Journey less travelled: Female nursing students’ experiences in providing intimate care in two nursing education institutions in Gauteng province, South Africa

Background Intimate care is not facilitated in South African nursing education and training. Nursing students encounter it for the first time in clinical practice, where they see and touch the naked bodies of patients. The societal segregation of gender roles has led to the feminisation of the nursing profession, suggesting that women are more caring and maternal and that intimate care implementation comes more easily to them than to their male counterparts. Aim This study explored female nursing students’ experiences of intimate care for diverse patients. Setting The study was conducted in two nursing education institutions in Gauteng province, South Africa. Methods Descriptive phenomenology was used to describe the lived experiences of participants. Seventeen female nursing students were purposively sampled. Data were collected using semi-structured interviews and analysed using Moustakas’ (1994) eight steps. Results Four themes emerged: intimate care comprehension, preparedness for providing intimate care, reactions in providing intimate care and coping mechanisms when providing intimate care to diverse patients. Conclusion Intimate care forms a basis on which nursing students prioritise the physical needs of patients by providing care that exposes their bodies and requires touch. The students were taught to provide care with respect, maintaining patient autonomy and nursing professionalism. Unfortunately, age and gender barriers create feelings of discomfort and embarrassment. More needs to be done to support and empower nursing students in providing intimate care to diverse patients competently, confidently and comfortably. Contribution Understanding the experiences of participants in providing intimate care to diverse patients will assist nurse educators in intimate care facilitation and support. The female nursing students will be empowered and trained to execute intimate care in a manner that is culturally, religiously and ethically acceptable.


Introduction
Care in nursing involves assisting patients with daily health-related needs such as hygiene, elimination and nutrition, leading to intimate encounters . The nursing care routines are task-oriented, aimed at promoting physical and psychological comfort where touch is essential and unavoidable (Pedrazza et al. 2018). Nurses touch patients when performing care procedures such as assistance with intimate bodily functions such as bathing and elimination (toileting), communicating care and ensuring comfort (Kelly et al. 2018;O'Lynn, Cooper & Blackwell 2017). Physical touch requires sensitivity, responsiveness and involvement from a nurse as it implies physical, cognitive and emotional proximity to the patient (Pedrazza et al. 2018). Intimate care occurs in any clinical setting where a patient needs assistance with personal care. Nursing students have to touch a patient's body, and a patient allows a stranger to see and touch his or her fragile body. Provision of intimate care may produce feelings of discomfort, anxiety, or fear and might be misinterpreted as having sexual intent (O'Lynn et al. 2017). Thus, nurses are constantly required to negotiate boundaries and spaces (Kelly et al. 2018) during patient care to avoid discomfort for both parties.
Sexualisation of touch is different for male and female nurses; to date, female nurses' touch is seen as natural and maternal (Kelly et al. 2018). This confirms the image of nurses as feminine, subordinate and altruistic providers of love and care . Caring behaviour stems from having special affection or concern for the recipient (Liu et al. 2019). This has led to the belief that female nurses are more caring and therefore, they do not require support in providing caring skills. Most of the literature focuses on male nurses' experiences of intimate care and touch. Kelly et al. (2018) indicate that men and women as initiators and recipients of care may misinterpret touch, overshadowing the potential benefits of providing basic care and comfort.
Nursing students enter the nursing profession with their socialisation, values and beliefs about touch and intimacy; such practices are generally private and happen within the safe space of a family . South African nursing students are from diverse communities, so nurse educators are challenged to facilitate methods of intimate care that are culturally and religiously acceptable (Shakwane & Mokoboto-Zwane 2020a). Providing intimate care can be stressful for nursing students; touching patients' private body parts may evoke feelings of distress and apprehension . Little emphasis is placed on how nurses should provide touch with respect and dignity (O'Lynn et al. 2017). Shakwane and Mokoboto-Zwane (2020b) attest that in South African nursing education institutions (NEIs), the socio-cultural aspects of intimate care are not emphasised during the facilitation of intimate care procedures. Yet, nursing students are expected to provide it to diverse patients.
The study explored the experiences of female nursing students in providing intimate care to diverse patients. The objectives were to: • describe female nursing students' perceptions of intimate care • explore and describe nursing students' experiences when providing intimate care to diverse patients • identify the coping mechanism that female nursing students use when providing intimate care to diverse patients.

Study design
A theory-generating study was conducted. This article presents the findings of female nursing students' experiences when providing intimate care to diverse patients. A qualitative phenomenological design was used to explore these experiences. Phenomenology is a theoretical perspective that attempts to generate knowledge about how individuals experience things. It aims to examine people's experiences of a phenomenon (Liamputtong 2013 In analysing, the researcher contrast and compare the final data to determine the patterns and themes (Brink et al. 2018). Data were analysed using Moustakas' (1994) method, which requires working with the detailed data analysis results to discover essences and universal themes. Finally, describing is the phase where the researcher comprehends and defines the phenomenon (Greening 2019;Polit & Beck 2017). This was carried out in the discussion and critical description of the findings.

Setting
The study was conducted in two NEIs accredited by the South African Nursing Council to provide education and training for the comprehensive nursing programme R.425 in Gauteng province. A government nursing college and a university were sampled. Both NEIs offered the R.425 nursing education programme. Intimate care procedures related to hygiene and elimination are simulated during the Fundamental Nursing Sciences (first year) and General Nursing Sciences (second and third year).

Study population and sampling strategy
The sampling population were female nursing students registered for a comprehensive nursing education programme leading to registration as a registered nurse (R.425) in the selected NEIs in Gauteng province. Nonprobability purposive sampling was undertaken to deliberately choose specific individuals who could provide crucial information about the phenomenon under study (Liamputtong 2013). Female nursing students who were registered for the R.425 nursing education and training programme and who had been allocated in general wards (medical and surgical) for 6 months or more in accredited clinical placements were selected. The female nursing students were selected to obtain information-rich data that provided an in-depth understanding of their experiences when providing intimate care to diverse patients. The sample consisted of 17 female nursing students in their second and third academic years in R.425 programme. Ten nursing students were in the second year and seven in their third academic year. The first-year female nursing students were excluded as they did not have 6 months experience in clinical placement. The fourth-year female nursing students were busy with clinical exams during the data collection period and thus they were also excluded from the study.

Data collection
The data were collected using individual semi-structured interviews that were captured with a digital voice recorder. Non-verbal communication was recorded in the field notes. The interviews were conducted in a designated classroom in the NEIs. The duration of the interviews was 30-45 min. The interview guide was pretested by conducting two semistructured interviews (one from each NEI). These interviews were analysed, and the questions were refined to meet the set objectives. Data were collected over three months (April -June 2016), till saturation was reached. This means that after 15 interviews, no new information was obtained. Two more interviews were conducted to confirm the saturation.
Three semi-structured questions were asked during the interviews: • What is your understanding of intimate patient care?
• Can you describe your experiences when providing intimate care to diverse patients? • Can you share how you coped with intimate care challenges/conflicts when caring for diverse patients?

Data analysis
The data were analysed manually, starting verbatim transcription of the digital audio-recorded interviews. Phenomenological analysis is characterised by the procedures of bracketing, identifying common meanings and essences, horizontalisation of data and textual and structural analysis (Padilla-Diaz 2015). The researcher used a reflective journal to record her experiences during the study to identify personal judgement or bias. Horizontalisation of data was carried out by listing each relevant quote to help provide a textual description. Relevant topics were grouped into units of meaning to create core themes. Textual descriptions were accompanied by verbatim quotes. Structural denotations were devised and followed to identify the essence of the phenomenon. A literature control was conducted to validate or refute the invariant constituents (Greening 2019). The services of an independent coder were used. The researcher and coder independently analysed the data, discussed their findings, and agreed on the presented findings.

Ethical considerations
The study received an ethical clearance certificate from the University of South Africa Health Studies Higher Degrees Committee (certificate number HSHDC/ 496/2015) and approval to conduct the study from the Gauteng Department of Health and the two selected NEIs. The participants were informed about the purpose and benefits of the study and that participation was voluntary. They were also made aware that they could withdraw from the study at any time. All participants signed informed consent before their semi-structured interviews.

Measures of trustworthiness
Rigour is how a researcher demonstrates integrity and competence, a way of demonstrating the legitimacy of the research process (Liamputtong 2013). The principles of trustworthiness of Lincoln and Guba (1985) were used to enhance the quality of the study. Credibility and authenticity were maintained by purposively selecting the participants for their knowledge and unique experiences of intimate care. The service of an independent coder was used; the researcher and the independent coder discussed their independent analyses and agreed on the presented themes. The multiple realities described by the participants were presented using direct quotes, allowing the reader to recognise the descriptions and interpretations of the findings. Transferability was maintained by describing the research processes used in the study, which are sampling factors, setting, sample size, data collection and analysis. This distribution contributes to the credibility of the results, which determines their transferability to different contexts. For dependability, the research method was reported in detail to indicate that proper research practices were followed and that in future, the researcher could repeat the study (Polit & Beck 2017).

Participants' characteristics
Seventeen female nursing students between 20 and 39 years of age participated. All participants were registered for the comprehensive nursing education programme R.425. Ten participants were in the second academic year and seven in the third year. The second-year nursing students had day duty clinical experience in general nursing care (medical and surgical), whereas the third-year nursing students had both day and night clinical experiences. Two participants were already trained as Enrolled Nurses and joined the R.425 nursing education programme on the basis of Recognition of Prior Learning. Table 1 provides the summary of the participants' characteristics.

Interview results
Four themes were developed from the analyses, namely, (1) intimate care comprehension, (2) preparedness for providing intimate care, (3) reactions to providing intimate care, and (4) intimate care coping mechanisms. The sub-themes are discussed under each theme in the following subsections.

Theme 1: Intimate care comprehension
There were three sub-themes in which the theme of intimate care comprehension was derived. The participants' overarching intimate care understanding was based on an individual's ability to take care of his/her own body. When patients receive intimate care, they are vulnerable and dependent on the care provided by a nurse.
'… when you are bathing a patient, it's you and the patient, and a patient is exposed and vulnerable and is under your care, and you have to protect them.' (FP11,27,NEI1) Each patient is unique in the body parts that he or she considers sensitive. When providing intimate care, nurses have to listen to a patient's needs: '[I]s based on what a patient regards as sensitive to them, the patient is not comfortable when you are holding a certain part of their bodies ….' (FP15, 25, NEI2)

Theme 2: Preparedness for providing intimate care
The theme of preparedness for providing intimate care was derived from three sub-themes. These sub-themes confirm that the participants were taught basic nursing care procedural principles. These principles include respect for the patient, patient involvement and maintaining professionalism.

Sub-theme 3: Maintaining professionalism:
The participants alluded to their expected behaviour during the provision of intimate care. They expressed the ability to control intimate care reactions in the following excerpts:

Theme 3: Reactions to providing intimate care
Two sub-themes provided the unique reactions and experiences of the participants when they were providing intimate care to diverse patients. The provision of intimate care requires nursing students to be in close physical contact with a patient. The majority of the participants related experiences of discomfort because of patients' physical, psychological and visual sexual advances. These experiences are discussed below: 'You find a patient can walk, but he will call you to come and do a bath. I am not comfortable.

Discussion
The study aimed to explore the lived experiences of female nursing students when providing intimate care to diverse patients.

Intimate care comprehension
Intimate care was perceived to be the care provided when patients can no longer care for themselves; thus, this is a care generally occurred within the family's safety. De Beer and Brysiewicz (2017) assert that in a South African context, family care embraces the principle of ubuntu, where a family provides care as a sign of compassion and caring. It is hard for individuals to be dependent on others for basic human necessities, which may lead to feelings of being a burden to others and psychological distress (Thompson et al. 2021).
The participants also viewed intimate care as those nursing tasks required to care for a patient's basic physical needs. Intimate care activities are basic physical care that is necessary for daily living, which may evoke strong emotions in individuals who are recipients of such care (Thompson et al. 2021). Mainey et al. (2018) consider intimate care as fundamental nursing care routines such as hygiene, elimination, and nutrition to assist patients with their physical needs. These procedures are often considered simple, humble tasks and carry less prestige (Thompson et al. 2021).
Intimate care also involves physical and psychological closeness between a nurse and a patient. The provision of intimate care transforms private and personal activities into a social process shaped by complex beliefs, behaviours, attitudes and cultures (Thompson et al. 2021). The nurse comes into contact with a patient's body, and the patient allows a nurse to touch his or her body (Shakwane & Mokoboto-Zwane 2020a). Touch cannot be avoided when caring for the patient's body and often it includes exposing a patient's sensitive body parts. O'Lynn and Krautscheid (2011) define intimate care as task-oriented touch to areas of patients' bodies that might evoke feelings of discomfort, anxiety and fear or might be misinterpreted as having a sexual purpose.

Preparedness for providing intimate care
During the simulation of clinical procedures, the participants were taught to show respect, provide patients with care information, and maintain professionalism. Respect requires a nurse to treat patients with regard, concern, protect their privacy, be sensitive to their diverse culture, and allow them to make choices (Umbreen & Jabeen 2019). This is further stated by Zirak, Ghafourifard and Aliafsari Mamaghani (2017) that respect assists one to develop self-worth through maintaining dignity, protecting patients' privacy and allowing them to have their autonomy.
Providing information to the patient about what will be performed is essential. According to O'Lynn and Krautscheid (2011), patients expected nurses to communicate the nature of the procedure to be performed, seek permission and be involved in the execution of intimate care. Nursing professionalism encourages nursing students to respect the patients and create boundaries that protect the profession's image. Professionalism conceptualises the obligations, attributes, and interactions concerning the patients and society (Fantahun et al. 2014). Shakwane and Mokoboto-Zwane (2020b) emphasise a therapeutic nurse-patient intimate relationship that is based on trust, respect and dignity. This relationship increases patient satisfaction and acceptance of care (Hosseini et al. 2019).

Reactions to providing intimate care
Experiences of providing intimate care are guided by the patient's age, gender and sexual orientation. When providing intimate care to female patients, the majority of participants experienced refusal of care and discomfort because of the age difference. Nursing students are novices in age, social maturity and responsibility (Crossan & Mathew 2013), and age is pivotal in accepting and rejecting intimate care (Shakwane & Mokoboto-Zwane 2020a). Some female patients refused intimate care because the participants were young.
Yet, Crossan and Mathew (2013) found that nurses even had challenges while providing intimate care to patients of the same age.
Caring for male patients created discomfort and embarrassment. The participants described their values of not seeing or touching the naked body of a man. Nursing students have socio-cultural values and beliefs in which touch and intimacy are private and not spoken of, and they have to view a sick person as a patient only (Crossan & Mathew 2013). With the increased diversity in healthcare, nurses are expected to provide sensitive and appropriate care to all patients. Providing effective and culturally sensitive care requires nurses to be aware of personal and patient's cultural and social beliefs (Shahzad et al. 2021

Intimate care coping mechanism
For the participants to cope with the challenges of intimate care, they put the needs of patients first. This is congruent with the study of Crossan and Mathew (2013) that female nursing students sought to prioritise the comfort and privacy needs of the patients. Many studies have discussed strategies used by male nurses to cope with intimate care challenges, such as using female nurses as chaperones (Whiteside & Butcher 2015) and respecting patients' gender preferences (O'Lynn & Krautscheid 2011). It is acceptable for female nurses to care for all patients irrespective of their gender (Crossan & Mathew 2013). In contrast, male nurses take overt cautious care to avoid potential accusations that might result from the misinterpretation of intimate care (O'Lynn et al. 2017). However, the participants received little support and feared disapproval if they expressed difficulties associated with intimate care. Nurse educators focus clinical simulations on hygiene and elimination psychomotor aspects, neglecting the affective intimate care skills such as touch and navigating personal body space in practice . Lack of intimate care instruction leads to the care being taken for granted and nursing students not being prepared for or supported in providing such care competently, confidently and comfortably (Shakwane & Mokoboto-Zwane 2020b).

Limitations
The study was conducted in Gauteng province in South Africa. Because of the sensitive nature of intimate care, some participants may have withheld valuable information. Future studies should be conducted using different methods and in more provinces of South Africa.

Recommendations
Intimate care should be considered important, and female nursing students should be prepared for providing it. Further studies should be conducted to explore the influence of culture in intimate care provision and examine sexual harassment and reporting systems for nursing students in South Africa.

Conclusion
The current study demonstrates the value of intimate care, its challenges for female nursing students and the need for continuous support. Intimate care addresses the basic physical and psychological needs of a patient. The participants experienced rejection because of their youthfulness, inexperience, and physical and psychological sexual advances when executing this care. Lack of support and fear of mentioning intimate care conflicts may lead to discontinuity in quality patient care. The findings suggest that teaching intimate care will prepare female nursing students to assess intimate care risks and handle patients' bodies.