Vol.7, No.2 July 2001
Editorial | Contents
Problem-based Learning and Masculinities: Unique opportunities for Mr. Fix it? Well, maybe.
Refereed Article
Author
John Oliffe, RGN, Grad Cert Paediatric Nursing, M.Ed
Lecturer
Deakin University
221 Burwood Highway
Burwood VIC 3125
Email oliffe@deakin.edu.au;Fax 61 3 92446159; Ph 6 13 9244-6625
Background
I watched a smoker of 30 years being admitted to the Coronary Care unit following an acute Myocardial Infarction (heart attack). The message from the male clinician was simple, accurate, but somewhat behaviourist: " the death of part of your heart muscle is the result of your smoking, if you don’t stop smoking the damage will continue and you will die." A global, proactive and humanistic consultation demonstrating an understanding of the man’s addiction to a legal and accessible drug and illuminating prevention strategies may have been more appropriate. Maybe the interaction was about competing masculinities, the risk taker and the problem solver. The irony? As I left the hospital that night I observed the same clinician strategically positioned in a secluded hospital doorway drawing heavily on a cigarette. Hypocrite? No, invincible late 20’s male? Maybe. Smoking was someone else’s problem – at least today.
In my 16 years as a clinician such scenarios are common. Clinical practice based predominantly on problem solving potentiates hegemonic masculine approaches to treating men in clinical practice, often justified by limited health resources and increasing patient acuity. Ironically, Problem-based Learning (PBL) curriculums commonly used in health sciences higher education encourages, nurtures and rewards such problem solving approaches. As a teaching academic with current clinical practice it occurs to me that health science education and PBL has an opportunity if not obligation to empower clinicians to establish holistic approaches to male health presentations.
This paper explores the interconnections of Problem-based Learning (PBL) curriculums, health promotion, male nurses’ health-related behaviours and the implications and specificities of masculinity. The pilot study offers an insight into the perceptions of three male nurses that completed undergraduate nursing studies in PBL curriculums. The data obtained introduces some connections that could be illuminated by further research.
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PBL: Background, Rationale and Practice
PBL evolved from innovative health sciences curricula introduced in North America in the 1950s and Canada in the late 1960s ( Boud & Feletti, 1997). The principle idea behind PBL is that the starting point for learning should be a problem, a query that the learner wishes to solve. PBL is a way of constructing and teaching courses using problems as the stimulus and focus for student activity. PBL starts with the problem rather than the exposition of disciplinary knowledge. The move toward acquisition of knowledge and skills is facilitated through a staged sequence of problems presented in context, together with associated learning materials and support from facilitators (Engel, 1997).
The PBL approach values content and process equally, acknowledging that learning takes place most effectively when students are actively involved and learn the context in which the knowledge can be used. The centrality of the PBL process is its ability to stimulate a questioning attitude and a search for meaning that encourages students to learn how to think and act as beginning graduates (Margetson, Cooke & Don, 1995).
PBL incorporates facilitated sessions, planned resource sessions and nursing laboratories. Planned resource sessions provide information, pertinent to the clinical scenarios, from both a nursing and bioscience perspective. This information is complemented by facilitated sessions and nursing laboratories in which clinical Problem Situated Scenarios (PSS) are explored, and student learning needs identified. The PSS are based on real patient presentations that are ill-structured, open ended, or ambiguous( Fogarty, 1997). It is often a complex situation with a number of interrelated concerns that seek to engage students in intriguing, real and relevant intellectual inquiry, facilitating learning from life situations (Barrell 1995).
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Men's health- the problems with problems
Courtenay (2000) identifies that men are more likely than women to adopt beliefs and behaviours that increase their risks, and are less likely to engage in behaviours that are linked with health and longevity. Problem solving in response to symptomatic health problems is a common characteristic of men's health behaviours. Ziuras (1998) defines this as reactive self-care in which men respond to an illness already developed, characterised by
• using some form of self treatment
• asking friends for advice; and finally
• seeking professional help
Furthermore Ziuras (1998) identifies that men tend to engage in reactive self-care behaviours much later than women.
In contrast to reactive self-care practices, proactive self-care encompasses all those everyday activities that people engage in to keep themselves healthy and to prevent disease (Ziuras 1998). Men stereotypically engage in few of the following practices to actively maintain their own health.
• eating a well balanced diet
• providing time to relax
• paying attention to personal hygiene
• exercise
Avoiding known health risks
• drink driving
• smoking
• engaging in unprotected sex
The nursing profession has promoted the concept of self-care primarily in the reactive sense. For example, Orem's (1991) theory of nursing centred around the patient’s incapacity to provide the care they need because of their condition. PBL coupled with the biomedical model potentiates this approach where clinicians are primarily interested in responses to specific diseases and appropriate cure. PBL and PSS from an illness perspective accept, validate and promote men's reactive health behaviours, encouraging problem solving rather than prevention.
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Health Promotion , Masculinity and Clinicians
Nutbeam (1998) defined health promotion as one that embraces actions directed at strengthening the skills and capabilities of people and also those directed towards changing social, environmental and economic conditions that create and sustain health.
In recent decades, health education and health promotion have assumed increasing importance within society generally and in particular within the health professions. Health promotion is widely accepted as part of the role of the nurse, indeed the World Health Organisation (WHO) (1989) identified that nurses have the potential to lead the health promotion movement. Nurses work in diverse areas, with many employment opportunities in community health, acute care and independent practice. Such workplace environments offer opportunities for health promotion and education practices to be adapted as foundational clinical practice.
Students undertaking nursing degrees may not establish health promotion practice as the focus is often on the treatment rather than prevention of disease. Benson and Latter (1998) argue that an integrated model should be transparent in all undergraduate nursing courses, identifying competency as promoters of health as a major objective of current nurse education in the United Kingdom. Empowering students to investigate how problems can be avoided as well as treated can facilitate a health promotion perspective in PBL.
Assessing men's health promotion needs and identifying effective strategies to inform men’s self-care is difficult without an understanding of the socio-cultural construction of masculinities. Connell (1997) identified that there is no one pattern of masculinity, offering the concept of plural masculinities based on different cultures and periods of history that construct gender differently. In multicultural societies such as Australia, there are multiple definitions of masculinity with no one kind of masculinity found in hospital, the community or private health practice. Masculinities are continually contested, and renegotiated in each context that a man encounters. Masculinities require compulsive practice, because they can be contested and undermined at any moment such as in illness and hospitalisation (Courtenay 2000).
Moynihan (1998) identifies gender as a floating signifier that may be a puzzling concept for medical professionals trained to think differently. As Lloyd (1995) reports, real men don't have needs, and research has often focussed on the public behaviours and attitudes rather than the private. While men have featured in medical research and health promotion campaigns, there has, until recently, been little detectable effort to consider how masculinities figure in health and disease.
Many clinicians attach vital importance to anatophysiobiochemical factors in men’s health, as it is congruent with the focus of traditional Western medicine. Furthermore Moynihan (1998) argues that medicine acknowledges ambiguity in anatomical states, but seldom recognises the complex, social issue of gender. Clinician acknowledgement and analysis of male gender roles as socio-cultural constructions demand holistic approaches to men's health. The social concept of gender legitimises the belief that what is learnt, can be unlearnt or reconstructed. Hence men whose lifestyles are pathogenic, can reconstruct negative behaviour in collaboration with clinicians willing to empower them.
Generalisations such as "it’s a male thing" and "he's so blokey" are superficial and anchored in biological essentialist constructs of gender. Such judgements result in one dimensional, self-defeating practice for clinicians that ignore the diversity and complexity of masculinities and potential health promotion strategies.
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"Practice what we preach" – Male nurses’ health-related behaviours
There is a demonstrated empirical link between nurses' personal health habits and their tendency to raise health issues with clients. Researchers suggest that nurses can improve their health promotion role if they adopt health-related behaviours (Callaghan, 1999). This claim is supported by Goldstein, Hellier and Fitzgerald (1987) who reported a link between nurses' personal health habits and their tendency to counsel clients about health issues, concluding that if nurses are poor health exemplars the safety, competence and professionalism of their practice, as well as their health, could be compromised. Changing nurses' beliefs about the importance of health-related behaviours through incorporating a health promotion focus in PBL PSS may inform students' health promotion strategies and inform nurses' health promotion practice.
Leonard (1998) reports that men are increasing in numbers within nursing. Squires (1995); Boughn (1994); Perkins, Bennett, and Dorman (1993) identified that for men entering nursing, caring was a reoccurring theme. Male nurses have challenged the traditional model of masculinity, crossing the gendered boundaries and stepping outside the hegemonic constructions of masculinity in performing what has traditionally been seen as women's work. It has been identified that men seek permission from other men to step outside stereotypical masculinities. Men who want to take greater responsibility for their health will need not only to cross gendered boundaries, but also learn new skills.
Male nurses are in a prime position to empower other men to take this journey. The caring quality identified in male nurses facilitates humanistic therapeutic client interactions, likely to empower rather than oppress men to speak passionately about their health. Male nurses generally engage in some form of self-analysis of their masculinity as a consequence of engaging in a non-traditional male occupation. As a result they are likely to be willing to address and analyse the hegemonic constructions of masculinity that lead men to believe that to be a man means to behave self-destructively. Their understanding and empathy of males is likely to increase their effectiveness as educators of men's health promotion practices.
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Interrogating PBL and its efficacy with Male Students
As a facilitator in PBL, I have observed males to be active in facilitated sessions, engaging in the challenge of solving clinical problems. Edley and Wetherell (1995) identify problem solving, competitiveness, self-reliance and planning as desirable and perhaps culturally scripted, socially reinforced traits found in many males. PBL and males appear well suited given PBL’s problem solving focus and the socially constructed dominant stereotypical masculinity propensity toward problem solving. However I hypothesise that PBL can facilitate more than validate male problem solving in the clinical environment. Specifically, PBL should inform men's health promotion strategies, male students’ health care practices and produce clinicians capable of empowering men to adapt illness prevention practices. Method
A semi-structured interview style was used based around prompt questions; closed or leading questions were avoided as the intention was to let participants speak for themselves. With these questions as a framework I conducted a pilot study that provided some initial data regarding male perceptions of the PBL process.
The prompt questions were:
• How did you feel as a gender minority within the PBL process?
• How did the PBL PSS empower you to solve clinical problems and develop health promotion strategies?
• How has PBL informed your self-care health practices?
Sample
Three PBL graduate male nurses were interviewed.
Pseudonyms Rick, Billy and Jim
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Findings
• Gender minority.
The gender split in the undergraduate nursing program at Deakin University is approximately 94 % female and 6% male. The interviewees perceived the gender split as an advantage, as illustrated by the following excerpts from the discussions.
Rick: I felt less intimidated by studying with more women than men in a way.
I’m a bit assertive, but I felt that I talked a bit too much, maybe there were times when others were not engaging much, so I would say more.
Studying with women there was less competition than in studying with males. I felt more easy in that setting. Some guys would be worried but I was comfortable in the environment.Billy: I tend to talk a lot in class, I tend not to hang with the crowd.
I would be constantly saying too much within a group of people. But that’s just me.
I didn’t think about the fact that I was the only bloke there. The only time at uni when I noticed I was a bloke in a group of women was when they all went off somewhere at night socially.Jim: I did not perceive any advantages or disadvantages gender wise. The group dynamics were good and everyone was open.
Research indicates that men and boys experience comparatively greater social pressure than women and girls to endorse gendered societal prescriptions (Williams and Best 1990, Golombok and Fivush 1994, Martin 1995). The interviewees revealed characteristics such as assertiveness, competitiveness, strong personalities, dominance and independence, despite being a gender minority. Kilmartin (1994) Edley and Wetherell (1995) identify such behaviours as representative of masculine stereotypes.
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• Clinical problem solving verses health promotion
The interviewees expressed comfort and familiarity with problem solving. However they did not perceive that the PBL, PSS were intended to trigger health promotion considerations and strategies.
Rick: I had problem solving skills prior to the course, but the PBL helped me to develop higher level thinking and problem solving skills.
I didn’t see health promotion as the focus of the problem solving scenarios at the time. We were working out clinical strategies to solve the problems.
It seems a little separate in a way, the problems and health promotion, we were more about educating about current medical problems.
I enjoyed learning in a self-directed manner.
Billy: Having had the life experience, I had had to solve lots of problems before. The PBL demanded more specific problem solving.
Sometimes it was hard to see what the actual problems were. The PSS helped me with my clinical practice, I have learnt base knowledge that I can apply to new content because I can problem solve.
The emphasis was always there, that not to just treat the symptoms but getting back to the base problem.
The lectures contained scientific data and the health promotion message was not there. We are selective clinically about the problems we solve.
Jim: There weren’t any real health promotion messages in the PSS’s.
The approach to solving problems clinically is different to solving everyday problems. I just had not had the experience of solving the problems clinically when completing the undergraduate program. The scenarios did inform my practice.
The turn around on the ward is so quick that the health promotion messages are pretty smash and grab.
The interviewee responses confirmed an acceptance of the illness model and prioritising of treatments and focus on solving immediate, potentially life threatening patient problems. They did not perceive that the PBL, PSS were intended to inform health promotion practices. Indeed there was recurrent reference to the seperateness of illness and health promotion, congruent with much clinical decision making. The data confirms the participants’ comfort with problem solving, however interviewees perceived a specific or higher level of problem solving was facilitated by PBL PSS.
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• Health-related behaviours of Male nurses
The interviewees did not perceive that PBL had changed or informed their own health-related behaviours. A re-occuring theme was that the PBL, PSS portrayed patient problems and provided undergraduates with an opportunity to solve other people’s problems. This detachment may be linked to health being inextricably tied up with the image of the perfect man, a signifier of strength and control (Moynihan, 1998).
Rick: I kept it as somebody else’s problems, maybe because you don’t like to think of yourself as sick.
Billy: I still smoke but I think more about the fact that I smoke. My approach is a little more informed.
Jim: I am probably worse now than what I was previously. You are sort of aware of things, but with the shift work you get into bad habits, eating habits, exercise habits, its just much harder to get into healthy practices.
I drink more coffee, more alcohol, much less regular exercise and disrupted sleeping patterns.
Implications of the Research: The challenge for PBL and Higher Education
When confronted by men's health problems we often advocate 'better education'. Getting better education is not so easy. The challenge for PBL and the illness model is to integrate medical problems and health promotion problems that will engage the learner. It is naive to assume that PBL does not have a place in health science education. Far from it, such a robust curriculum could easily be refined to incorporate health promotion considerations and strategies as well as actual clinical problems. The synthesis of why illness occurs extends beyond aetiology, familial or idiopathic characteristics. At an academic level, health promotion has emerged as a reaction against traditional Western biomedical explanations for health and illness. Perhaps a more proactive interpretation of health promotion is 'the process of enabling people to increase control over, and to improve their health' (World Health Organisitaion (WHO) 1986). Higher education through PBL has a wonderful opportunity, if not obligation to empower clinicians to inform, empower and treat and treat ill and well men.
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Recommendations for further research
From this pilot study, several strands for further research have been identified.
• How best to integrate health promotion strategies and clinical skills in a PBL curriculum?
• How to empower male nurses to adapt and teach other men self-care practices?
• How to deal with, negotiate, resist the negative impact of being a gender minority?
• What are the links between male nurses’ health-related behaviours and their roles as health promoters?
Conclusion
I recently listened to a nursing handover of a male patient post bowel resection surgery that resulted in a permanent Colostomy. The handover included the patient’s demographic data and identification of a number of medical problems including the leaking of faeces from the attached bag. The final summation included the nurse’s observation that the patient was a "wimp, with a degree of learned helplessness, who needed a bomb under him to get him moving". The judgement was disturbing, and said much about the clinicians’ hegemonic expectation of masculinity. It would seem that clinical problem solving is selective in the problems it addresses, the faecal drainage problem was solvable with a new prosthesis but the patient non-compliance was labeled rather than analysed. Such scenarios evidence Courtenay’s (2000) perception that "the health care system does not simply adapt to men's masculinity; rather, it actively constructs gendered health behaviour and negotiates among various forms of masculinity"(p.1395).
"Few health scientists, sociologists and dominant theorists identify dominant constructions of masculinity as a risk factor; fewer still have attempted to identify what it is about men, exactly, that leads them to engage in behaviours that seriously threaten their health. Instead, men's risk taking and violence are taken for granted" (Courtenay, 2000 p.1396). It would seem health science education has an opportunity to conduct research that will inform curriculum, students, graduates and ultimately clinical practice. PBL curriculums through PSS's designed with cues that empower students to think outside the illness model afford beginning practitioners consideration and adaptation of a multi-layered approach to men's health.
Interestingly, unsolicited, Billy offered the following at the conclusion of our interview:
I have an empathy for male patients, I can relate to them a lot better, there’s still a lot of blokes out there who feel they can relate better to another bloke about health. I’ve looked after three or four male patients that were quite difficult with other nurses, I’ve had no trouble with them at all. That older generation of men often feel more comfortable with a bloke.My hope is that male clinicians’ willingness and wish to improve the state of men’s health will be encouraged and empowered by higher education undergraduate programs, and that they will be equipped with the skills to realise their ambitions.
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Last modified on: Monday, 23-Jul-2007 10:56:02 EST
