Nursing Attitudes and Beliefs
Nursing Attitudes and Beliefs
Nursing Attitudes and Beliefs
urpose and Objectives: The purpose of this study was to use a collaborative process
P between Advanced Practice Nurses and a nurse researcher to identify barriers to
incorporating sexuality assessment and counseling into nursing practice. Design/Approach:
This article provides an historical account of the collaborative group processes leading to the
development and testing of the Sexuality Attitudes and Beliefs Survey (SABS). Background/
Rationale: Nurses often are called upon to talk to patients about their sexuality and sexual
concerns. Many nurses believe that sexuality assessment, evaluation, and counseling is a
part of their professional role, however, nurses do not necessarily integrate this awareness
into their patient care. Discomfort, embarrassment, or strongly held attitudes about the
nurse’s role in discussing sexuality with patients can act as barriers to responding to these
patient concerns. Setting: A Midwestern urban healthcare facility, affiliated with a university
served as the setting. Sample: Thirty-five nurses working outpatient and inpatient settings in
oncology and HIV/AIDS. Method: Instrument development and voluntary survey. Outcomes:
The collaborative initiative developed and piloted an instrument to measure nurses` attitudes
and beliefs about human sexuality. Results of the pilot study suggest that what nurses believe
patients expect from them, time availability, and confidence in one`s ability to address issues
related to human sexuality present significant barriers to incorporating sexuality assessment
and counseling into nursing practice. Conclusion: Successful collaboration among clinicians
and researchers required administrative support as well as a individual commitment and is a
model that can be adapted to other settings and for other projects. Implications for Practice:
This study highlights the benefits of collaboration between clinicians and researchers to
support evidenced based practice. The findings from this study will be used to develop
strategies for removing barriers to sexuality assessment by nurses.
KEY WORDS: Collaborative research, advanced practice nursing, sexuality
From the Karmanos Cancer Hospital, Detroit Medical Center, Detroit, MI (Ms Reynolds); and School of
Nursing, Oakland University, Rochester, MI and College of Nursing, Wayne State University, Detroit,
MI (Dr Magnan).
Corresponding author: Morris A. Magnan, PhD, RN (e-mail: mamagnan@wayne.edu).
Clinical Nurse SpecialistA Copyright B 2005 by Lippincott Williams & Wilkins, Inc.
Copyr ight © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
I t is expected that the increasing demand for evidence-
based practice will reshape the work that nurses do and
lead to improved patient outcomes. Demand alone does
avoiding. Eventually, a core group of 9 APNs expressed an
interest in exploring the topic further.
Establishing and maintaining a working group was chal-
not ensure success. Collaboration among clinicians, lenging. Scheduling meetings was a problem complicated
researchers, and scholars is needed if nurses are to move by varying work schedules and clinical roles and settings.
beyond common sense models of care to a professional The first group meeting, in July 2003, was designed to de-
level of evidence-based practice.1Y4 Healthcare practi- termine: (1) what was meant by the term Bhuman sexuality,^
tioners have come to demand evidence from research that (2) what aspects of human sexuality needed to be studied,
will predict the highest probability of effectiveness in and (3) what were the potential barriers to moving forward.
improving patient care. Nursing science needs to produce While recognizing that the general area of interest was
researched evidence that supports a technique or nursing human sexuality, the study group had to determine
intervention that will produce the best results. A greater whether it should start by examining patient issues related
understanding of nursing attitudes and beliefs toward to human sexuality or nursing issues related to addressing
patient sexuality and medical illness, along with under- human sexuality in nursing practice. It was decided to
standing patients` expectations for nursing intervention in begin by evaluating nursing attitudes and beliefs about
this arena, will guide more holistic nursing interventions. human sexuality because it is not clear to what extent
This article describes the nature of the collaboration nurses` sexual attitudes affected clinical practice.6
between a group of Detroit Medical Center Advanced Barriers to studying nursing attitudes and beliefs about
Practice Nurses (APN) and a Wayne State University human sexuality were anticipated. First, human sexuality
(WSU) nurse researcher, and presents results of a pilot was identified as a controversial topic. Therefore, support
study on human sexuality conducted by the medical center from the management team was essential. To address this
APNs. The APNs involved in this study consisted of Nurse challenge, frequent meetings with the management team
Practitioners and Clinical Nurse Specialists (CNSs) in were held. Next, the possibility of a negative reaction from
oncology, medical surgical nursing, rehabilitation nursing, the nursing staff was considered. The group wanted to
psychiatric nursing, maternal child nursing, and research as further their understanding of the kinds of barriers nurses
well as an enterostomal nurse. might have to overcome in order to incorporate sexuality
into daily practice. It was difficult to foresee whether the
COLLABORATION staff would be offended, resistant, or even honest in re-
porting their discomfort surrounding human sexuality. A
Professional standards of practice require nursing involve- pilot study was designed to seek information on these issues
ment with research.5 However, the basic education pro- as well as measurement issues. Finally, the group had to deal
vided to most nurses does not prepare them adequately to with inexperience in doing research. The strengths that
initiate, participate in, produce, use, or disseminate the moved it forward were their history of working together,
health research that is relevant to their areas of practice. mutual professional respect, an appreciation of the wide
Nursing faculty from Wayne State University College of variety of expertise brought to the table, and the consul-
Nursing functioned as consultants guiding DMC nurses tant`s willingness to uphold the value of clinical scholarship.
through each step of the research process from identifying The research consultant brought expertise to the table in
researchable topics to disseminating research findings. establishing the time line and necessary processes required
to initiate and complete a research project. The group was
COLLABORATION AMONG CLINICIANS given guidelines for defining the problem, making group
decisions about the tool to be used or created, piloting the
AND RESEARCHERS
tool for validity and reliability, and moving to data
One of the first activities initiated by the research consul- collection. The research consultant also clarified and
tants was to schedule brainstorming sessions with the facilitated the passage of the project through the institu-
APNs at the DMC. The question raised was: BWhat kinds tional review board (IRB) and administrative approval.
of phenomena or clinical problems are you seeing repeat- The consultant`s expertise in statistical interpretation of the
edly in your area of specialization?^ Pain, anxiety, and data brought an often-muddy picture into clear focus. This
postoperative nausea were identified by APNs from dif- allowed the group to move forward with expansion of the
ferent specialty areas. The topic of human sexuality seemed study to a wider group of participants.
to have the widest area of application and was relevant to Any similar research group needs to carefully select a
almost every specialty practice area. Issues of self-esteem, consultant who understands the role of advisor while
relationships to significant others, body image, physical allowing the group independence and creativity. Without
stamina, and issues related to sexual functioning seemed clear role boundaries established from the beginning, the
pertinent and consistent no matter which medical treat- research group might find itself being managed and directed
ment or patient diagnosis was highlighted. At the com- by the consultant rather than guided and supported.
pletion of the brainstorming sessions, volunteers were
solicited to act as the point-person or coordinator for each
INSTRUMENT DEVELOPMENT
topical area within the medical center. Recruiting mem-
bers to join the human sexuality interest group met with Initially, the group focused on nursing attitudes and beliefs
some resistance. Several APNs supported the idea of ad- about human sexuality. A literature review was conducted
dressing issues related to human sexuality, others discour- to find authoritative definitions of the term Bhuman
aged tackling this controversial topic that nurses have been sexuality,^ and to determine what was already known
B
256 CLINICAL NURSE SPECIALIST
Copyr ight © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
about nurses` attitudes and beliefs about human sexuality socially desirable responses rather than honest responses to
as it relates to nursing practice. survey questions. To minimize the burden to nurses of
The World Health Organization`s (WHO)7 definition of answering many questions, a shortened 10-item version of
sexual health provides an appropriate orientation to study- the Marlowe-Crowne Social Desirability Scale (M-C2)19
ing human sexuality although it does not explicitly define was used to assess social desirability response bias.
human sexuality. Sexual health, according to WHO7 is After planning the details of the research project, the
Bthe integration of the somatic, emotional, intellectual and consultant helped write the research proposal, which was
social aspects of sexual being, in ways that are positively then submitted to the Wayne State University Human
enriching and that enhance personality, communication Investigation Committee for review. Because the research
and love.^ The literature also made it clear that studies of involved minimal risk to the research subjects, it was
human sexuality involved medical students more often than approved using an expedited review process.
nurses and often dealt with Bsexual practices^ rather than
the more global perception of the sexual being. Barriers to
RESULTS OF THE PILOT STUDY
providing sexual counseling to patients included but were
not limited to: (a) staff embarrassment, (b) believing that The focus for the pilot study was to evaluate the psy-
sexuality issues are not relevant to the patient`s medical chometric properties (validity and reliability) of the SABS,
problems, (c) feeling inadequately trained or lacking and to determine: (1) whether the SABS was subject to
knowledge, and (d) absence of role models.6,8Y12 A number response bias related to social desirability; (2) to what
of research tools developed specifically to assess sexual extent the nurse`s age and years working as a nurse might
attitudes and beliefs were examined during the review of influence SABS responses; (3) whether prior exposure to
the literature.12 From the review, research tools used to educational programs on human sexuality might influ-
assess attitudes about sexuality were too long for use in a ence SABS responses; and (4) what barriers to incorporat-
clinical setting. To provide an appropriately focused, con- ing human sexuality assessment/counseling into practice
cise assessment of nurses` attitudes about human sexuality, were most salient.
the development of a different instrument was needed. The SABS was pilot tested in May 2004 by recruiting 35
The group dedicated several months to developing a nurses working in outpatient clinics at the DMC to
self-report questionnaire (Sexual Attitudes and Beliefs participate in the study. After reading an information sheet
Survey [SABS]) to assess attitudes and beliefs that might about the study, 34 of 35 nurses agreed to participate. The
act as barriers to human sexuality assessment and counsel- age range for these nurses was 27 to 61 years (M = 43; SD
ing in nursing practice. Each group member was charged = 9.62). Nurses reported working as a nurse from 4.5 to 39
with reviewing at least 2 similar tools and bringing them to years (M = 19.4; SD = 10.5). The nurses in the pilot project
the table for consensus building. This process consisted of held different positions within the organization. Most were
reviewing many similar tools from the literature, as well as staff nurses (n = 29), 3 were APNS, and 2 were nurse
tools previously used in participant`s own settings, and managers.
coming to a consensus on the variety and depth of attitudes Support for the construct validity of the SABS was
they wanted to understand and an acceptable length for the demonstrated by its significant correlation (r = j.37, P G
tool. The SABS consists of 12 items presented in a Likert- .05) with the attitudes scale of the SKAT. Further support
type format (1 = strongly disagree; 6 = strongly agree). To for the construct validity of the SABS was demonstrated by
avoid response set bias, scores are reversed on 6 of the 12 its significant correlation (r = j.43; P = .01) with the
items (Fig. 1).13 Total SABS scores range from 6 to 72 with sexual myths subscale of the SKAT attitudes scale. These
higher scores indicating more barriers to incorporating results suggested that the SABS was in fact measuring
human sexuality assessment/counseling into nursing prac- attitudes about human sexuality. Moreover, they suggest
tice. Sample items include: (1) I am uncomfortable talking that nurses whose attitudes are apt to create barriers to
about sexual issues; (2) Sexuality is too private to discuss incorporating human sexuality assessment/counseling into
with patients; (3) Discussing sexuality is essential to their practice are more apt to hold conservative attitudes
patients` outcomes. about human sexuality and adhere to a greater number of
If the SABS were actually measuring attitudes and sexual myths.
beliefs about human sexuality in nursing practice, then The SABS appears to be an internally consistent measure
SABS scores should correlate with other valid and reliable of barriers to incorporating human sexuality assessment/
measures of sexual attitudes. The construct validity of the counseling into nursing practice with Cronbach alphas of
SABS was assessed by correlating SABS scores with scores .75 and .82 over 2 separate administrations. In addition,
obtained on the attitudes section of the Sexual Knowledge the instrument provides a stable measure of attitudes with
and Attitudes Scale (SKAT14). The SKAT was selected for good test-retest reliability (r = .85; P G .001) over a 7- to
this activity because it has been used widely in other studies 10-day interval.
involving nurses and medical students.14Y17 The nurses` SABS scores did not correlate significantly
When faced with questions about a sensitive topic, some with scores obtained on the shortened version of the
people give answers they feel are more acceptable to others Marlowe-Crowne Social Desirability Scale (r = .28; P =
rather than stating their honest opinion. This can result in a .10). Thus, nurses seemed to be giving honest responses to
response referred to as a social desirability response bias.13 the SABS items rather than giving responses they thought
Crowne and Marlowe18 developed a social desirability scale might be more socially desirable. Additionally, the SABS
to be used specifically for the purpose of determining the scores in the pilot study were unrelated to the nurse`s age
extent to which survey respondents were apt to provide or the number of years working as a nurse. Nurses who
Copyr ight © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Figure 1. The Sexuality Attitudes and Beliefs Survey (SABS). Reverse coding is used for items 1, 2, 4, 6, 8, 10, and 12.
had attended workshops on human sexuality had lower atic for nurses. The 5 items with the highest mean scores
SABS scores (fewer barriers) than nurses who had not (more of a barrier) are listed below in descending order:
attended human sexuality workshops (t = j3.83; df = 32;
P = .001). This last finding needs to be interpreted cau- 1. Patients expect nurses to ask about their sexual
tiously as it is not clear whether attendance at workshops concerns (M = 3.96).
resulted in fewer barriers or whether nurses with fewer 2. I make time to discuss sexual concerns with my patients
barriers were more apt to attend sexuality workshops. (M = 3.79).
Some barriers to incorporating human sexuality assess- 3. I am more comfortable talking about sexual issues
ment/counseling into nursing practice seemed to be more with my patients than are most of the nurses I work
salient than others. Examining responses to individual with (M = 3.69).
items on the SABS helped to identify which barriers to 4. I am uncomfortable talking about sexual issues (M =
sexuality assessment/counseling were particularly problem- 3.50).
B
258 CLINICAL NURSE SPECIALIST
Copyr ight © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
5. I feel confident in my ability to address patients` sexual J. Maklebust, MSN, APRN-BC, AOCN, FAAN. Appreci-
concerns (M = 3.24). ation is extended to the nurse managers and staff who
participated in the data collection. We would also like to
These findings suggest that what nurses believe patients acknowledge the significant support we received from the
expect from them, time availability and confidence in one`s Detroit Medical Center, the Center for Clinical Research;
ability to address issues related to human sexuality, present Dr. Virginia Rice, Professor, Wayne State University,
significant barriers to incorporating sexuality assessment College of Nursing; Iris Taylor PhD, RN, President of
and counseling into nursing practice. Harper and Hutzel Hospitals; and Karen Goldman, MSN,
RN, Vice President for Cancer Patient Services, Karmanos
Cancer Hospital, Detroit Medical Center, Detroit, Michi-
CONCLUSION gan for their support and assistance with this project.
The success of this group and its accomplishments can
be attributed to the collaborative process that evolved as References
well as the expertise of the team members. A team should 1. Caramanica L, Maljanian R, McDonald D. Evidence-based
be formed from diverse arenas, both in practice and in nursing practice, Part 1: A hospital and university collabo-
expertise. This team should make an early commitment to: rative. J Nurs Adm. 2002;32:27Y30.
working together, dividing the tasks, maintaining a flexi- 2. Dickenson-Hazard N. CollaborationVare we really ready?
bility and tenacity of character, respecting each other`s con- J Prof Nurs. 1999;15:261.
tributions and a willingness to devote time to the project. 3. Gawlinski A. Champions of change. ADVANCE for nurses
Engaging administrative commitment and support is essen- [Serial online]. 2004;1:13Y14. Available at: http://www.
advanceb.com. Accessed June 6, 2004.
tial to the success of the project. An expert consultant, pref-
4. Pillar B, Solem G. Cooperation and collaboration for clini-
erably with research expertise as well as clinical credibility, cal nursing research: the Akron-Canton clinical nursing re-
is essential to guide the direction and depth of the process. search network. Orthop Nurs. March/April 1999:54Y57.
The next steps include using the SABS to replicate the 5. American Nurses Association. Nursing: Scope and Standards
study with a larger and more diverse group of nurses at the of Practice. Washington, DC: Author; 2004.
DMC. The results of the larger survey are expected to 6. Hughes MK. Sexuality issues: keeping your cool. Oncol Nurs
clarify the kinds of educational programs needed to help Forum. 1996;23:1597Y1600.
nurses feel more comfortable and confident in dealing with 7. WHO Education and Treatment in Sexuality: The Training of
human sexuality issues in nursing practice. Health Professionals. Geneva: World Health Organization;
In collaboration with a research consultant, a nursing 1975. Technical Report Series; No. 572.
8. Kautz DD, Dickey CA, Stevens MN. Using research to
team identified a researchable problem, developed a valid
identify why nurses do not met established sexuality nursing
and reliable instrument to measure nurses` attitudes and care standards. Nurs Qual Assur. 1990;4:69Y78.
beliefs about human sexuality, and pilot tested that instru- 9. Matocha LK, Waterhouse JK. Current nursing practice
ment in less than 1 year. The intention of this study was to related to sexuality. Res Nurs Health. 1993;16:371Y378.
develop an understanding of nurses` perceptions of the im- 10. Williams HA, Wilson ME, Hongladarom G, McDonell M.
portance of this issue in regards to nursing practice and the Nurses` attitudes toward sexuality in cancer patients. Oncol
barriers that nurses perceive impact their practice. The Nurs Forum. 1986;31:39Y43.
group will also expand the study to gain an understanding of 11. Wilson ME, Williams HA. Oncology nurses` attitudes and
patient expectations of nursing practice related to their sex- behaviors related to sexuality of patients with cancer. Oncol
uality concerns. The study will be used to develop strategies Nurs Forum. 1988;15:45Y53.
12. Mick J. Oncology nurses and the sexuality of cancer patients.
for nursing education within the DMC medical system as
Hematol Oncol News. 2005;4:18Y23.
well as proposals for additions to early nursing education 13. Polit DR, Hungler BP. Nursing Research: Principles and
at the university and community college levels. Ultimately, methods. New York, NY: Lippincott; 1999.
the SABS and the DMC study would be used to fuel wide- 14. Miller WR, Lief HI. The sex knowledge and attitude test
spread assessment of nursing attitudes and beliefs to impact (SKAT). J Sex Marital Ther. 1979;5:282Y287.
the direction of nursing research and practice on this topic. 15. Lewis S, Bor R. Nurses` knowledge of and attitudes towards
sexuality and the relationship of these with nursing practice.
J Adv Nurs. 1994;20:21Y259.
16. Payne T. Sexuality of nurses: Correlations of knowledge,
ACKNOWLEDGMENTS attitudes, and behavior. Nurs Res. 1976;25:286Y292.
17. Webb C. A study of nurses` knowledge and attitudes about
The authors thank the members of the Nursing Attitudes
sexuality in health care. Int J Nurs Stud. 1988;23:235Y244.
Study Committee for their expertise and contributions of 18. Crowne DP, Marlowe D. The Approval Motive. New York:
time and commitment to the study: E. Galvin, MS, RN, R. Wiley; 1964.
Allan, MSN, RN, C. Bauer, BSN, RN, OCN, CWOCN, 19. Strahan R, Gerbasi KC. Short, homogenous versions of the
S. Brooks, MS, RN, OCN, AOCNS, J Burns, MSN, RN, Marlowe-Crowne Social Desirability Scale. J Clin Psychol.
APRN-BC, ACRN, R. Ososki MSN, RN, AOCN, and 1972;28:191Y193.
Copyr ight © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.