moreover, numerous studies have emphasized the influence of patients‘ preference for providers‘ gender in the provision of Patient centred care and in ensuring patient satisfaction and better health (Lee & Lin, 2010; MacWilliams, Schmidt, & Bleich, 2013). The primary aim of this study was to investigate patients‘ preference for nurses‘ gender in nursing care at the Komfo Anokye Teaching Hospital, Kumasi. The study was guided by the Rational Choice Theory by Homans in 1961. An exploratory descriptive design to qualitative research was employed in the 134 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care study. A purposive sampling technique was used to recruit participants from adult medical and surgical ward and a semi-structured interview guide based on the research objectives was used to collect data from participants. Saturation was achieved at the 14th participant. Thematic content analysis was used to analyze the data. The main themes that emerged included: the most preferred gender in nursing care, patients‘ reasons for the preference or no preference for nurses‘ gender in nursing care, effect of the preference for nurses‘ gender, barriers associated with the preference of a nurse‘s gender in nursing care and perspective of patients on issues in nursing. The findings showed that patients had varying preference for their nurses. However, majority (8) of the participants did not have preference for a particular gender of a nurse. They consider their wellbeing, the type of care, the religion, the culture, the condition, attitude of nurses and the hospital‘s policy before deciding on a preferred nurse though their major priority was their welfare that is, the nurse with the qualities that will help them improve in their health and not the gender of a nurse. However, same gender nurse was preferred for intimate care procedures. Secondly, participants become comfortable, relaxed and satisfied when nursed by a preferred gender. In addition, they feel embarrassed, uncomfortable, angry and guilty when they do not get a preferred gender of a nurse especially for intimate procedures. Finally, other result that emerged from the data revealed that some nurses were good but the majority of them had bad attitude, male nurses were labelled as unsuitable for the nursing profession whiles female nurses were viewed as better nurses in Ghana and finally there is the need to increase the number of male nurses in the nursing profession in Ghana to be able to meet the needs of patients who prefer male nurses in nursing care. However, male nurses were noted by participants as excellent nurses when it comes to lifting of patients and procedures which involve the use of extra energy. 135 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care In addition, participants mentioned that male nurses are preferred by patients because male nurses are able to operate certain devices or machines better when it comes to patients‘ care. The findings were consistent with the Rational Choice theory which was employed for the study. The theory explained that an individual has preferences among available choice alternatives and chooses the self-determined best choice of action according to the available information, personal interest, believes and values, probabilities of events and the constraints facing them (Levin & Milgrom, 2004). Such an individual acts after balancing costs against benefits to arrive at action that maximizes personal happiness, satisfaction, utility or advantage (Grüne-Yanoff, 2012). 6.2 Implications for Nursing The findings of the study suggest several implications for nursing practice, nursing education, nursing administration and nursing research in general. First, the implications for nursing practice in. 6.2.1 Implications for Nursing Practice The results would help nurses to better understand patient preference and design care that would enhance patient satisfaction. Due to cultural, religious influence as well as issues of morality and decency on health seeking behaviours: there is the need to involve a chaperon (a third person to serve as a witness during intimate care procedures) in nursing practice to prevent issues of immorality; nurses should incorporate patient centred care into their practice, provide care based on patient values, needs and preference to ensure quality nursing care; nurses should improve their knowledge and 136 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care develop themselves on transcultural nursing to be able to improve the quality of patients‘ care resulting in patient‘s satisfaction. The responses indicate that when patients get a preferred gender of a nurse they may be relieved of their psychological and physical burdens and that may enhance their interactions with nurses and influence the overall recovery. Patient‘s rights and preferences for nurses gender in nursing care should therefore be respected and adhered to in order to improve quality of care. As a result of the bad attitude of nurses indicated by the participants of this study, there is the need for policy makers in nursing to institute measures to hold nurses who abuse clients or clients‘ relatives accountable and saction them appropriately to ensure discipline in nursing pactice. 6.2.2. Implications for Nursing Education The findings of the study revealed that it would be difficult to relate to the opposite gender, there may be tension on the part of both the nurse and the patient. Therefore education on privacy and dignity as well as the provision of intimate care procedures should be integrated into the nursing curricula at all levels. Secondly, nursing faculty should prepare nursing students to interact with opposite gender clients in a way that will promote and enhance future interactions after their training and provide counsellors to discuss problems that may emerge during their training and experience with client. For instance, through role play student nurses can learn how to interact with opposite and same sex in a meaningful and acceptable manner. The study has revealed the need for integration of diverse culture and religion into the nursing curriculum to prepare student nurses to manage patients with diverse culture background appropriately without cultural conflicts. 137 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care In the study, it was realized that some nurses first seek financial gains before rendering nursing cares to patients, ignore patients‘ needs and complaints and finally rain insults on patients which impacted negatively on patients‘ satisfaction with health care. This implies that nurses as well as student nurses should be taught the rights of patients and be encouraged to respect them. Secondly, the attitude and good qualities of nurses were paramount to patients‘ satisfaction in the study therefore nurses should be trained periodically through workshops and in-service trainings to improve on their care qualities whiles in school and in practice. Nursing is still a largely female dominated profession. Male nurses are faced with challenging traditional gender-defined roles and stereotypes from the society. At the same time, their contributions to patients care are being recognized by patients in this research. For example, their outstanding input when it comes to lifting of patients and procedures which involve the use of extra energy as well as machines. There is therefore the need for institutional support programs for male nurses in school and in practice to help build their capacity and enhance their self esteem. Secondly, the positive experience of male nurses such as their excellent contribution to the nursing profession needs to be publicized in the media, to encourage recruitment and retention of more men into the profession. School educators should encourage students to manage gender related problems by emphasizing nurse‘s role identity without any gender segregation. The findings of this study suggest that the Nursing and Midwifery Training Schools should admit adequate number of male students to help minimise this challenge. Nursing profession should be provided the best candidates without any gender segregation in order to attract people with good qualities and good attitude into nursing. Nursing schools, media and professional journals should emphasize nursing roles and portray positive image of the nursing profession as well as males in nursing. A community education campaign to 138 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care improve the image of nursing profession should be initiated. There is also an urgent need in regulations on rights of nursing professionals and males in nursing. Clarifying the role identity of the graduates under different titles but same job content in Ghana will help both public and students to accept nursing as an excellent career. 6.2.3 Implications for Nursing Administration The results of the study show that:  Hospital employment policies should factor in the gender of nurses and ensure that the required gender(s) are placed in every department and on shift basis to cater for the preferences of patients if any. In addition, nursing administration desks at the Ministry of Health and Ghana Health Service may team up and develop policies which may encourage patients‘ rights in terms of preference for nurses gender during their care at all levels.  Routine and periodic supervision of nurses is also needed to ensure that nurses are rendering the needed cares to patients in their custody. 6.2.4 Implications for Nursing Research The study may serve as a foundation for other research and also inform future research since it is likely to be the first of its kind in Ghana. The study pointed out that patients prefer a nurse with good qualities rather than showing any relationship between the demographic characteristics of the nurse and type of preference of the patient for a particular gender. This therefore calls for a future study on the influence of demographic characteristics on a patient‘s preference for the gender of their nurses in Ghana. For example, age, gender religion and educational level. Another research is recommended on the 139 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care qualities of the most preferred nurse, from patients‘ perspectives. The findings of such research may give us a better understanding of the qualities that nurses should exhibit in their interactions with patients, which will go a long way to define quality of nursing care in particular and overall quality health care. The study findings have shown the need for further research with patients from several public and private hospitals in the rural and urban towns to appreciate the phenomenon of patients‘ preference for their nurses‘ gender in nursing care better using a quantitative approach with a larger sample to allow generalization of the findings. This is because the phenomenon in question is influenced by religious and sociocultural factors which vary in different geographical locations. Patients indicated a strong need for the same gender nurse especially in intimate care procedures. As a result, further research needs to be carried out to understand experiences of female patients receiving care from male nurses and the experience of men in nursing in Ghana. Future research on preference of women for the gender of their midwives in Ghana is also recommended to inform the continuation of male midwifes or not since the training of male midwives in Ghana has come to a halt. Further research needs to explore patients‘ understanding of intimacy in nursing care to understand how patients feel when going through such procedure. 6.3 Limitations of the study There were several limitations with the present study. First, gathering of literature was difficult for the researcher since literature on the area of research is limited. Second, 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 140 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care participants were from the medical and surgical wards, preferences of patients from other wards might be different. Therefore the findings of this study may not be widely generalizable. Therefore, a replication of the study is recommended with patients from other departments of the KATH, public, mission and private hospitals in Ghana in order to justify statistical connection. 6.4 Researcher’s Reflections on the study During the process of data collection, the researcher saw that most of the patients were passionate about the area understudy. However, they factored into the conversation their experiences with the hospital environment especially with the attitude of nurses and the challenges they faced at the hospital which were not in line with what were actually asked. In addition, most of them were much concerned about the provision of intimate care procedures and suggested a same gender nurse or the involvement of a chaperon with such procedures. Moreover, some participants were not straight forward in their responses, and needed extensive probing before given detailed responses of their experience on the issue under study. 6.5 The influence of the study on the researcher The researcher has been educated by this research as the findings have offered her a better understanding of patients‘ perceived preferences for nurses‘ gender in their care. The researcher has also gained insight into the experiences that patients go through when receiving care at the hospital. As a professional nurse, she has recognized what patients‘ perceptions are through this qualitative research and have learnt so much in terms of the processes involved in qualitative research 141 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care 6.6 Conclusion Patients have preference for their nurses. They preferred a nurse with good qualities yet others are interested in the gender of the nurse as that enhances the wellbeing of patients. 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‘ preference 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 policy makers factor patients‘ needs and preferences into health policy to satisfy the preference of patients. It is important that nurses demonstrate good attitude towards patients to improve the recovery process of patients. Health training institutions should increase the number of male intake in the nursing training schools to cater for patients who prefer male nurses. Also the education of the general population should be intensified through the media, churches, schools and institutions by nurses against negative stereotypes associated with nurses in Ghana to attract more men into nursing profession. Patients would feel comfortable and satisfied with the services of nurses when nurses demonstrate good attitude during patients‘ care. As the number of the nurses grows, it may create a cultural change in the profession and the creation of a more ethically sensitive and empathetic mode of nursing that responds holistically to the wishes of male and female patients. Patient satisfaction and quality of care may improve in the health-care setting if the system takes into account peoples' strong feelings about modesty. If there is more focus on privacy and respect, patients may feel more valued and respected. This would make the health care attractive and appreciative to patients irrespective of the cultural or religious background. 142 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care 6.7 Recommendations 6.7.1. To Management of the Komfo Anokye Teaching hospital It seems that the Patients‘ Charter is been violated because patients‘ rights are not considered in most times due to lack of resources to accommodate patients‘ needs. It is recommended that all hospitals assess nurses‘ attitudes regularly to ensure that patient care is not compromised. The religious and cultural background of patients should be considered and their values factored into health care to provide gender-concordant care. From the above, the effect of not getting a preferred gender of a nurse could be detrimental as such patients‘ voice should be heard and given the needed attention so that health care would be attractive to patients. The findings of this research draw attention to the need to offer patients gender-concordant healthcare providers to maximize communication between patients and providers to achieve patients‘ goals and aspirations 6.7.2 To The Ministry Of Health (MOH), Ghana The researcher recommends that a high percentage of male nursing students need to be reconsidered by health policy-makers in Ghana. Recruitment of adequate number of male applicants into the Nursing Training Institutions is recommended to compensate for such situation and also to match the number of female nurses for every patient to get access to his preference when needed. It appears that stereotypes still abound in our society that females are better nurses and males are not and this is affecting the image of males in the nursing profession. It is therefore recommended to speak against the existing stereotypes that shun young individuals especially 143 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care males from entering the profession and leaving the profession before retirement. In addition, a public awareness campaign on the capabilities of nurses with more of them veering into specialties and higher positions in the society will clarify misconceptions that nursing is an auxiliary job. Due to the bad attitude of some nurses towards patients, inservice training, workshops and training seminars should be organized periodically for health workers especially nurses on legal issues surrounding the profession for them to be abreast with legal issues on patients. Patients should be education on their rights and the patient‘s charter should be displayed at vantage point in all health facilities for easy accessibility. Legal practitioners should be encouraged on the area of health law to advocate for patients‘ right. In addition, there should be sanctions from regulatory bodies such as the nursing and midwifery council of Ghana against nurses who violate patients‘ right as the body do not tolerate breaches of patients‘ rights. 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PREFERRED GENDER a) Tell me about the gender you prefer most when you are receiving nursing care? b) What other characteristic do you look for in a preferred nurse apart from the gender? 2. REASONS FOR THE PREFERENCE a) Why do you prefer this particular gender you have mentioned? a) Tell me about your previous interaction with both male and female nurses? b) Tell me if you have any religious, cultural or social restrictions that prevent a particular gender of a nurse from providing nursing care for you? c) What do you think about male nurses providing intimate care for female patients? d) What do you think about female nurses providing intimate care for male patients? 3. EFFECT OF THE PREFERENCE a. Describe a situation where you have had a positive experience while receiving nursing care from a male and female nurse. b. Tell me about when you experience an uncomfortable situation while receiving nursing care from a male or female nurse? c. Tell me how you feel when you are not nursed by a nurse with the gender of your choice? d. Describe how dissatisfied you become when you are not nursed by a nurse with the gender of your choice? e. What are the effects when you ask for a preferred gender of a nurse for nursing care. 4. BARRIERS TO THE PREFERENCE OF A NURSE IN A PATIENT’S CARE a. In your view what are the barriers that may prevent you from being nursed by a preferred gender of your choice? b. What reasons do you have in mind, which are likely to prevent you from getting your preferred gender? c. What else do you have in mind to share with me in terms of your preference for nurses‘ gender during nursing care in this hospital? Thank you. 2 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care APPENDIX C: INDIVIDUAL CONSENT FORM CONSENT FORM Title: Patients’ Preference for Nurses’ Gender at the Komfo Anokye Teaching Hospital, Kumasi. Principal Investigator: Akua Owusua Asante Address: School of Nursing, College of Health Sciences, University of Ghana. General Information about Research I would like to seek information about your preference for nurses‘ gender when receiving nursing care. The information that will be collected will help to understand why a patient prefers a particular gender of a nurse than the other or has no gender preference, factors that influence a patient‘s preference for a nurse‘s gender, the effect of the preference and the barriers associated with the preference of a nurses‘ gender. I will have a face to face interview with you, and this will last for about forty five to sixty minutes in English or Twi Languages. There will be no right or wrong answer and therefore you should be free to share your views on the questions posed to you. The interview will be related to your preference for a particular gender of a nurse, that is a male or a female nurse. You will be asked to sign a consent form before the interview. The interview will be recorded with your permission. Possible Risks and Discomforts It is not expected that your participation in this study will expose you to any harm; however, if during the interview you become emotional, the researcher will give you a break for you to relax and put yourself together before continuing the interview. Possible Benefits You may not have a direct benefit at the moment; however, your participation in this study will help to understand why a patient may prefer a particular gender of a nurse than the other. This will help to improve the knowledge base of nurses, health workers and the society at large and will help them to improve upon health delivery and the quality of nursing care to patients. 3 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care Confidentiality Although the conversation between you and I will be recorded, you will not be named in any reports. A pseudonym or a code number will be attached to the information you will give during the interview. The only other person who can have access to the information will be my two supervisors. Secondly, the audiotapes, transcripts, field notes, demographic information and consent forms will be kept in the office of the head of adult health department, School of Nursing, University of Ghana for five years until it is finally discarded. Permission has been sought from the IRB and the hospital to interact with you on this topic. Compensation You will be provided with a snack at the end of the interview as an appreciation for your time. Voluntary Participation and Right to Leave the Research Your participation in this study is voluntary, and therefore you have the right to withdraw from the study at any point in time without given any explanation. Your participation in the study or your withdrawal at any particular time will not affect your treatment in this hospital. Contacts for Additional Information If you have any challenges or questions, you may contact any of the following persons: Akua Owusua Asante Presbyterian University College P. O. Box 42, Agogo-Asante Akyem Phone Number:+2330244572818 Email: akuaowusuaasante@yahoo.com Dr. Kwadwo Ameyaw Korsah School of Nursing, University of Ghana Phone Number: +2330243547317 Email Korsah19@yahoo.com 4 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care Ms. Patricia Avadu School of Nursing, University of Ghana Phone Number: +233244560130 Email patavad62@yahoo.com Your rights as a Participant This research has been reviewed and approved by the Institutional Review Board of Noguchi Memorial Institute for Medical Research (NMIMR-IRB). If you have any questions about your rights as a research participant you can contact the IRB Office between the hours of 8am-5pm through the landline 0302916438 or email addresses: nirb@noguchi.ug.edu.gh VOLUNTEER AGREEMENT The above document describing the benefits, risks and procedures for the research title (Patients’ Preference for Nurses’ Gender at the Komfo Anokye Teaching Hospital, Kumasi) has been read and explained to me. I have been given an opportunity to have any questions about the research answered to my satisfaction. I agree to participate as a volunteer. _______________________ _________________________________________________ Date Name and signature or mark of volunteer 5 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care If volunteers cannot read the form themselves, a witness must sign here: I was present while the benefits, risks and procedures were read to the volunteer. All questions were answered and the volunteer has agreed to take part in the research. _______________________ _________________________________________________ Date Name and signature of witness I certify that the nature and purpose, the potential benefits, and possible risks associated with participating in this research have been explained to the above individual. _______________________ __________________________________________________ Date Name Signature of Person Who Obtained Consent 6 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care SECTION C – SIGNATURES I. As the Student Investigator on this project, my signature confirms that: 1. I will ensure that all procedures performed under the study will be conducted in accordance with all relevant policies and regulations that govern research involving human participants. 2. I understand that if there is any change from the project as originally approved I must submit an amendment to the NMIMR- IRB for review and approval prior to its implementation. Where I fail to do so, the amended aspect of the study is invalid. 3. I understand that I will report all serious adverse events associated with the study within seven days verbally and fourteen days in writing. 4. I understand that I will submit progress reports each year for review and renewal. Where I fail to do so, the NMIMR-IRB is mandated to terminate the study upon expiry. 5. I agree that I will submit a final report to the NMIMR-IRB at the end of the study. II. As the Student Supervisor on this project, my signature confirms that I have read the students work which has been reviewed and approved by the departmental review committee/ scientific and technical committee: 7 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care APPENDIX D: GENERAL PROFILE OF PARTICIPANTS Name Age Gender Ward Educational Tribe Religion Marital (Years) level status Linda 22 Female Surgical BSc. Ga Christian Single Special ward Aseda 62 Female Medical Masters Akan Christian Widow Special ward Dorothy 36 Female Special Masters Akan Christian Married ward John 35 Male Special Class four Akan Traditional Married ward Blazu 46 Male Surgical JSS Kussase Muslim Married B2 Nanama 23 Female Surgical BSc. Ewe Christian Single C4 Obeng 36 Male Medical Primary Akan Christian Single D3 Agyarko 40 Male Medical JSS Ewe Christian Married D4 Kweku 51 Male Surgical Nil Dagomba Muslim Married B1 Happy 25 Female Surgical SHS Bissa Muslim Married C3 Aboagye 24 Male Surgical JSS Akan Christian Single BICU Augesta 31 Female Medical SHS Akan Christian Single D5 Ekow 61 Male Medical Middle Akan Traditional Married D3 School Comfort 70 Female Surgical Nil Kussase Muslim Married BICU 8 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care APPENDIX E: SUMMARY OF THEMES AND SUB-THEMES THEMES SUB-THEMES  Most preferred Gender in Nursing Patients‘ Preference for Male Care. Nurses in Nursing Care. Patient Preference for Female Nurses in Nursing Care. Patients with no Preference for either Male or Female Nurse. • Reasons for the Preference or no Patients‘ Gender as a Reason Preference for Nurses‘ Gender in for the preference of the gender Nursing Care. of a nurse in nursing care. Patients‘ Preference based on Past Experiences. Situation as a determinant for Patients‘ Preference for Nurses‘ Gender. Qualities of nurses not Gender as a determinant for Patients‘ Preference in Nursing Care. Personal Interest as a determinant for Patients‘ Preference for nurses‘ Gender in Nursing care. Religion as a factor in patients‘ preference for Nurses Gender. Cultural factors as a determinant for the preference of a Nurses‘ Gender for Nursing Care. 9 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care  Effect of the Preference for Nurses‘ Effect of asking for a preferred Gender in nursing care. gender of a nurse for nursing care. Effect of not getting a preferred gender of a nurse for nursing care. Benefit of getting a preferred gender of a nurse for nursing care.  Barriers Associated with the Preference Attitude of nurses as a barrier of a Nurse‘s Gender in Nursing Care. for not getting a preferred gender of a nurse. Hospital policy as a barrier for not getting a preferred gender of a nurse. Inadequate male nurses as a barrier for not getting a preferred gender of a nurse. Attitude of patients as a barrier for not getting a preferred gender of a nurse.  Perspectives of Patients on certain Qualities of a preferred nurse, Issues in Nursing. Perspectives of Participants. Attitude of a bad nurse, participant perspectives. Stereotypes associated with nurses in Ghana. The need to increase the number of male nurses in the nursing profession. 10 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care APPENDIX F: INTRODUCTRY LETTER TO UNIVERSITY OF GHANA HOSPITAL. 11 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care APPENDIX G: ETHICAL APPROVAL FROM NOGUCHI MEMORIAL INSTITUTE OF MEDICAL RESEARCH 12 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care APPENDIX H: INTRODUCTORY LETTER FROM SCHOOL OF NURSING AND MIDWIFERY. 13 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care APPENDIX I: CERTIFICATE OF REGISTRATION FROM KATH 14 University of Ghana http://ugspace.ug.edu.gh Patients‘ preference for nurses‘ gender in nursing care APPENDIX J: ETHICAL APPROVAL FROM KATH 15