RELATIONSHIP BETWEEN THE KNOWLEDGE, ATTITUDE, AND SELFEFFICACY ON SEXUAL HEALTH CARE ☆,☆☆ FOR NURSING STUDENTS SU-CHING SUNG, PHD, RN*, HUI-CHI HUANG, MSN, RN†, AND MEI-HSIANG LIN, PHD, RN‡ Promoting patients' sexual health for better quality of life is an important task for nurses. Little is known about the factors impacting nursing students to better prepare for the future nursing practice on sexual health care. The purpose of the study is to address the need for nursing education on sexuality by exploring the relationship between nursing students' knowledge, attitude, and self-efficacy for patients' sexual health care. A total of 190 senior nursing students were purposely enrolled to the study by answering a self-report questionnaire, and the data were analyzed using structural equation modeling (SEM). The results demonstrated positive correlation of the relationship between knowledge of sexual health care (KSH) and attitude to sexual health care (ASH; γ = .35, t = 3.31, P b .001), the relationship between KSH and selfefficacy for sexual health care (SESH; γ = .29, t = 2.98, P b .01), and relationship between ASH and SESH (γ = .34, t = 4.30, P b .001). Therefore, nursing educators need not only provide students the knowledge and skills on sexual health care but also educate them about positive attitudes on sexuality to enhance their efficacy to deal with the patients' sexuality matters in the future nursing practice. (Index words: Attitude; Knowledge; Nursing student; Self-efficacy; Sexual health care) J Prof Nurs 31:254–261, 2015. © 2015 Elsevier Inc. All rights reserved.

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EXUALITY IS AN essential part of being human, and it is expressed throughout one's lifetime. Problems linked to sexual health can often accompany ill health, and therefore, sexual health care is required to mitigate negative outcomes and promote positive quality of life. Promoting patients' sexual health for better quality of life is an important mission for nurses. However, although

*Assistant Professor, Graduate Institute of Health Care, Chang Gung University of Science and Technology, Taiwan. †Lecturer, Department of Nursing, Chang Gung University of Science and Technology, Taiwan. ‡Associate Professor, School of Nursing, Taipei University of Nursing and Health Sciences, Taiwan. ☆ Conflict of interest statement: No conflict of interest has been declared by the authors. ☆☆ Funding statement: This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Address correspondence to Dr. Sung: Assistant Professor, 261, Wen-Hwa 1st Rd., Kwei-Shan, Tao-Yuan, Taiwan. E-mail: scsung@gw. cgust.edu.tw 8755-7223

most nurses and nursing students acknowledge that they have a role in sexual health care, their preparation and willingness to address it in practice are limited (Tsai, Huang, Liao, Tseng, & Lai, 2013). It is argued in this article that it is important to teach nursing students about the centrality of sexual health care for patients as a core part of their undergraduate education program to facilitate the breaking down of barriers around what is often thought of as a taboo subject. A review of the literature shows that disease and health conditions may affect sexuality. For example, female cancer survivors would experience significantly negative sexual dysfunction due to treatment (Krychman & Millheiser, 2013), and cancer-related female sexual dysfunction did not seem to be appropriately acknowledged and addressed in primary care treatment settings (Bober, Carter, & Falk, 2013). Another survey in a gynecological outpatient department found that 51.8% of the participants (n = 137) reported sexual problems with the highest complaints of pain during intercourse (71.8%), reduced desire (54.9%), and orgasmic problem (43.66%; Jahan,

Journal of Professional Nursing, Vol 31, No. 3 (May/June), 2015: pp 254–261 © 2015 Elsevier Inc. All rights reserved.

254 http://dx.doi.org/10.1016/j.profnurs.2014.11.001

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Billah, Furuya, & Watanabe, 2012). For males diagnosed with rectal cancer, sexual dysfunction was reported frequently following treatment mainly caused by surgical damage resulting from lateral lymph node dissection (Nishizawa et al., 2011). In a study on chronic obstructive pulmonary disease patients, 74% of respondents reported at least one sexual dysfunction, with erectile dysfunction being the most common, and most were dissatisfied with their current and expected sexual function (Collins et al., 2012). Moreover, it was found that a female patient's sexual function was inversely associated with the severity of depression and positively to her premenopausal status (Mezones-Holguin et al., 2011). In addition, in one study on HIV-infected patients (N = 447), 43% of the patients wanted to talk with health care professionals about sexual health. Of these patients, only 12–35% reported receiving regular advice or discussion on sexuality, and about 25% had never discussed topics of sexual health during their HIV care visits (Dukers-Muijrers et al., 2012). The literature therefore highlights two key issues: first, patients' sexual concerns are not sufficiently taken cared of, or indeed often remained unresolved, and second, that such avoidance of the topic can impact their self-concept and can result in unsatisfactory behavior patterns of altered body image and body function (Mosack & Steinke, 2009; Tsai, Chen, Tsai, Ho, & Su, 2009). Therefore, patients' sexual health care needs require a comprehensive approach, including consideration of the biological, physiological, psychological, and social dimensions of sexuality and sexual health. The provision of care that focuses on sexual health is often an ignored area of nursing health care, although it has been widely recognized as a necessary component of holistic nursing practice (East & Hutchinson, 2013). A study (N = 100) in Swedish found that although more than 90% of nurses reported understanding the implications of patients' disease and treatment on their sexuality and about two-thirds felt comfortable discussing sexual concerns with their patients, 60% still did not have confidence in their ability to take care of patients' sexuality concerns (Saunamaki, Andersson, & Engstrom, 2010). Another study in Hong Kong found that although nursing students positively acknowledged the nursing role in sexual health care, they still felt hesitant to proactively participate in the related activities of nursing sexual health care. A variety of personal and contextual reasons are given as self-limiters with respect to nurses' willingness to address patients' sexuality concerns. Issues such as age and gender differences, lack of time, privacy, and knowledge and training on dealing with sexual dysfunction, and restricted perception of nursing role, discomfort, work environment-related issues, have been found by other researches (Huang, Tsai, Tseng, Li, & Lee, 2013; Kotronoulas, Papadopoulou, & Patiraki, 2009; Nakopoulou, Papaharitou, & Hatzichristou, 2009; Nicolai et al., 2013; Sung, Yeh, & Lin, 2010). Helland, Garratt, Kjeken, Kvien, and Dagfinrud (2013) reported that having relevant education and being comfortable with the topic area were significant predic-

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tors of nurses' willingness and likelihood of initiating sexual topics. An early study by Stoke and Mears (2000) demonstrated that education and knowledge had a positive effect on nurses' attitudes toward discussing sexuality. A study in Taiwan found that nurses who presented more knowledge on sexual health care would show a more positive attitude and self-confidence for sexual health care (Tsai, Yau, Hsu, & Hwang, 2005). Another study by Huang et al. (2013) reported that nursing students felt most comfortable with accepting patients' expression of sexual concerns, and nurses with higher level of nursing education showed greater responsibility, and were more comfortable and willing to be proactively address patient's sexual concerns (Saunamaki et al., 2010; Sung, Lin, Hong, & Cho, 2007; Sung et al., 2010). Furthermore, Tsai et al. (2013) found that nursing students' learning needs for addressing patients' sexual health care included knowledge of sexuality in health and illness, communication skills of discussing patients' intimacy, and ways to provide sexual health care. Moreso, in addition to physical issues associated with sexuality, nurses and nursing students stressed the need of further specialized training in preparing attitude to approach and selfconfidence to communication behavior (Nakopoulou et al., 2009; Sung & Lin, 2013). Therefore, the education program and clinical practice for nursing students by valuing the affective aspect of education, formal recognition of this extended role, and advancing related education would benefit the development of nursing sexual health care (Kong, Wu, & Loke, 2009). Although there were some studies on relationship of nurses' knowledge, attitude, and nursing practice about sexual health care, little is known about the factors of impacting nursing students to better prepare for the future nursing health care on sexuality. To understand the gap, the study tested the need for nursing education on sexuality by exploring the relationship between nursing students' knowledge, attitude, and self-efficacy for patients in the area of sexual health care. To evaluate the relationship, structural equation modeling (SEM) was used in the study. This study hypothesized that nursing students' knowledge of sexual health care (KSH) and attitude to sexual health care (ASH) would have a positive correlation. In addition, it was also hypothesized that nursing students' KSH and self-efficacy for sexual health care (SESH) would have a positive correlation, and so would ASH and SESH. The details of the study are discussed in the subsequent sections.

Methods Design, Participants, and Procedure This was a cross-sectional study. A total of 190 senior nursing students were recruited from a nursing college in Taiwan via the recruitment seminar at campus, which explained the study objectives, procedure, and program contents. The participants were purposely selected from senior grade because they all had nursing clinical practice experience. The study was approved by the ethics committee.

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Figure 1. The proposed SEM model of nursing students' knowledge, attitude, and self-efficacy on sexual health care.

All participants were required to sign a consent form after explaining the study objectives, procedure, and contents. Data were collected by answering a self-report questionnaire in 2010. Each participant took 20–30 minutes to complete the questionnaires.

Instruments A structured questionnaire in Sung and Lin (2013) was used to examine the hypothesized SEM. The questionnaire was adapted from those used in prior studies (Lin, Chen, & Pai, 2000; Sung et al., 2007, 2010), with their structure and format based on the questionnaire of Steinke and Patterson-Midgley (1996), which was developed to evaluate nurses' attitudes related to comfort, responsibility, and practice of sexual counseling, and that of Lin et al. (2000), which was used to evaluate the sexuality education program. For content validity, which was conducted by six subject experts, KSH, ASH, and SESH achieved 0.83, 0.96, and 0.92, respectively. For the test–retest reliability by the intraclass correlation coefficient with the interval of 2 weeks, KSH, ASH, and SESH showed 0.73, 0.91, and 0.94, respectively. Therefore, the questionnaire has achieved acceptable validity and reliability (Sung, 2011). The questionnaire consisted of four sections, including one section about collecting participants' demographic information and three sections about evaluating participants' KSH, ASH, and SESH. The details of the questionnaire are described below. The demographic information collected in the study contained participants' gender, age, religion, family structure, parent–child relationship, and specific sexual related data (including experience of the sex/gender education, falling in love, dating behavior, commitment to the boy–girl relationship, sexual behaviors, and sexual harassment). KSH was designed to measure nursing students' knowledge on the effects of illness, disability, medical treatment to sexual problems, and nursing assessment and

communication about sexual health care. KSH consisted of 31 items and was rated using a 2-point scale (0 for wrong or unknown and 1 for right) with a range of possible scores from 0 to 31. There were three domains in KSH, including medicine (e.g., illness and medical treatment), nursing assessment in sexual health care (e.g., nursing assessment, history taking, communication), and forensic nursing (e.g., sexual assault and sexual harassment; Sung & Lin, 2013). ASH in the study represented nursing students' attitude about their professional role, comfort, and providing patients' information related to sexual health care (Sung & Lin, 2013). The scale was composed of 18 attitude items rated on a 5-point Likert scale, ranging from 1 (strongly disagree) to 5 (strongly agree). The scores of ASH ranged from 18 to 90. A higher score represented more positive ASH. ASH consisted of three domains, including six items of perceived comfort while talking with patients about their sexual concerns, six items of opinions of a nurse's professional role associated with discussing patient sexual concerns, and six items of providing information of sexual health. Through factor analysis to analyze the construct validity of ASH, the results showed that Kaiser–Meyer–Olkin (KMO) value was 0.835 and Bartlett test of Sphericity (BT) value was 1,953.857 (P b 0.000). Moreover, to analyze the total variation of ASH, the questions with eigenvalue greater than 1.0 by principal components analysis were processed using varimax rotation, and there were three components revealed with a factor loading greater than 0.6 with the variance of 18–22%, resulting in a total variance of 60% with internal consistency with Cronbach's α of .89 (Sung, 2011). Finally, Cronbach's α for the ASH in this study was .89. SESH in the study depicted nursing students' confidence in their capabilities to perform nursing sexual health care; to improve patients' sexual health by assessing, communicating, and providing support on sexual issues; and to manage their discomfort feelings and then seek help if necessary (Sung & Lin, 2013). SESH consisted of 22 items

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Table 1. Convergent Validity (Internal Quality) of the Scales in the CFA Analyses Scale/subscale

Number Mean factor of item loading CR AVE (%)

Knowledge (KSH) Medicine Assessment Assault and harass Attitude (ASH) Comfort Role Information Self-efficacy (SESH) Communication Support Self-management

8 18 5

.27 .21 .41

.39 .46 .53

.10 .06 .26

6 6 6

.66 .73 .73

.82 .87 .87

.45 .54 .54

13 5 4

.77 .81 .81

.95 .90 .88

.60 .65 .66

using a 5-point Likert scale, ranging from 1 (strongly disagree) to 5 (strongly agree), for scaling each item, and its total scores ranged from 22 to 110. There were three domains in SESH, including 13 items of nursing students' confidence of communicating sexual matters, 5 items of providing support and information, and 4 items of self-managing discomfort feeling and help seeking. The construct validity of SESH was analyzed by factor analysis with KMO value of 0.938 and BT value of 3,558.894 (P b 0.000). Furthermore, to analyze the total variation of the scale, by processing the questions chosen with eigenvalue greater than 1.0 from principal components analysis, three components were identified through varimax rotation with a factor loading greater than 0.6 with the variance of 19– 30%, resulting in a total variance of 69% with internal consistency with Cronbach's α of .89 (Sung, 2011). Finally, Cronbach's α for the SESH in this study was .96.

factor structures was evaluated with three aspects for a good model fit: item's factor loading higher than 0.50, average variance extraction (AVE) of subscale higher than 0.50, and construct reliability (CR) of subscale greater than 0.60 (Hair, Black, Babin, & Anderson, 2010). Then, the SEM was used to explore the relationship between latent variables (constructs) under different measurement models as shown in Figure 1. The model fit of the SEM was assessed on the basis of the criteria suggested by Hu and Bentler (1999). The model fit was considered “relative good” between the hypothesized model and observed data if meeting the following criteria: all cutoff values of nonnormed fit index (NNFI), incremental fit index (IFI), relative noncentraility index (RNI), and comparative fit index (CFI) close to 0.95, a cutoff value of standardized root mean square residual (SRMR) close to 0.08, and a cutoff value of root mean square error of approximation (RMSEA) close to 0.06 (Hu & Bentler, 1999). According to the number of latent variables (three), the number of items of each latent variable (three), and the modest communalities among items (the average of squared factor loadings close to 0.50) in the proposed SEM model, the required minimum sample size was 150 (Hair et al., 2010). The test statistics (critical ratio) of multivariate normality was 4.39, which was lower than the threshold of 5 suggested by Kline (2005), indicating no apparent problem of multivariate normality and outliers in the proposed SEM model. Few missing values were found during the key-in process and imputed by using the mean value of other participants with complete responses. Therefore, no imputation method was used in both CFA and SEM analyses.

Data Analysis

Results

The main analyses in the study comprised confirmatory factor analyses (CFAs) and SEM using SPSS software (v17.0) and AMOS 7.0. The study hypothesized that KSH and ASH were positively correlated, and so were KSH and SESH, and additionally, ASH and SESH. The CFA was conducted to assess the internal quality (convergent validity) for the subscales. The convergent validity of

Characteristics of Participants All nursing students were female and single with average age of 21.12 years old (SD = 0.52; age range = 20–23 years), and the statistics of their other demographic data was as follows: 46% having no specific religious belief, 66% from nuclear family, 43% having received sex/ gender education course before, 44% perceiving good

Table 2. Descriptive Statistics and Correlations of Each Observed Variable in the Proposed SEM Model (N = 190) Variables Knowledge (KSH) 1. Medicine 2. Assessment 3. Assault and harass Attitude (ASH) 4. Comfort 5. Role 6. Information Self-efficacy (SESH) 7. Communication 8. Support 9. Self-management * P b .05.

M

SD

1

2

12.92 6.67 4.48

2.70 1.10 0.76

.30 * .25 *

.25 *

19.34 21.48 24.77

3.37 3.41 2.80

.21 * .05 .24 *

33.49 15.07 12.88

9.23 4.11 3.33

.12 .21 * .22 *

3

4

5

.07 .03 .14

.06 .08 .02

.30 * .39 *

.54 *

.21 * .15 * .29 *

-.09 -.05 .002

.22 * .20 * .26 *

.20 * .13 .16 *

6

7

8

.19 * .25 * .32 *

.79 * .69 *

.72 *

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Table 3. Selected Model Fit Indices of the Proposed SEM Model Model Fit IFIs NNFI IFI RNI CFI Absolute fit indexes SRMR RMSEA

Acceptable criteria

Values

Appraisal

.95 .95 .95 .95

.904 .937 .846 .936

Fair Good Poor Good

Close to .08 Close to .06

.065 .086

Good Fair

Close Close Close Close

to to to to

Note. The criteria were according to Hu and Bentler (1999).

parent–child relationship, 85% having dating experience before, 82% having experience of falling in love, 39% having sexual experience, 56% having experience committed boy or girl relationship, and 54% having experienced sexual harassment before.

CFA for Each Scale (Measurement Model) The values of mean factor loading, CR, and AVE for the subscales of each scale are listed in Table 1. The internal quality of KSH was poor because the mean factor loading and AVE were both smaller than 0.50, and CR was under 0.60 for the three subscales. This is because KSH was designed by a dichotomy with a 2-point scale so the intercorrelations among items were small due to low variance, resulting in smaller factor loadings. This is the limitation of the present study. In contrast, the internal qualities of ASH and SESH subscales were generally good, representing adequate convergent validity (Hair et al., 2010). Furthermore, KSH, ASH, and SESH were input to the SEM model for further analysis. The descriptive statistics and intercorrelation of the observational variables used in SEM were depicted in Table 2.

Overall Model Fit of the Proposed SEM The results of overall model fit are shown in Table 3. As described in Table 3, the results generally reveal fair model fit indexes, including the NNFI (.904), IFI (.937), RNI (.846), CFI (.936), SRMR (.065), and RMSEA (.086). Although the performance of model fit was modestly at best (not excellent), model modification according to the modification index (e.g., allowing the correlation between errors of observation variables) was not made Table 4. Parameter Estimates of the Structural Model Path Knowledge (KSH) X attitude (ASH) Knowledge (KSH) X self-efficacy (SESH) Attitude (ASH) X self-efficacy (SESH) Note. SE = standard error.

** P b .01. *** P b .001.

Standardized coefficient

SE

t value

.35

0.11 3.31 ***

.29

0.10 2.98 **

.34

0.08 4.30 ***

because modification can only be made in terms of the theory being tested, but our proposed model was hypothesized without any driving theories. According to the literatures of (Diamantopoulos & Siguaw, 2000; MacCallum, 1995), model modification is not needed if there is no driving theory in the proposed model.

Structural Model in the Proposed SEM As depicted in Table 4 and Figure 2, the relationship between KSH and ASH is positively correlated (γ = .35, t = 3.31, P b .001). Moreover, the relationship between KSH and SESH (γ = .29, t = 2.98, P b .01) and the relationship between ASH and SESH (γ = .34, t = 4.30, P b .001) are also positively correlated. Therefore, KSH, ASH, and SESH are all positively correlated with each other.

Discussion It has been generally perceived that additional education on sexuality for nursing clinical practice is significantly related to nurses' being more comfortable attitude in sexual health care (Jaarsma et al., 2010; Sung et al., 2010) and can lead to improvement of self-efficacy (Sung & Lin, 2013; Tsai et al., 2005). This study demonstrates that, for nursing students, KSH, ASH, and SESH are positively correlated with each other. In other words, nursing students with more KSH would have a more positive attitude on sexual health care that would then have more confidence to discuss and provide related information on sexual health care. This finding is similar to the results of Helland et al. (2013), which found that the health providers with relevant education in sexuality had significantly more comfortable attitude to talk about sexuality and raised sexual issues significantly more often. Because attitudes are formed as a result of experiences as well as from knowledge, cognitive knowledge and facts will lead us to believe (Bruess & Greenberg, 2009). However, Kong et al. (2009) also found that although nursing students has satisfactory knowledge of sexual health, they still felt hesitant to proactively address patients' sexual issues in practice due to possibly lack of self-confidence and worries of patients' negative responses in the future practice environment. Therefore, if nursing education only focuses on providing students' KSH, it won't be sufficient to support nursing students' readiness and ability on sexual health care in the future clinical practice. Development of knowledge to support nursing students' positive attitude and enhance their confidence for sexual health care is essential. Without supporting knowledge and positive attitude, nursing students cannot have the prerequisites to take an active role and have confidence into nursing practice. Because attitude and SESH have a positive correlation found in the study, nursing students with a more positive attitude toward sexual health care would have more positive SESH, and vice versa. This is similar to Helland et al. (2013), who found that being comfortable to some extent or to a large extent remained significant predictors to initiating sexual topics. However, SESH is not a behavior, yet the enhancement of self-efficacy can

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Figure 2. Standardized estimates for the proposed SEM model (**P b .01 and ***P b .001 of the structural coefficients between latent variables; all factor loadings of observed variables were significant at the P b .001 level).

definitely lead to behavior changes (Bandura, 2001), as it has been demonstrated as a predicting factor of behavioral change across multiple task settings (Bandura, 2000). Saunamaki et al. (2010) found that although nurses felt comfortable talking about patients' sexual matters and are responsible of providing sexual health care, they still did not have confidence in their ability to deal with patients' sexual concerns. Therefore, to improve trend in provision of sexual health care, educational curricula should pay more attention to educational strategies, such as role-play opportunities (Steinke, Mosack, Barnason, & Wright, 2011) and the practice of the intervention model as guidance for sexual health care (Quinn & Happell, 2013) that can result in a positive and active attitude and self-confidence toward discussing sexual matters and providing sexual health care to patients rather than just an attitude of respect and acceptance. Individual competencies and perception of self-efficacy on sexuality could be constantly modified by environmental conditions (Hogben & Byrne, 1998), and variations in nursing practice could affect nursing students' experiences about performing sexual health care to patients (Johnston, 2009). This may impact nursing students' self-efficacy transformation to further ability on sexual health care in their future nursing practice. However, development of knowledge, increase of skills practice, and positive selfconfidence can improve self-efficacy (Kear, 2000), and perceive more comfortable and active in delivering sexual health care (Jaarsma et al., 2010). Therefore, not only do nursing educators need to provide students knowledge and skills of sexual health care, but they also need to educate them about positive and proactive attitudes to address human sexuality. By conducting well-designed education related to sexual health care, the gap between patients' sexual health care needs and what nurses would be comfortable to provide can be minimized. Such programs can include clarification of current personal beliefs, values,

and experiences related to nursing and sexuality, building knowledge on sexual functions, and development of capabilities of assessment and communication on sexual health care (Sung & Lin, 2013).

Limitations First, the study only considered senior nursing students from one college. Second, the study only measured the relationship between knowledge, attitude, and selfefficacy to sexual health care. Further studies can consider examining students from different grades or schools as well as related variables such as age, gender, sexual relationship, and clinical practice experience. This would further enable deepening the understanding of performance ability to sexual health care. Third, KSH was designed by a dichotomy with a 2-point scale so the intercorrelation among items was small due to low variance, resulting in smaller factor loadings. Finally, future studies can consider utilizing both quantitative and qualitative methods to obtain an in-depth understanding of the reality of individual's perspectives toward the research questions.

Conclusion The structural model derived in this study reveals that knowledge, attitude, and self-efficacy have positive association to sexual health care on nursing students. The results allow nursing educators to scrutinize the relationship among knowledge, attitude, and self-efficacy to sexual health care for nursing students. Nursing educators need not only provide students the knowledge and skills on sexual health care, but also educate students' appropriate attitudes exploring their own values and perception on patients' sexuality health care issues to enhance their confidence to deal with the patients' sexuality matters in future nursing practice.

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Relationship between the knowledge, attitude, and self-efficacy on sexual health care for nursing students.

Promoting patients' sexual health for better quality of life is an important task for nurses. Little is known about the factors impacting nursing stud...
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