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ORIGINAL RESEARCH

JOURNAL OF ADVANCED NURSING

Elderly peoples experience of nursing care after a stroke: from a gender perspective
sa Andersson & Go A rel Hansebo
Accepted for publication 24 April 2009

. Andersson: Correspondence to A e-mail: asa.andersson@swenurse.se sa Andersson RN, MN A Director Swedish Society of Nursing, Stockholm, Sweden Go rel Hansebo PhD Senior Lecturer Ersta Sko ndal University College, Stockholm, Sweden

(2 0 0 9 ) Elderly peoples experience of nursing care after a stroke: from a gender perspective. Journal of Advanced Nursing 65(10), 20382045 doi: 10.1111/j.1365-2648.2009.05060.x

. & HANSEBO G. ANDERSSON A

Abstract
Title. Elderly peoples experience of nursing care after a stroke: from a gender perspective. Aim. This paper is a report of a study conducted to explore, from a gender perspective, older peoples experiences of nursing care after a stroke. Background. Little attention has been given to gender differences in nursing care. The majority of people who have a stroke are older. Improving knowledge of the gender perspectives of older men and women regarding nursing care after stroke is crucial. Method. This was a qualitative study based on interviews with ve women and ve men between 66 and 75 years of age, who had received nursing care at a ward for stroke rehabilitation. The data were collected in 2006. Qualitative content analysis of the interviews was carried out. Findings. A main theme and ve categories, all common to both men and women, were identied. The main theme, to promote recovery of the body, encompassed the categories. There were, however, gender differences in how the nursing care received was experienced. The ways patients experienced nursing care seemed to be linked with their lives as women and men before they had the stroke. Their perceptions are linked with their lives as women and men before they had their stroke. Both men and women will reclaim former abilities but what they perceive to be the goals of nursing care and rehabilitation may differ. Conclusion. Nurses need to increase their awareness and knowledge concerning the similarities and gender differences in the experiences and needs of older people, both men and women. Keywords: gender, interviews, nursing, older people, qualitative research, stroke

Introduction
Over recent years on the impact of the gender perspective within the eld of public health has increased. Studies have shown that healthcare professionals have subconscious
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perspectives on gender (Foss 2002, Kvigne et al. 2005). Little attention has been paid to gender differences in nursing care. There is still a lack of knowledge about how older men and women experience nursing care. As the majority of people having a stroke are older, it is important to learn more about

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their experience and perceptions of nursing care from a gender perspective.

Background
The concept of gender emphasizes the process of being a man or a woman in a social context. The concept of sex refers to biological sex, while gender refers to the social, historical and cultural construction of male and female (Hammarstro m 2004). Gender originates in the interplay between biological sex, and the socio-cultural environment. What is perceived as masculine or feminine varies over time, societies and cultures. Gender is formed in the interaction between an individual, an organization and a society (Connell 1987, Hirdman 1988). The framework for gender is created in a societys politics, labour market, education, entertainment and media. At an individual level, or close to the individual, gender is created in the family, in couples, attitudes and personalities (Connell 1987, Hirdman 1988). According to Hirdman (1988), ideas of gender and descriptions of what is masculine and feminine are formed in social interaction. Physicians and nurses credit male and female patients with different, seemingly natural, patterns of behaviour. Female patients are described as bad-tempered, wary and more timeconsuming, while men are seen as pushy, inquisitive, better at getting on together and lodging claims (Swedish Association of Local Authorities and Regions 2002, Foss & Sundby 2003). In an experiment with postoperative patients, nurses were asked to plan care on the basis of an identical vignette differing only by sex. The nurses recommended more activities, analgesics and emotional support for male patients (McDonald & Bridge 1991). Similar results were seen when preregistration house ofcers were asked to assess two identical patients, one of each sex (Hamberg et al. 2002). From a gender perspective the interaction between nurse and patient is important for understanding how gender is created in nursing care, where person-to-person encounters are fundamental. Gender is probably fashioned when patient and nurse meet. Nursing care consists partly of the care which is carried out and partly of the relationship within which it is carried out. Care and relationships are fundamental and are always present at the same time (Norberg et al. 1997). The relationship is both a process and a means of fullling a patients need of care. Nurses are responsible for the establishment and the sustainability of the relationship, but this responsibility must be shared. Quality nursing care is dependent on the extent to which nurses are able to treat patients as unique individuals and respect their needs and expectations (Hansebo & Kihlgren 2000).

To our knowledge no studies have focused on older patients perceptions of nursing care from a gender perspective. Stroke is one of the worlds major diseases. About 15 million people every year worldwide have a stroke. The majority of these people are older and, as the population grows older, the number affected continually increases (Mackay & Mensah 2004). More patients will survive stroke into old age but will be in need of nursing care and rehabilitation (The National Board of Health and Welfare 2005). Women are older than men when they have their rst stroke (The National Board of Health and Welfare 2005). According to Glader et al. (2003) and Kelly-Hayes et al. (2003), women often need more assistance at home and receive institutional care more frequently. Depression after stroke is more common in women (Wyller 1999, Glader et al. 2003, The National Board of Health and Welfare 2005). Westergren et al. (2002) found that women being treated for stroke eat less than men, both when admitted to and when discharged from care. Womens eating disorders are more prevalent, and their progress in overcoming them slower than mens. According to Kvigne et al. (2002), women who left with obvious disabilities after a stroke often feel especially vulnerable, as their bodies are associated with femininity. They could be subjected to double objectication, as a woman and as a disabled person.

The study
Aim
The aim of the study was to explore, from a gender perspective, older peoples experiences of nursing care after a stroke.

Design
A qualitative study with individual interviews was conducted.

Participants
A convenience sample was selected. Five women and ve men between 66 and 75 years of age who were being cared for at a ward for stroke rehabilitation situated in urban Sweden participated. The criteria for participation were: 66 years of age or older and ability to understand and take part in an interview in Swedish. Patients who met the criteria were asked by a nurse, during their rst days on the ward, whether they were interested in taking part in the study, and all agreed.
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Data collection
Data were collected in 2006 using open-ended interviews. The interviews were initiated by the question, Could you please tell me about your experience of nursing care?. An interview guide was used to ensure that the following nursing care problems were included; eating difculties, impaired bladder and bowel function, hygiene, immobilization, communication difculties and increased need for rest and sleep. Participants were encouraged to talk about their experiences of different caring situations. Follow-up questions were asked to allow informants to elaborate on their experiences. The interviews were carried out on the ward, lasted for half an hour to an hour and were tape-recorded and transcribed verbatim.

Ethical considerations
According to Swedish law at the time for this study (Swedish Statue Book 2003:460), no approval by an ethics committee was required to conduct interviews. Permission for the study was obtained from the university and the managers of the clinic. All participation was voluntary and informed consent was obtained. Participants were informed in writing and orally that they could opt out of the study at any time. They were also informed about condentiality. Their personal details were known only to the authors. The material in the present study is unidentiable and quotations are used with caution. We were not employed at the place of the study and are not responsible for the care of any of the participants. Prior to the interviews, the researcher stressed that participation in the study would not inuence the care participants received.

interviews of men and women were analysed side by side, but documented in different groups to compare experiences. The analysis was carried out in the following steps: The texts were read many times with as open a mind as possible and the intention of grasping the overall content and becoming well-acquainted with the text. The text was read once more and, when a new meaning appeared, meaning units were marked. The meaning units were condensed but the core content was kept intact. The condensed meaning unit was coded according to content. The codes that had something in common were grouped into categories, thus forming an abstraction. The meaning of the text belonging to the categories was interpreted and a theme identied, as all the categories were intertwined and had something in common. Finally, the same procedure was followed with analyses based on a gender perspective. The process of analysis was nonlinear and involved repeated readings. We worked together and discussed and validated preliminary codes, categories, the theme and the gender difference several times. We moved forward and backward between the categories and data to ensure that the categories covered all aspects. The texts were reread before nalizing the categories, theme and gender analysis. The trustworthiness and credibility of this study is demonstrated by describing how the steps of the process were conducted. To achieve trustworthiness of the analysis, we compared and discussed each step in the process. During the analysis, we discussed the interpretation and tried to remain open to new ideas and willing to relinquish ideas which were not appropriate.

Data analysis
Qualitative content analysis was performed, a method that makes it possible to nd the subjective meaning in interviews (Sandelowski 2000). In qualitative content analysis, the meaning is searched for in every part of the text. Each interview is read with the aim of grasping both its manifest and latent content (Berg 2004, Graneheim & Lundman 2004). The overall theme reects the latent content of texts, i.e. it can be interpreted from the text but is not explicitly stated (Graneheim & Lundman 2004). In the present study, the ndings were analysed from a gender perspective. The interviews were transcribed by an assistant, who marked pauses, hesitation, laughter and tears in the text. By A) familiarized listening to the recordings, the researcher (A herself with the text. The analysis was focused on the participants experience of the nursing care received. The
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Findings
A main theme and ve categories, all common to both men and women, were identied. The categories were: bodily nursing care, support in reclaiming functions, lack of participation in care, supportive relationships and seeking consolation in sorrow. The meaning in the categories was interpreted in the main theme, namely to promote recovery of the body. There were, however, gender differences in the experiences between men and women in all categories with the exception of supportive relationships.

To promote recovery of the body

Men and women shared the experience of a change of bodily functions and the way in which the environment promoted

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recovery. The fact that the body no longer obeyed commands and was vulnerable was described as a loss that dictated considerable changes in daily life. Not being able to trust their body caused feelings of sorrow and anxiety. Nursing care can be seen to be important in the form of support and encouragement in the struggle to reclaim the body and to be connected closely with the task of recovery, adjustment and reorientation to be restored to health. Irrespective of gender, it appeared that this was essential to mark independence, whatever the patients disabilities and need of help in daily life. Bodily care meats nursing care which is linked to intimacy, such as touching, handling or examining genital areas. Bodily nursing care involved help with incontinence pads, visits to the toilet, washing, dressing and undressing. Losing control over parts of the body meant that there was a need, to some extent, for nursing care that involved bodily care. The ndings showed gender differences in how these were experienced. Women described in matter-of-fact and specic terms the type of help they needed. The nursing care was perceived as positive when they found nurses helpful, when they listened, and when they were considerate. No feelings were recorded about nakedness or embarrassment in situations of bodily care. The nurses sex was not mentioned:
I needed help on the toilet and things like that, washing myself and having a shower, but I was alright with help. (Woman, Born 1931)

Support in regaining functions

Both men and women wanted to participate in their recovery by taking an active part in rehabilitation classes and individual training, which were usually geared to personal goals. Hope of being able to regain lost functions seemed to be important. Every sign of recovery generated energy. Goals for rehabilitation harboured by men and women were not communicated to nurses, physiotherapists or occupational therapists. There was a wish to get back to life as it was before becoming ill. The goals seemed to be linked with the various traditional roles these older persons had before their stroke. For women in the study, it seemed that their goals were linked to their homes, being able to manage the homes, cook or sew and embroider:
When I get home I am going to do the washing and ironing and cleaning. After that I am going to do a lot of cooking and put it in the freezer, that way its easier to eat, sitting in a wheelchair to eat. And then I am going todo some embroidering and knitting and other things. (Woman, Born1934)

The goals for men in the study seemed to be focused on activities outside the home: going back to their leisure-time activities, driving a car or maintenance of the summer house:
I have just one goal and it is my measure of quality of life, and that is to get back on the tennis courtI know its going to happen, its going to happen. Researcher: Have you included it in the plan, that you want training? No, I havent, absolutely not. I would never dare say that, theyd just tell me to take it easy. And then nothing would get done. (Man, Born 1940)

Men showed vulnerability. They wished to manage by themselves and felt vulnerable when they had to rely on nursing care that involved bodily care. They seemed to have various strategies for dealing with this situation: to accept it or to take command and say how they wanted to be treated. Men described embarrassment at being naked in front of nurses, and also that nurses were sometimes shy of their nude bodies. By conforming to the role of patient the tension could be eased:
I mean I realize, or I accept, that I am in their handsAnd what have I got to show? Nothing but what God created. You have to sort of either accept it or you beat your head against a wall, isolate yourself or whateverI mean, you do your head in. (Man, Born 1934)

Lack of participation in care

Neither women nor men felt that they had been involved in planning their care. That said, there was ambivalence about being part of the process and they accepted handing over the responsibility for their care. There were differences in the attitudes of men and women. Women tended to accept that the various professionals made the decisions about their care, and the majority of women said that they did not have enough knowledge about stroke, treatment and rehabilitation:
I wouldnt say I took part in the planning of my rehabilitation and care. They have looked into the difculties I have had and what needs to be done, and they have a programme for it. As I have got better I have participated more in the activities they have here. Its worked well. I dont know what it takes to get better. (Woman, Born 1931) 2041

None of the men in the study preferred male nurses in connection with bodily care. Female nurses were preferred. The mens positive experiences of nursing care were that they received help when they needed it, nurses came when they called, they were treated well and they had no qualms about leaving their care in the hands of nurses.

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There were also women who wanted more information and who questioned how nurses did their job, but they felt ignored. Men seemed to be ambivalent. They did not ask to be part of the rehabilitation process and said nothing about their own goals. At the same time, they tried in different ways to have an inuence. Knowledge about the afiction of disease and its treatment presented opportunities for asking questions. Another tactic was to discuss and question decisions and put forward suggestions. A third way was negotiation:
They wanted to tube-feed me four times a day from day one, but I said I couldnt swallow more than twice. They have kept on and on about this, I only wanted twice, but then I lost a few kilos of weight. But they listened to me, they didnt force me. I said I cant take it and I pulled it out if they put it in. Theres been a bit of a ght over it. A nurse said Im the one who is a ghter. (Man, Born 1940)

Married men felt that they might worry their wives if they showed how sad they were. Therefore they did not let their sorrow be seen by the nurses in case their wives got to know of it through them.

Discussion
Study limitations
There are limitations to this study. It was conducted in only one ward for stroke rehabilitation situated in a big city and with a limited number of interviewees. This may have limited the variation in the data and the transferability of the ndings. The interviews were performed soon after the acute stroke event when the patients still needed nursing care, which could limit their experiences. However, the participants seemed to feel the need to talk about their experiences. Although the ndings cannot be generalized, the insight gained from the study can be used to make nurses aware of the gender perspective of care.

Supportive relationships
Relationships with family and fellow patients, but also with nurses, were essential. No differences from a gender perspective were found in this category. Common to both men and women was that knowing nurses by name was the basis for a relationship and having trust in the care. A closer relationship with one individual nurse was described as especially important. Any break in continuity was felt to be an obstacle for relationships with nurses. Relationships with fellow patients appeared to be of major importance. They provided opportunities not only for sharing experiences of the illness, but also for socializing in daily life. Being able to help fellowpatients hold on to their hopes and assist with practical tasks, despite the illness, was vital.

The body from a gender perspective

The theme to promote recovery of the body can be interpreted as if womens and mens experiences of nursing care after a stroke are intertwined with the unexpected changes in the body that affect the whole of life. It was obvious that nursing care was crucial to recovery of the body. Similar results can be found in Bendzs (2000) study, where the conclusion is that carers attitude is of essential importance for patients after stroke. Patients trust carers and are in need of support and guidance. Our study revealed how frightening is the experience of the partial loss of physical and cognitive functions that changes the body and appearance, thus affecting identity. Our participants had to cope with ordinary things that were taken for granted before but now had to be learnt again or accepted as disabilities. It seems that consciousness of being-in-the-world changes when the body changes. The body can be perceived as body and person in an inseparable unity. Kvigne and Kirkevold (2003) also found that change in the body after stroke leads to dramatic change in interactions with the surrounding world. In their study, women after a stroke felt that their bodies were unpredictable, demanding and extended. The bodys experience of interaction and communication with other people and things is fundamental for its constitution being-in-the-world. The body is always directed towards someone or something and is the place from which a person experiences the world (Merleau-Ponty 1945/1999).

Seeking consolation in sorrow

Family relationships seemed to be important for bringing consolation for the sorrow caused by the illness. Nurses were less important here. Both men and women stated that they hid their sorrow from the nurses:
Yes of course, its a relief to share your feelings with someone. But even though I talk a lot I dont talk about that, about those things that are so emotional. They are so emotional that I might start to cry. (Man, Born 1934)

Some participants felt that nurses were not prepared to share their sorrow; however, some patients, both women and men, actively chose not to mention sorrow to nurses. It appeared that women spoke more with close family members about their sorrow and the loss of control over their bodies.

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Ones own body is not a thing, but is the permanent condition of being in the world. A person experiences themselves and others as a lived body. The body is intimately connected with who I am, without the body there is no I. In the light of the body being-in-the-world, our ndings could be interpreted as indicating that men felt more vulnerable when they need bodily care as their identity as a man was threatened. Women seemed more comfortable with bodily care and described unemotionally, in specic and matter-of-fact terms, the help they needed. Nurses need to be aware that they also are a body being-inthe-world. In nursing care, a patients body is a lived body and patients bodies interpret nurses care. Men can associate the body with sexuality and nd bodily care embarrassing, whether the nurse is male or female. By conforming to the role of patient they may feel less embarrassed and the relationship between nurse and patient can become neutral. According to Malmsten (1999), bodily care is surrounded by many taboos. Nakedness and contact with the private parts of the body are taboo. Feelings such as shame and embarrassment are rendered invisible. Dealing with peoples intimate and private spheres and care has been a large part of womens work, both in the home and professionally. Nursing care which involves bodily care is socially designed for female carers, and it could therefore be easier for men to accept care carried out by women. Historically, male nurses went against the socially accepted pattern and the feel of another man touching another mans body can be perceived as containing sexual aspects. Women, on the other hand, carry with them the cultural construction that it is socially natural for women to care for sick bodies. The concept of gender may help women to feel that close bodily contact in nursing is not sexually charged. Previous ndings do not agree about the importance of a nurses sex. Ba ck and Wikblad (1998) found that women, more than men, preferred nurses of their own sex. Chur-Hansen (2002) found that both women and men tended to prefer someone of their own sex for bodily care. The tendency was most relevant in young women, while men and older women said that the sex of nurses did not matter. However, male patients in that study did not agree that they preferred male nurses.

showed that the values of the generation in which a woman grew up are important for her perception of the world she lives in. Older womens responsibilities for the home and as mothers are links to their bodies prior to the stroke. This was conrmed in a study by Kvigne et al. (2004), showing how women who had had a stroke struggled to regain their family lives and keep or recreate the feminine role of mother, wife, grandparent and housewife. Gustafsson et al. (2003) came to similar conclusions, namely that older women value their independence in issues related to food, and they fear of becoming dependent on others. Mens goals focused on activities outside the home and could be interpreted as a struggle to regain their male role. This is supported by Flemings (2001) study of older men suffering from long-term diseases, stroke among others, where men were concerned with upholding traditional male roles and tasks. For example, Lo fmark and Hammarstro m (2005) found that men, but not women, who had had a stroke were worried about not being able to keep their driving licence. Both men and women in our study seemed to hide their sorrow about the illness from healthcare professionals. Women, more often than the men, spoke to family members about their sorrow. Married men did not want to worry their wives by showing how sad they were. One interpretation of this is that the ability to handle sorrow is inuenced by socio-cultural notions. Women are expected to discuss emotions with their families, while men are expected to protect their families. When a man loses his abilities, he carries with him previous experiences of protecting his wife, and this makes it more difcult for men to seek the comfort of the family.

Different attitudes towards lack of participation in care

Neither the women nor men communicated their goals to the nurses, physiotherapists or occupational therapists concerning the outcome of their rehabilitation. This corresponds with the nding that they were not able to participate in their care. Previous research conrms that patients take very little part in their own care (Bendz 2000). Jones et al. (2000) described the negotiation of a rehabilitation plan, where it was the physiotherapist who suggested the goals and the patient went along with them. According to Bendz (2000), professionals expertise and power limit patients opportunities to describe what is most important to them in rehabilitation. In the present study it seemed, from a gender perspective, that men tried various ways to gain inuence over healthcare while most of the women tended to let professionals make the decisions. One interpretation of these differences is that
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The will to regain former roles

There was a wish to get back to life as it was before the stroke. Men and women had different goals, apparently as a result of older women and men having different traditional roles in the home (Skrede 1996).This interpretation is supported by Kvigne and Kirkevold (2003) research, which

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What is already known about this topic

The majority of people who have a stroke are older and will need nursing care and rehabilitation. Gender originates in the interplay between biological sex and the socio-cultural environment, and what is perceived as masculine or feminine varies over time. Everyone, including nurses and other healthcare professionals, has a subconscious gender perspective.

Further research is needed to improve our knowledge of the importance of gender-sensitive nursing care. In addition, more research is needed into how gender affects patients experiences and perceptions of nursing care and how genderrelated aspects of how patients participate in their own care can be taken into account.

Funding statement
This research received no specic grant from any funding agency in the public, commercial, or not-for-prot sectors, but the Swedish Society of Nursing paid for help with translation from Swedish to English.

What this paper adds

The differences in older patients experiences of nursing care may be based on their gender. Their perceptions are linked with their lives as women and men before they had their stroke. Both men and women will reclaim former abilities but what they perceive to be the goals of nursing care and rehabilitation may differ.

Conict of interest
No conict of interest has been declared by the authors.

Author contributions
AA and GH were responsible for the study conception and design; AA performed the data collection; AA and GH performed the data analysis; AA was responsible for the drafting of the manuscript; GH and AA made critical revisions to the paper for important intellectual content; AA obtained funding; GH supervised the study.

Implication for practice and/or policy

Nurses need to increase their awareness and knowledge of similarities and gender differences in how nursing care is experienced by older men and women. Further research is needed to clarify how gender affects patients perceptions of nursing care. gender originates in the interaction of biological sex, social and cultural environment. Men have more access to power in society and womens position at the workplace and in politics is lower-ranking (SOU 1998:6). This has implications for men and women both as patients and nurses, and can lead to different attitudes in situations when patients do not take part. These ndings are both conrmed and contradicted by Lo fmark and Hammarstro m (2005). Their study conrmed that patients lack participation in care, but they also found that both older women and men negotiated their care with healthcare staff.

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Conclusion
Our ndings indicate that there are gender differences in older patients experience of nursing care after a stroke. Older patients perceptions of nursing care are linked with their gender and to experiences of their lived bodies before they had the stroke. Nurses need to increase their awareness and knowledge about similarities and gender differences between the experiences and needs of older men and women.

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