JONA Volume 44, Number 9, pp 481-486 Copyright B 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
THE JOURNAL OF NURSING ADMINISTRATION
Magnet Nurse Administrator Attitudes and Opportunities Toward Improving Lesbian, Gay, Bisexual, or TransgenderYSpecific Healthcare Ralph Klotzbaugh, PhD, RN, APRN Gale Spencer, PhD, RN OBJECTIVE: This study explored Magnet hospital chief nursing officers’ (CNOs’) attitudes toward gays and lesbians and the impact that these attitudes have on providing advocacy for lesbian, gay, bisexual, or transgender (LGBT) patients and staff. BACKGROUND: Homonegativity encompasses both heterosexism and homophobia and has profound effects on the health of LGBT populations. Little has been reported about the attitudes of CNOs toward LGBT populations and how these might impact advocacy for LGBT healthcare. METHODS: Surveys were electronically mailed to 343 Magnet CNOs. The Modern Homonegativity Scale was used to assess attitudes, and additional statements were developed to assess the comfort level of the respondent in advocating for LGBT populations. RESULTS: Attitudes among CNOs toward LGBT populations and comfort with advocating for LGBT populations were positively correlated. Those demonstrating less homonegative attitudes were more likely to feel comfortable advocating for LGBT patients and staff. CONCLUSIONS: Recognizing and addressing bias among nurse leaders through education are important to ensure equitable healthcare for patients and employees. A
Author Affiliations: Assistant Professor (Dr Klotzbaugh), Department of Nursing, University of New Hampshire, Durham; SUNY Distinguished Teaching Professor and Decker Endowed Chair in Community Health Nursing (Dr Spencer), Decker School of Nursing, Binghamton University, New York. The authors declare no conflicts of interest. Correspondence: Dr Klotzbaugh, Department of Nursing, University of New Hampshire, Hewitt Hall, 4 Library Way, Durham, NH 03824-3563 ([email protected]). DOI: 10.1097/NNA.0000000000000103
JONA Vol. 44, No. 9 September 2014
Research demonstrates that homonegativity has negative effects on the health and well-being of lesbian, gay, bisexual, and transgender (LGBT) patients, as well as coworker interactions in nursing and healthcare.1-6 Homonegativity is a term representing a continuum of discrimination against LGBT people. This continuum includes both heterosexism, or rather the presumption that everyone is assumed or expected to be heterosexual, and homophobia, which represents a fear and hatred of LGBT people, resulting in verbal or physical assault.6 It is reported that ‘‘LGBT populationsIexperience health disparities and barriers related to sexual orientation and/or gender identity or expression. Many avoid or delay care or receive inappropriate or inferior care because of perceived or real homophobiaI’’5(p1) Nursing has been identified as a profession having ‘‘been slower than other health disciplines in changing policies to include sexual orientation and gender identity, and has been silent when other professional groups have issued statements about topics such as same-sex marriage and reparative therapies.’’7(p206) Additional research supports that homonegativity frequently occurs within the nursing profession.2,3,6,8-13 Numerous professional nursing organizations and societies, including the National League of Nursing and the National Magnet Recognition Program , have not introduced specific standards to advocate for this population as further evidence for the need to raise awareness among the profession.14,15 Chief nursing officers (CNOs) are recognized for the position power, business skills, and clinical acumen to establish new programs and services to meet the needs of diverse A
481
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
patient populations.16,17 In Magnet organizations, CNOs are purported as leaders of clinical excellence and evidence-based practice.18,19 For purposes of this study, attitudes toward LGBT patients and employees among CNOs in Magnet-designated hospitals were assessed. The study also investigated the effect that such attitudes might have on the comfort of CNOs in engaging in LGBT-specific advocacy. A
Conceptual Framework The Health Belief Model (HBM)20 was used as the framework for the study. According to the HBM, perceived low self-efficacy is associated with deterring the adoption of health-related actions and is thus an obstacle in implementing corrective action. With the HBM, modifying factors such as attitudes and beliefs and demographic variables were theorized as influencing one’s perceived self-efficacy. This discussion focuses on CNO attitudes and beliefs toward LGBT populations and their consequent effects on self-efficacy in LGBT-related advocacy. Although the model’s original purpose was to explain population response to public health initiatives, it is a useful framework in which to examine CNO behaviors in the provision of population (LGBT) advocacy.
Methods This project was approved by the Binghamton University Human Subjects Research Review committee. A questionnaire was electronically mailed to 343 CNOs in Magnet-designated organizations. A cover letter that included a link to the survey was sent with the questionnaire via the Binghamton University e-mail system. Completion and return of the survey indicated the respondent’s consent to participate. The survey collected basic sociodemographic data, including whether participants were familiar with anyone who identified as LGBT. Attitudes toward lesbian and gay populations were measured using the Modern Homonegativity Scale (MHS) developed by Morrison and Morrison.21 This scale was developed in response to the concern that traditional measures of homonegativity were no longer accurate because of changes in attitudes over time. It has been suggested that societal shifts in attitudes toward lesbian and gay individuals cause people to be less likely to express overt prejudice than heretofore. The MHS was therefore developed as a more subtle approach to measuring people’s negative attitudes without the respondent’s concern or fear of explicitly exposing their prejudice. The MHS consists of 10 items specific to gay men and 10 items specific to lesbians and 2 items that pertain to either gay men or lesbians. The instrument has demonstrated high reliability in measuring specific attitudes toward
482
gay men (Cronbach’s ! = .91) and lesbians (Cronbach’s ! = .92). Reliability data calculated on these combined subscales revealed that the MHS could be used as a measure of attitudes toward both gay men and lesbians (Cronbach’s ! = .92). The MHS uses a 5-point Likerttype scale of agreement; 3 items were reverse scored. Higher scale scores indicate more negative attitudes toward lesbian and gay populations, defined for this study as higher levels of homonegativity (Table 1). No previous studies have investigated the effects of homonegativity on self-efficacy in advocating for LGBT populations; thus, a survey assessment of selfefficacy was developed by the authors. Self-efficacy was assessed at both a personal level of comfort in advocating for LGBT patients and staff as well as comfort in advocating for LGBT patients and staff in the professional role of CNO. Personal self-efficacy data were collected from 2 questions developed for this study based on combined responses to the questions ‘‘I would not personally feel comfortable advocating for LGBT patients’’ and ‘‘I would not personally feel comfortable advocating for LGBT staff.’’ Scores on the 2 items Table 1. The MHS Many lesbians (gay men) use their sexual orientation so that they can obtain special privileges. Lesbians (gay men) seem to focus on the ways in which they differ from heterosexuals and ignore the ways in which they are the same. Lesbians (gay men) do not have all the rights they need.a The notion of universities providing students with undergraduate degrees in Gay and Lesbian Studies is ridiculous. Celebrations such as ‘‘Gay Pride Day’’ are ridiculous because they assume that an individual’s sexual orientation should constitute a source of pride. Lesbians (gay men) still need to protest for equal rights.a Lesbians (gay men) should stop shoving their lifestyle down other people’s throats. If lesbians (gay men) want to be treated like everyone else, then they need to stop making such a fuss about their sexuality/culture. Lesbians (gay men) who are ‘‘out of the closet’’ should be admired for their courage.a Lesbians (gay men) should stop complaining about the way they are treated in society and simply get on with their lives. In today’s tough economic times, United States tax dollars shouldn’t be used to support lesbian (gay men’s) organizations.b Lesbian (gay men) have become far too confrontational in their demand for equal rights. a
Items reverse scored. Item changed to reflect US currency, with authors’ permission.
b
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measuring self-efficacy were summed for a personal self-efficacy score (scores range from a low of 2 to high of 6). Items were scored from 1 = disagree to 3 = agree, with lower scores indicating greater likelihood of personally advocating for LGBT patients and staff. Professional self-efficacy data were based on combined responses to the questions ‘‘I would not, as CNO, feel comfortable advocating for LGBT patients’’ and ‘‘I would not, as CNO, feel comfortable advocating for LGBT staff.’’ Scores on the 2 items measuring selfefficacy were summed for a professional self-efficacy score (scores range from a low of 2 to high of 6). Items were scored from 1 = disagree to 3 = agree, with lower scores indicating greater likelihood of professionally advocating for LGBT patients and employees. The instrument has preliminarily demonstrated high reliability in measuring personal self-efficacy (Cronbach’s ! = .89) and professional self-efficacy (Cronbach’s ! = .97). Reliability data calculated on the combined subscales revealed that the scales could be used as a measure of self-efficacy (Cronbach’s ! = .93). Statistical analysis was performed using Statistical Package for the Social Sciences (SPSS) 20.0 (Armonk, New York). An a priori ! level of .05 was set to reduce the risk of a Type I error. Descriptive statistics were used to discuss the characteristics of the total participants. Standard deviation, range, and means were reported for interval level data. Scores on the MHS were derived from 24 items on the MHS Scales, with a low score of 24 to a high score of 120. Self-efficacy scores were derived from 4 items, with a low score of 4 to a high score of 20. Relationships between CNO attitudes and beliefs about LGBT populations and their self-efficacy in advocating for LGBT patients and staff were statistically analyzed using a correlation coefficient.
what religious, whereas a quarter of the sample indicated that they were very religious (25.4%). Results are summarized in Table 2. It is worth noting that demographic effects on MHS total scores were examined by analysis of variance (ANOVA) and independentsamples t test. There were no significant differences between the MHS score for lesbians and the MHS score for gay men. Of the sample’s demographic information, religiosity was the only one that had a significant effect on MHS scores. A 1-way ANOVA was conducted to compare MHS scores as they relate to the participants’ indicated level of religiosity. Results of the ANOVA depicted a significant effect for religiosity and scores on the MHS (F2, 100 = 5.27, P = .007). Tukey post hoc comparisons of the scores indicated that those participants describing themselves as very religious had significantly higher MHS total scores (mean, 68.12; 95% confidence interval [CI], 63.08-73.16) than did those describing themselves as not religious (mean, 58.42; 95% CI, 53.00-63.84; P = .005), indicating higher levels of homonegativity among those who identified themselves as very religious (Table 3). Comparisons between those indicating their level of religiosity as somewhat religious and those indicating their level of religiosity as very religious or not at all religious were not statistically significant at P G .05. The statistically significant finding of this study reflects the findings of other studies in terms of effect of religiosity on homonegativity. Religiosity has been the most frequently examined demographic for its effect on homonegativity.8,9,22-24 The characteristics of this sample were similar to available national Magnet CNO demographic data as
Table 2. Demographics
Results Surveys were completed by 115 Magnet-designated hospital CNOs (33.5%). Analyses of the demographic statistics revealed that of the 114 subjects who reported their gender, 89.5% (n = 102) were women. Representative age group was reported by 115 subjects, with most of the sample being between 55 and 64 years of age (58.3%; n = 67). Of the 115 subjects reporting their race, most (96.5%; n = 111) identified themselves as white. Of the 109 subjects who indicated their sexual orientation (94.8%), most indicated their sexual orientation as heterosexual (90%; n = 98). All 115 subjects reported their highest level of education, with most (74.8%) indicating master’s degree. All 115 subjects also indicated knowing or having known someone who identified as lesbian, gay, bisexual, and/or transgender. More than half (57.0%) of the 114 respondents described themselves as some-
JONA Vol. 44, No. 9 September 2014
Variable
Categories
Age
35-45 y 46-55 y 56-64 y Q65 y
Race/ethnicity
n (%) 4 40 68 3
(3.5) (34.8) (59.1) (2.6)
African American White Hispanic Native American
2 111 1 1
(1.7) (96.5) (0.9) (0.9)
Biological sex
Male Female
12 (10.5) 102 (89.5)
Sexual orientation
Heterosexual Gay or lesbian Bisexual
98 (89.9) 7 (6.4) 4 (3.5)
Education
Master’s PhD
86 (74.8) 29 (25.2)
Religiosity
Very religious Somewhat religious Not at all religious
29 (25.4) 65 (57.0) 20 (17.5)
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Table 3. Religiosity and MHS Scores Indicated Level of Religiosity, Mean (95% CI) Very Religious
Somewhat Religious
Not at All religious
68.12 (63.08-73.16)
64.51 (62.38-66.63)
58.42 (53.00-63.84)
Religiosity and MHS Scores Level of Religiosity (I)
Level of Religiosity (J)
Very religious
Somewhat religious Not at all religious
Somewhat religious
Very religious Not at all religious
Not at all religious
Very religious Somewhat religious
Mean Difference (I - J)
SE
P
95% CI Lower
95% CI Upper
2.352 3.000
.279 .005
j1.98 2.56
9.21 16.84
j3.612 6.087
2.352 2.600
.279 .055
j9.21 j0.10
1.98 12.27
j9.699a j6.087
3.000 2.600
.005 .055
j16.84 j12.27
j2.56 0.10
3.612 9.699a
a
Mean difference is significant at the .05 level.
the targeted population. The average age for Magnet CNOs has been reported as approximately 56 years, with 92.4% being women and 75.8% indicating their highest degree to be at the master’s level.18,25 Demographic information on race, sexual orientation, and religiosity has not been reported in these studies. Attitudes and Beliefs and Personal Self-efficacy The relationship between CNO attitudes and beliefs about LGBT individuals and their personal self-efficacy in advocating for LGBT patients and staff was analyzed using Pearson product-moment correlation coefficient. The analysis used a composite score (ranging from a low of 24 to high of 120) for the independent variable composed of the 24 items on the MHS. Items were scored from 1 = strongly disagree to 5 = strongly agree. Scoring on items 3, 6, and 9 were reversed to be consistent with positive scoring. The scores were summed for the attitude score. Higher scores on the MHS indicate higher levels of homonegativity. The homonegativity scores were reduced to 3 categories composed of scores ranging from 24 to 56, indicating no homonegativity to mild homonegativity, whereas scores from 57 to 88 indicate moderate homonegativity. Scores ranging from 89 to 120 indicate moderate to extreme homonegativity. Scores on the MHS demonstrated a mean score of 64.13 (range, 32-90). Mean MHS scores indicated moderate levels of homonegativity among the sample. The scores on the 2 items measuring selfefficacy were summed for a personal self-efficacy score, with lower scores indicating greater likelihood of personally advocating for LGBT patients and staff. The mean (SD) score for personal self-efficacy in this sample was 3.53 (1.63), indicating that respondents generally perceived their personal self-efficacy in LGBT advocacy to be moderate. The correlation coefficient was used to test the relationship between personal self-efficacy and atti-
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tudes. The results of the correlational analysis indicated that self-efficacy and attitudes were positively correlated (n = 91, r = 0.333, P = .001). The results suggested that CNOs who have less homonegative attitudes also tend to believe that they are more personally efficacious in advocating for LGBT patients and staff. Attitudes and Beliefs and Professional Self-efficacy Pearson product-moment correlation coefficient was again used to analyze the relationship between beliefs and attitudes about LGBT individuals among CNOs and professional self-efficacy. The summed attitude score was again used as independent variable. The scores on the 2 items measuring self-efficacy were summed for a professional self-efficacy score, with lower scores indicating greater likelihood of professionally advocating for LGBT patients and staff. The correlation coefficient was used to test the relationship between professional self-efficacy and attitudes. The results of the correlational analysis indicated that professional self-efficacy and attitudes were positively correlated (n = 91, r = 0.481, P = .000). The results suggested that CNOs who have less homonegative attitudes also tend to believe that they are more professionally efficacious in advocating for LGBT patients and staff. Again, the mean (SD) attitude score was 64.1 (10.29), indicating moderate levels of homonegativity. The mean (SD) score for professional self-efficacy in this sample was 3.29 (1.45), indicating that respondents generally perceived their professional self-efficacy in LGBTadvocacy to be slightly more than moderate.
Conclusion Findings from this study indicate that CNOs demonstrate moderate levels of homonegativity in their attitudes and beliefs toward lesbian and gay populations.
JONA Vol. 44, No. 9 September 2014
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Although this study’s findings are specific to executivelevel nurses, these findings are consistent with findings from other studies on nurses, in general, regarding negative attitudes toward LGBT individuals.2,3,6,12 More positive attitudes and beliefs among CNOs in this study were found to be positively correlated with perceived self-efficacy in advocating for LGBT staff and patients at both personal and professional levels. These findings suggest that CNOs with higher personal self-efficacy were more positive in their attitudes and beliefs about LGBT populations. This finding also suggests that CNOs with higher professional self-efficacy are more positive in their attitudes and beliefs about LGBT patients and employees as well. Less bias, therefore, may suggest more advocacy for both LGBT patients and staff. In addition, CNOs who have more positive attitudes and beliefs about LGBT populations may have less bias toward this population and therein may be more comfortable in advocating for LGBT patients and staff. Self-efficacy in this study was conceptualized to reflect a level of comfort and competence in providing LGBT-related advocacy. Bandura,26 whose work supports the self-efficacy component of the HBM, suggested that one’s estimation of self-efficacy was related inversely to the degree of negative somatic arousal. Increased comfort in providing advocacy may have low negativity, thereby resulting in higher self-efficacy.
Evidence provided by this study indicates moderate levels of homonegativity among nurse executives in what are recognized as the nation’s premier medical institutions. Implications for investigating methods of recognizing, assessing, and improving cultural competency significantly and substantively inclusive of LGBT populations are imperative. This consideration will broaden the understanding of diversity and cultural competency providing for greater clinical, academic, and social sensitivity. In addition, these advancements will support nursing professional responsibility for advocacy, equality, and human rights. Finally, in support of quality healthcare for all, this awareness must become an essential component of institutional culture. Limitations Limitations were related to generalizability of findings. The population for this study was quite specific. Relating findings to subjects outside those surveyed would require additional research. The MHS was specific to measurement of attitudes toward gay and lesbian populations. Attitudes toward transgender populations therefore can only be surmised pending further research. In addition, although the MHS instrument was chosen to decrease likelihood of respondents answering what they perceive to be socially desirable responses, the possibility of this occurring could not be eliminated.
References 1. Button SB. Organizational efforts to affirm sexual diversity: a cross level examination. J Appl Psychol. 2001;86(1):17-28. 2. Blackwell CW. Registered nurses’ attitudes toward the protection of gays and lesbians in the workplace. J Transcult Nurs. 2008; 19(4):347-353. doi:10.1177/1043659608322420. 3. Harding T. The construction of men who are nurses as gay. J Adv Nurs. 2007;60(6):436-644. 4. US Department of Health and Human Services. Office of Disease Prevention and Health Promotion Healthy People 2020. Lesbian, Gay, Bisexual, and Transgender Health. http://www.healthypeople .gov/2020/topicsobjectives2020/overview.aspx?topicid=25. Updated May 28, 2014. Accessed May 28, 2014. 5. Gay and Lesbian Medical Association. Guidelines for care of lesbian, gay, bisexual, and transgender patients. 2006. http:// glma.org/_data/n_0001/resources/live/GLMA%20guidelines% 202006%20FINAL.pdf. Accessed January 6, 2014. 6. Irwin L. Homophobia and heterosexism: implications for nursing and nursing practice. Aust J Adv Nurs. 2007;25(1):70-76. 7. Eliason MJ, Dibble S, Dejoseph J. Nursing’s silence on lesbian, gay, bisexual, and transgender issues: the need for emancipatory efforts. Adv Nurs Sci. 2010;33(3):206-218. doi:10.1097/ ANS.0b013e3181e63e49. 8. Schlub SM, Martsolf DS. Orthodox Christian beliefs and homophobia in baccalaureate nursing students. Nurs Forum. 1999; 34(2):15-22.
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9. Smith GB. Homophobia and attitudes toward gay men and lesbians by psychiatric nurses. Arch Psychiatr Nurs. 1993;7(6):377-384. 10. Blackwell CW. Belief in the ‘‘free choice’’ model of homosexuality: a correlate of homophobia in registered nurses. J LGBT Health Res. 2007;3(3):31-40. 11. Eliason MJ. Correlates of prejudice in nursing students. J Nurs Educ. 1998;37(1):27-29. 12. Gray DP, Kramer M, Minick P, McGehee L, Thomas D, Greiner D. Heterosexism in nursing education. J Nurs Educ. 1996;35(5):204-210. 13. Pickles D, King L, Belan I. Attitudes of nursing students towards caring for people with HIV/AIDS: thematic literature review. J Adv Nurs. 2009;65(11):2262-2273. doi:10.1111/j.1365-2648 .2009.05128.x. 14. A commitment to diversity in nursing and nursing education. National League of Nursing Web site. http://www.nln.org/aboutnln/ reflection_dialogue/refl_dial_3.htm. Accessed May 28, 2014. 15. Patient non-discrimination: LGBT-inclusive policy statements from healthcare organizations. Human Rights Campaign Web site. www .hrc.org/resources/entry/patient-non-discrimination-lgbt-inclusivepolicy-statements-from-healt. Accessed May 28, 2014. 16. Kirk H. Nurse executive director effectiveness: a systematic review of the literature. J Nurs Manag. 2008;16(3):374-381. doi:10.1111/j.1365-2834.2007.00783.x. 17. Clement-O’Brien K, Polit DF, Fitzpatrick JJ. Innovativeness of nurse leaders. J Nurs Manag. 2011;19:431-438.
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18. Clavelle JT, Drenkard K, Tullai-McGuinness S, Fitzpatrick JJ. Transformational leadership practices of chief nursing officers in Magnet organizations. J Nurs Adm. 2012;42(10):S3-S9. doi:10 .1097/NNA.0b013e31824ccd7b. 19. Batcheller JA. On-boarding and enculturation of new chief nursing officers. J Nurs Adm. (2011);41(5);235-239. 20. Champion VL, Sugg-Skinner C. The health belief model. In: Glanz K, Rimer BK, Viswanath K, eds. Health Behavior and Health Education: Theory, Research, and Practice. 4th ed. San Francisco, CA: Jossey-Bass; 2008:45-62. 21. Morrison MA, Morrison TG. Development and validation of a scale measuring modern prejudice toward gay men and lesbian women. J Homosex. 2002;43(2):15-37.
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22. Johnson ME, Brems C, Alford-Keating P. Personality correlates of homophobia. J Homosex. 1997;34(1):57-69. 23. Eldridge VL, Mack L, Swank E. Explaining comfort with homosexuality in rural America. J Homosex. 2006;51(2):39-56. 24. Walch SE, Orlosky PM, Sinkkanen KA, Stevens HR. Demographic and social factors associated with homophobia and fear of AIDS in a community sample. J Homosex. 2010;57(2):310-324. 25. Thompson R, Wolf DM, Sabatine JM. Mentoring and coaching: a model guiding professional nurses to executive success. J Nurs Adm. 2012;42(11):536-541. doi:10.1097/NNA.0b013 e31827144ea. 26. Bandura A. Social Foundations of Thought and Action: A Social Cognitive Theory. Englewood Cliffs, NJ: Prentice-Hall; 1986.
JONA Vol. 44, No. 9 September 2014
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
THE JOURNAL OF NURSING ADMINISTRATION
Magnet Nurse Administrator Attitudes and Opportunities Toward Improving Lesbian, Gay, Bisexual, or TransgenderYSpecific Healthcare Ralph Klotzbaugh, PhD, RN, APRN Gale Spencer, PhD, RN OBJECTIVE: This study explored Magnet hospital chief nursing officers’ (CNOs’) attitudes toward gays and lesbians and the impact that these attitudes have on providing advocacy for lesbian, gay, bisexual, or transgender (LGBT) patients and staff. BACKGROUND: Homonegativity encompasses both heterosexism and homophobia and has profound effects on the health of LGBT populations. Little has been reported about the attitudes of CNOs toward LGBT populations and how these might impact advocacy for LGBT healthcare. METHODS: Surveys were electronically mailed to 343 Magnet CNOs. The Modern Homonegativity Scale was used to assess attitudes, and additional statements were developed to assess the comfort level of the respondent in advocating for LGBT populations. RESULTS: Attitudes among CNOs toward LGBT populations and comfort with advocating for LGBT populations were positively correlated. Those demonstrating less homonegative attitudes were more likely to feel comfortable advocating for LGBT patients and staff. CONCLUSIONS: Recognizing and addressing bias among nurse leaders through education are important to ensure equitable healthcare for patients and employees. A
Author Affiliations: Assistant Professor (Dr Klotzbaugh), Department of Nursing, University of New Hampshire, Durham; SUNY Distinguished Teaching Professor and Decker Endowed Chair in Community Health Nursing (Dr Spencer), Decker School of Nursing, Binghamton University, New York. The authors declare no conflicts of interest. Correspondence: Dr Klotzbaugh, Department of Nursing, University of New Hampshire, Hewitt Hall, 4 Library Way, Durham, NH 03824-3563 ([email protected]). DOI: 10.1097/NNA.0000000000000103
JONA Vol. 44, No. 9 September 2014
Research demonstrates that homonegativity has negative effects on the health and well-being of lesbian, gay, bisexual, and transgender (LGBT) patients, as well as coworker interactions in nursing and healthcare.1-6 Homonegativity is a term representing a continuum of discrimination against LGBT people. This continuum includes both heterosexism, or rather the presumption that everyone is assumed or expected to be heterosexual, and homophobia, which represents a fear and hatred of LGBT people, resulting in verbal or physical assault.6 It is reported that ‘‘LGBT populationsIexperience health disparities and barriers related to sexual orientation and/or gender identity or expression. Many avoid or delay care or receive inappropriate or inferior care because of perceived or real homophobiaI’’5(p1) Nursing has been identified as a profession having ‘‘been slower than other health disciplines in changing policies to include sexual orientation and gender identity, and has been silent when other professional groups have issued statements about topics such as same-sex marriage and reparative therapies.’’7(p206) Additional research supports that homonegativity frequently occurs within the nursing profession.2,3,6,8-13 Numerous professional nursing organizations and societies, including the National League of Nursing and the National Magnet Recognition Program , have not introduced specific standards to advocate for this population as further evidence for the need to raise awareness among the profession.14,15 Chief nursing officers (CNOs) are recognized for the position power, business skills, and clinical acumen to establish new programs and services to meet the needs of diverse A
481
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
patient populations.16,17 In Magnet organizations, CNOs are purported as leaders of clinical excellence and evidence-based practice.18,19 For purposes of this study, attitudes toward LGBT patients and employees among CNOs in Magnet-designated hospitals were assessed. The study also investigated the effect that such attitudes might have on the comfort of CNOs in engaging in LGBT-specific advocacy. A
Conceptual Framework The Health Belief Model (HBM)20 was used as the framework for the study. According to the HBM, perceived low self-efficacy is associated with deterring the adoption of health-related actions and is thus an obstacle in implementing corrective action. With the HBM, modifying factors such as attitudes and beliefs and demographic variables were theorized as influencing one’s perceived self-efficacy. This discussion focuses on CNO attitudes and beliefs toward LGBT populations and their consequent effects on self-efficacy in LGBT-related advocacy. Although the model’s original purpose was to explain population response to public health initiatives, it is a useful framework in which to examine CNO behaviors in the provision of population (LGBT) advocacy.
Methods This project was approved by the Binghamton University Human Subjects Research Review committee. A questionnaire was electronically mailed to 343 CNOs in Magnet-designated organizations. A cover letter that included a link to the survey was sent with the questionnaire via the Binghamton University e-mail system. Completion and return of the survey indicated the respondent’s consent to participate. The survey collected basic sociodemographic data, including whether participants were familiar with anyone who identified as LGBT. Attitudes toward lesbian and gay populations were measured using the Modern Homonegativity Scale (MHS) developed by Morrison and Morrison.21 This scale was developed in response to the concern that traditional measures of homonegativity were no longer accurate because of changes in attitudes over time. It has been suggested that societal shifts in attitudes toward lesbian and gay individuals cause people to be less likely to express overt prejudice than heretofore. The MHS was therefore developed as a more subtle approach to measuring people’s negative attitudes without the respondent’s concern or fear of explicitly exposing their prejudice. The MHS consists of 10 items specific to gay men and 10 items specific to lesbians and 2 items that pertain to either gay men or lesbians. The instrument has demonstrated high reliability in measuring specific attitudes toward
482
gay men (Cronbach’s ! = .91) and lesbians (Cronbach’s ! = .92). Reliability data calculated on these combined subscales revealed that the MHS could be used as a measure of attitudes toward both gay men and lesbians (Cronbach’s ! = .92). The MHS uses a 5-point Likerttype scale of agreement; 3 items were reverse scored. Higher scale scores indicate more negative attitudes toward lesbian and gay populations, defined for this study as higher levels of homonegativity (Table 1). No previous studies have investigated the effects of homonegativity on self-efficacy in advocating for LGBT populations; thus, a survey assessment of selfefficacy was developed by the authors. Self-efficacy was assessed at both a personal level of comfort in advocating for LGBT patients and staff as well as comfort in advocating for LGBT patients and staff in the professional role of CNO. Personal self-efficacy data were collected from 2 questions developed for this study based on combined responses to the questions ‘‘I would not personally feel comfortable advocating for LGBT patients’’ and ‘‘I would not personally feel comfortable advocating for LGBT staff.’’ Scores on the 2 items Table 1. The MHS Many lesbians (gay men) use their sexual orientation so that they can obtain special privileges. Lesbians (gay men) seem to focus on the ways in which they differ from heterosexuals and ignore the ways in which they are the same. Lesbians (gay men) do not have all the rights they need.a The notion of universities providing students with undergraduate degrees in Gay and Lesbian Studies is ridiculous. Celebrations such as ‘‘Gay Pride Day’’ are ridiculous because they assume that an individual’s sexual orientation should constitute a source of pride. Lesbians (gay men) still need to protest for equal rights.a Lesbians (gay men) should stop shoving their lifestyle down other people’s throats. If lesbians (gay men) want to be treated like everyone else, then they need to stop making such a fuss about their sexuality/culture. Lesbians (gay men) who are ‘‘out of the closet’’ should be admired for their courage.a Lesbians (gay men) should stop complaining about the way they are treated in society and simply get on with their lives. In today’s tough economic times, United States tax dollars shouldn’t be used to support lesbian (gay men’s) organizations.b Lesbian (gay men) have become far too confrontational in their demand for equal rights. a
Items reverse scored. Item changed to reflect US currency, with authors’ permission.
b
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measuring self-efficacy were summed for a personal self-efficacy score (scores range from a low of 2 to high of 6). Items were scored from 1 = disagree to 3 = agree, with lower scores indicating greater likelihood of personally advocating for LGBT patients and staff. Professional self-efficacy data were based on combined responses to the questions ‘‘I would not, as CNO, feel comfortable advocating for LGBT patients’’ and ‘‘I would not, as CNO, feel comfortable advocating for LGBT staff.’’ Scores on the 2 items measuring selfefficacy were summed for a professional self-efficacy score (scores range from a low of 2 to high of 6). Items were scored from 1 = disagree to 3 = agree, with lower scores indicating greater likelihood of professionally advocating for LGBT patients and employees. The instrument has preliminarily demonstrated high reliability in measuring personal self-efficacy (Cronbach’s ! = .89) and professional self-efficacy (Cronbach’s ! = .97). Reliability data calculated on the combined subscales revealed that the scales could be used as a measure of self-efficacy (Cronbach’s ! = .93). Statistical analysis was performed using Statistical Package for the Social Sciences (SPSS) 20.0 (Armonk, New York). An a priori ! level of .05 was set to reduce the risk of a Type I error. Descriptive statistics were used to discuss the characteristics of the total participants. Standard deviation, range, and means were reported for interval level data. Scores on the MHS were derived from 24 items on the MHS Scales, with a low score of 24 to a high score of 120. Self-efficacy scores were derived from 4 items, with a low score of 4 to a high score of 20. Relationships between CNO attitudes and beliefs about LGBT populations and their self-efficacy in advocating for LGBT patients and staff were statistically analyzed using a correlation coefficient.
what religious, whereas a quarter of the sample indicated that they were very religious (25.4%). Results are summarized in Table 2. It is worth noting that demographic effects on MHS total scores were examined by analysis of variance (ANOVA) and independentsamples t test. There were no significant differences between the MHS score for lesbians and the MHS score for gay men. Of the sample’s demographic information, religiosity was the only one that had a significant effect on MHS scores. A 1-way ANOVA was conducted to compare MHS scores as they relate to the participants’ indicated level of religiosity. Results of the ANOVA depicted a significant effect for religiosity and scores on the MHS (F2, 100 = 5.27, P = .007). Tukey post hoc comparisons of the scores indicated that those participants describing themselves as very religious had significantly higher MHS total scores (mean, 68.12; 95% confidence interval [CI], 63.08-73.16) than did those describing themselves as not religious (mean, 58.42; 95% CI, 53.00-63.84; P = .005), indicating higher levels of homonegativity among those who identified themselves as very religious (Table 3). Comparisons between those indicating their level of religiosity as somewhat religious and those indicating their level of religiosity as very religious or not at all religious were not statistically significant at P G .05. The statistically significant finding of this study reflects the findings of other studies in terms of effect of religiosity on homonegativity. Religiosity has been the most frequently examined demographic for its effect on homonegativity.8,9,22-24 The characteristics of this sample were similar to available national Magnet CNO demographic data as
Table 2. Demographics
Results Surveys were completed by 115 Magnet-designated hospital CNOs (33.5%). Analyses of the demographic statistics revealed that of the 114 subjects who reported their gender, 89.5% (n = 102) were women. Representative age group was reported by 115 subjects, with most of the sample being between 55 and 64 years of age (58.3%; n = 67). Of the 115 subjects reporting their race, most (96.5%; n = 111) identified themselves as white. Of the 109 subjects who indicated their sexual orientation (94.8%), most indicated their sexual orientation as heterosexual (90%; n = 98). All 115 subjects reported their highest level of education, with most (74.8%) indicating master’s degree. All 115 subjects also indicated knowing or having known someone who identified as lesbian, gay, bisexual, and/or transgender. More than half (57.0%) of the 114 respondents described themselves as some-
JONA Vol. 44, No. 9 September 2014
Variable
Categories
Age
35-45 y 46-55 y 56-64 y Q65 y
Race/ethnicity
n (%) 4 40 68 3
(3.5) (34.8) (59.1) (2.6)
African American White Hispanic Native American
2 111 1 1
(1.7) (96.5) (0.9) (0.9)
Biological sex
Male Female
12 (10.5) 102 (89.5)
Sexual orientation
Heterosexual Gay or lesbian Bisexual
98 (89.9) 7 (6.4) 4 (3.5)
Education
Master’s PhD
86 (74.8) 29 (25.2)
Religiosity
Very religious Somewhat religious Not at all religious
29 (25.4) 65 (57.0) 20 (17.5)
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Table 3. Religiosity and MHS Scores Indicated Level of Religiosity, Mean (95% CI) Very Religious
Somewhat Religious
Not at All religious
68.12 (63.08-73.16)
64.51 (62.38-66.63)
58.42 (53.00-63.84)
Religiosity and MHS Scores Level of Religiosity (I)
Level of Religiosity (J)
Very religious
Somewhat religious Not at all religious
Somewhat religious
Very religious Not at all religious
Not at all religious
Very religious Somewhat religious
Mean Difference (I - J)
SE
P
95% CI Lower
95% CI Upper
2.352 3.000
.279 .005
j1.98 2.56
9.21 16.84
j3.612 6.087
2.352 2.600
.279 .055
j9.21 j0.10
1.98 12.27
j9.699a j6.087
3.000 2.600
.005 .055
j16.84 j12.27
j2.56 0.10
3.612 9.699a
a
Mean difference is significant at the .05 level.
the targeted population. The average age for Magnet CNOs has been reported as approximately 56 years, with 92.4% being women and 75.8% indicating their highest degree to be at the master’s level.18,25 Demographic information on race, sexual orientation, and religiosity has not been reported in these studies. Attitudes and Beliefs and Personal Self-efficacy The relationship between CNO attitudes and beliefs about LGBT individuals and their personal self-efficacy in advocating for LGBT patients and staff was analyzed using Pearson product-moment correlation coefficient. The analysis used a composite score (ranging from a low of 24 to high of 120) for the independent variable composed of the 24 items on the MHS. Items were scored from 1 = strongly disagree to 5 = strongly agree. Scoring on items 3, 6, and 9 were reversed to be consistent with positive scoring. The scores were summed for the attitude score. Higher scores on the MHS indicate higher levels of homonegativity. The homonegativity scores were reduced to 3 categories composed of scores ranging from 24 to 56, indicating no homonegativity to mild homonegativity, whereas scores from 57 to 88 indicate moderate homonegativity. Scores ranging from 89 to 120 indicate moderate to extreme homonegativity. Scores on the MHS demonstrated a mean score of 64.13 (range, 32-90). Mean MHS scores indicated moderate levels of homonegativity among the sample. The scores on the 2 items measuring selfefficacy were summed for a personal self-efficacy score, with lower scores indicating greater likelihood of personally advocating for LGBT patients and staff. The mean (SD) score for personal self-efficacy in this sample was 3.53 (1.63), indicating that respondents generally perceived their personal self-efficacy in LGBT advocacy to be moderate. The correlation coefficient was used to test the relationship between personal self-efficacy and atti-
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tudes. The results of the correlational analysis indicated that self-efficacy and attitudes were positively correlated (n = 91, r = 0.333, P = .001). The results suggested that CNOs who have less homonegative attitudes also tend to believe that they are more personally efficacious in advocating for LGBT patients and staff. Attitudes and Beliefs and Professional Self-efficacy Pearson product-moment correlation coefficient was again used to analyze the relationship between beliefs and attitudes about LGBT individuals among CNOs and professional self-efficacy. The summed attitude score was again used as independent variable. The scores on the 2 items measuring self-efficacy were summed for a professional self-efficacy score, with lower scores indicating greater likelihood of professionally advocating for LGBT patients and staff. The correlation coefficient was used to test the relationship between professional self-efficacy and attitudes. The results of the correlational analysis indicated that professional self-efficacy and attitudes were positively correlated (n = 91, r = 0.481, P = .000). The results suggested that CNOs who have less homonegative attitudes also tend to believe that they are more professionally efficacious in advocating for LGBT patients and staff. Again, the mean (SD) attitude score was 64.1 (10.29), indicating moderate levels of homonegativity. The mean (SD) score for professional self-efficacy in this sample was 3.29 (1.45), indicating that respondents generally perceived their professional self-efficacy in LGBTadvocacy to be slightly more than moderate.
Conclusion Findings from this study indicate that CNOs demonstrate moderate levels of homonegativity in their attitudes and beliefs toward lesbian and gay populations.
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Although this study’s findings are specific to executivelevel nurses, these findings are consistent with findings from other studies on nurses, in general, regarding negative attitudes toward LGBT individuals.2,3,6,12 More positive attitudes and beliefs among CNOs in this study were found to be positively correlated with perceived self-efficacy in advocating for LGBT staff and patients at both personal and professional levels. These findings suggest that CNOs with higher personal self-efficacy were more positive in their attitudes and beliefs about LGBT populations. This finding also suggests that CNOs with higher professional self-efficacy are more positive in their attitudes and beliefs about LGBT patients and employees as well. Less bias, therefore, may suggest more advocacy for both LGBT patients and staff. In addition, CNOs who have more positive attitudes and beliefs about LGBT populations may have less bias toward this population and therein may be more comfortable in advocating for LGBT patients and staff. Self-efficacy in this study was conceptualized to reflect a level of comfort and competence in providing LGBT-related advocacy. Bandura,26 whose work supports the self-efficacy component of the HBM, suggested that one’s estimation of self-efficacy was related inversely to the degree of negative somatic arousal. Increased comfort in providing advocacy may have low negativity, thereby resulting in higher self-efficacy.
Evidence provided by this study indicates moderate levels of homonegativity among nurse executives in what are recognized as the nation’s premier medical institutions. Implications for investigating methods of recognizing, assessing, and improving cultural competency significantly and substantively inclusive of LGBT populations are imperative. This consideration will broaden the understanding of diversity and cultural competency providing for greater clinical, academic, and social sensitivity. In addition, these advancements will support nursing professional responsibility for advocacy, equality, and human rights. Finally, in support of quality healthcare for all, this awareness must become an essential component of institutional culture. Limitations Limitations were related to generalizability of findings. The population for this study was quite specific. Relating findings to subjects outside those surveyed would require additional research. The MHS was specific to measurement of attitudes toward gay and lesbian populations. Attitudes toward transgender populations therefore can only be surmised pending further research. In addition, although the MHS instrument was chosen to decrease likelihood of respondents answering what they perceive to be socially desirable responses, the possibility of this occurring could not be eliminated.
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