Journal of Nursing Education

Major Article 

Attitudes Among Nurse Educators Toward Homosexuality

Theodora Sirota, PhD, RN, CNL, PMHCNS-BC

Abstract

Homosexual populations have unique and specific cultures, psychosocial characteristics, health issues, and health care disparities that are currently ignored or insufficiently addressed in nursing education. To understand the reasons for these omissions, this descriptive study explores the attitudes of nurse educators (N = 1,282) toward homosexuality and the extent to which demographic, educational, and occupational factors are related to their attitudes. Responding to a direct online survey solicitation, self-selected participants completed the Attitudes Toward Lesbians and Gay Men Scale (ATLG) and a supplementary data questionnaire. Results indicate that the majority of participants have positive attitudes toward homosexuality, which is consistent with prior findings. Most participants believe it is important to teach nursing students about homosexuality, but they consider themselves unprepared to teach this content. Effects of various demographic and occupational factors on participants’ ATLG scores and implications of the findings for nursing education and nursing health care policy are discussed. [J Nurs Educ. 2013;52(4):219–227.]

Dr. Sirota is Associate Professor, Department of Nursing, Caldwell College, Caldwell, New Jersey. At the time this research was conducted, Dr. Sirota was Associate Professor, College of Nursing, Seton Hall University, South Orange, New Jersey.

This research was supported by a 2011 Seton Hall University Research Council Grant. The author thanks Martin S. Edwards, PhD, Associate Professor, John C. Whitehead School of Diplomacy and International Relations, Seton Hall University, for his generous and deeply appreciated assistance with statistical procedures for this research.

The author has disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Theodora Sirota, PhD, RN, CNL, PMHCNS-BC, Associate Professor, Department of Nursing, Caldwell College, 120 Bloomfield Avenue, Caldwell, NJ 07006; e-mail: tsirota@caldwell.edu.

Received: May 28, 2012
Accepted: August 29, 2012
Posted Online: March 20, 2013

Abstract

Homosexual populations have unique and specific cultures, psychosocial characteristics, health issues, and health care disparities that are currently ignored or insufficiently addressed in nursing education. To understand the reasons for these omissions, this descriptive study explores the attitudes of nurse educators (N = 1,282) toward homosexuality and the extent to which demographic, educational, and occupational factors are related to their attitudes. Responding to a direct online survey solicitation, self-selected participants completed the Attitudes Toward Lesbians and Gay Men Scale (ATLG) and a supplementary data questionnaire. Results indicate that the majority of participants have positive attitudes toward homosexuality, which is consistent with prior findings. Most participants believe it is important to teach nursing students about homosexuality, but they consider themselves unprepared to teach this content. Effects of various demographic and occupational factors on participants’ ATLG scores and implications of the findings for nursing education and nursing health care policy are discussed. [J Nurs Educ. 2013;52(4):219–227.]

Dr. Sirota is Associate Professor, Department of Nursing, Caldwell College, Caldwell, New Jersey. At the time this research was conducted, Dr. Sirota was Associate Professor, College of Nursing, Seton Hall University, South Orange, New Jersey.

This research was supported by a 2011 Seton Hall University Research Council Grant. The author thanks Martin S. Edwards, PhD, Associate Professor, John C. Whitehead School of Diplomacy and International Relations, Seton Hall University, for his generous and deeply appreciated assistance with statistical procedures for this research.

The author has disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Theodora Sirota, PhD, RN, CNL, PMHCNS-BC, Associate Professor, Department of Nursing, Caldwell College, 120 Bloomfield Avenue, Caldwell, NJ 07006; e-mail: tsirota@caldwell.edu.

Received: May 28, 2012
Accepted: August 29, 2012
Posted Online: March 20, 2013

Approximately 8 million adults, or 3.5% of the U.S. population, currently identify themselves as lesbian, gay, or bisexual (Gates, 2011). These figures indicate there is a substantial population of sexual minority individuals in the United States, although exact numbers may be underreported and difficult to determine accurately for many reasons (Savin-Williams & Ream, 2007).

Lesbians and gay men have distinct identity development and cultural characteristics with particular attitudes, beliefs, psychosocial traits, and health care needs (Eliason, 1993; Gee, 2006; Mayer et al., 2008; Rosario, Schrimshaw, Hunter, & Braun, 2006; Tate & Longo, 2004). Homosexual people also experience difficulty accessing and receiving comprehensive or sensitive health care, which is thought to be largely related to a pervasive climate of heterosexism and homophobia that exists throughout health care systems (Irwin, 2007; Mayer et al., 2008; Smith, 1993; Tate & Longo, 2004;). Gay and lesbian patients report numerous barriers to health care, including the presumption by health care providers that they are heterosexual, coping with homophobia among health care providers, and having a sense of being invisible or of being stereotyped, stigmatized, or treated in a prejudicial and discriminatory manner within health care settings (Fogel, 2005; Gay and Lesbian Medical Association, 2002; Neville & Henrickson, 2006). Fear of prejudice and discrimination prevents many lesbians and gay men from disclosing their homosexual orientation to health care providers, a situation that can affect their ability to receive comprehensive individualized care (Neville & Henrickson, 2006). Further, not enough health care providers have sufficient knowledge of lesbian, gay, and bisexual (LGB) identity, cultures, and health issues to meet their specific needs (Mayer et al., 2008). The Institute of Medicine’s Committee on Lesbian, Gay, Bisexual, and Transgender Health Issues and Research Gaps and Opportunities recently published a landmark report (2011) that focused on the health care needs and disparities for lesbian, gay, bisexual, and transgender (LGBT) populations and recommended implementation of a research agenda to identify and address their unique and specific health care needs. This report has spurred major interest and concern about addressing health care disparities for all sexual minority populations.

Despite the ongoing emphasis in nursing education on teaching cultural competence in health care (Morrissey, 1996; Tate & Longo, 2004), the American Association of Colleges of Nursing’s (2008) endorsement of gender identity and sexual orientation as areas needed for cultural competency in nursing, and the current interest and concern about LGBT rights and health care in the United States (Keepnews, 2011), content about homosexuality is remarkably absent or rarely developed and integrated into undergraduate and graduate nursing curricula. Little or no relevant educational material about sexual minority populations’ cultural, psychosocial, and particular health care needs appears in the most widely used basic nursing textbooks, including texts about cultural competence and psychiatric–mental health nursing. Possible reasons for such omissions include cultural homophobia among nurse educators that results in discomfort around homosexuals and reluctance to provide them with comprehensive nursing care (Eliason & Raheim, 2000; Gray et al., 1996; Schlub & Martsolf, 1999), as well as the lack of nurse educators’ acquaintance or contact with homosexuals, which is known to be associated with higher levels of prejudice toward them (Finlay & Walther, 2003; Herek & Glunt, 1993).

Nursing’s professional core values emphasize commitment to quality holistic health care for all individuals, but the nursing profession has only recently begun to address its failure to adequately address the health care needs of homosexual populations. Eliason, Dibble, and DeJoseph (2010) discussed how nursing has failed to keep up with other health professions in conducting research and formulating policies and practice guidelines related to the health care needs of the LGBT populations. Rondahl (2009) demonstrated that nursing students have inadequate knowledge about LGBT health care needs at the completion of their basic nursing programs. Several authors have stressed the need for developing nursing educational content related to health care for sexual minority populations (Bowers, Plummer, McCann, McConaghy, & Irwin, 2006; Brennan, Barnsteiner, Saintz, Cotter, & Everett, 2012; Douglas Scott, Pringle, & Lumsdaine, 2004; Keepnews, 2011; Smith, 1993). Recognizing the need for cultural competence education in caring for sexual minority patients, the National Student Nurses Association (2010) adopted a resolution to “support the need for increased awareness of LGBT education in nursing school curricula” (p. 11). However, currently only one major nursing organization, The American Academy of Nursing (2012), has issued a policy statement endorsing nursing efforts to support LGBT health care needs, and no specific standards related to introducing content about LGBT health care needs into nursing curricula are in place (Keepnews, 2011). Because nurse educators guide the development, adoption, and dissemination of appropriate content within nursing programs of study, investigating the factors affecting their inaction is relevant to explore the possible reasons for these omissions.

Purpose

The purpose of this descriptive correlational study was to explore the attitudes of nurse educators regarding homosexuality and to investigate the significance and extent to which selected, self-reported demographic, educational, and occupational factors are related to their attitudes toward homosexuality.

Theoretical Perspective

The theory of reasoned action, posited by Fishbein and Ajzen (1975) and Ajzen and Fishbein (1980) and extended by Ajzen (1991) as the theory of planned behavior, provided the study’s theoretical foundation. Fishbein and Ajzen defined an attitude as “a learned predisposition to respond in a consistently favorable or unfavorable manner with respect to a given idea, object, place, or person” (p. 6). The theorists posit that attitudes about particular behaviors are determined by a person’s beliefs about behavioral consequences and how he or she views the desirability of these consequences. According to this theory, which has extensive empirical support, behavioral intentions that lead to actual behaviors result from the combined effect of attitude, subjective norms surrounding a particular behavior (Fishbein & Ajzen, 1975), and perceived control over the behavior (Ajzen, 1991). Because negative attitudes toward homosexuality and homosexuals persist in American culture (Herek, 2000; Meyer, 2003; Patterson, 2005) and because nurses develop and are socialized in this environment (Schlub & Martsolf, 1999), the current study explored the theory that nurse educators’ attitudes toward homosexuality could be related to behaviors that translate into the lack of development and adoption of content about homosexuality into nursing curricula.

Related Literature

The literature is extensive about homophobia and attitudes toward homosexuality among various populations, including nursing students and graduate nurses. However, little research has been conducted about nurse educators’ attitudes toward homosexuality. The few studies available indicate that nurse educators tend to have low levels of homophobia (Dinkel, Patzel, McGuire, Rolfs, & Purcell, 2007; Erlen, Riley, & Sereika, 1999; Röndahl, Innala, & Carlsson, 2004) and express positive attitudes toward homosexuality (Mueller, Cerny, Armundson, & Waldron, 1992; Rondahl, 2005). However, one early survey of midwestern nurse educators (Randall, 1989) showed that 52% (N = 100) had homophobic attitudes toward lesbians. In another study, researchers found that although nurse educators expressed positive attitudes toward homosexuality, they could be observed behaving in a heterosexist or homophobic manner in clinical situations (Gray et al., 1996). This body of research consists of a mixture of quantitative and qualitative approaches with overall methodological issues, such as small or mixed samples, and use of some instruments that have uncertain reliability and validity. The studies have been performed in widely diverse geographic and cultural environments, and it is difficult to compare or generalize the findings. Clearly, there is a current paucity of sufficient valid and reliable data about nurse educators’ attitudes toward homosexuality on which to draw any reliable inferences.

Method

Design and Procedure

This study used a descriptive correlational design with electronic survey format. Approval for the study was received from the Seton Hall University Institutional Review Board. Direct online solicitation of all nurse educators whose names and e-mail addresses appeared on public Web sites for Commission on Collegiate Nursing Education-accredited colleges of nursing in the United States (N = 6,766) was performed. The electronic message contained a link to the study materials, including the 20-item Attitudes Toward Lesbians and Gay Men Scale (ATLG) (Herek, 1986, 1988, 1998), a demographic and supplementary data questionnaire, and a space for providing comments. SurveyMonkey® software was used to design and administer the self-report study materials, which required approximately 10 minutes to complete. Participants were advised that their data were confidential and anonymous to the researcher; no compensation or direct benefits were offered to participants. Minimum required sample size (N = 100) was established based on guidelines recommended by Nunnally and Bernstein (1994) and Tabachnick and Fidell (1996) for use with multiple regression analysis, which consists of 10 times as many cases for each independent (predictor) variable entered into regression equations. Because the overall response on the ATLG (n = 1,166) and the smallest response on any one demographic or supplementary questionnaire item (n = 1,205) exceeded 1,000 cases, adequate power was ensured for entering more than 10 independent variables into the regression models.

Sample

Nurse educators employed full time or part time in Commission on Collegiate Nursing Education-accredited colleges of nursing (N = 1,282) voluntarily submitted all or part of the survey materials. The sample size for analyzing the results of the ATLG was 1,166 after excluding all missing data. Sample size for each item on the demographic–supplementary data questionnaire differed somewhat throughout due to missing data, but it was never less than 1,205. For participants reporting gender (N = 1,272), 90.3% were women (n = 1,149), 9.4% were men (n = 120), 0.1% were transsexual (n = 1), and 0.2% were “other” (n = 2). For those reporting race (N = 1,267), 90.7% (n = 1,149) were White, 3.2% (n = 40) were Black, 1.8% (n = 23) were Hispanic, 1.5% (n = 19) were Asian, 0.8% (n = 10) were American Indian, and 2.1% (n = 26) were “other.” Ninety-five percent (n = 1,206) of the participants were born in the United States, and 68.7% were over the age of 51 years (42.3% aged 51 to 60 years; 26.4% aged 61 years or older). Sexual orientation of the participants (n = 1,267) was 89.3% (n = 1,132) heterosexual, 4.7% (n = 59) lesbian, 3.7% (n = 47) gay men, and 2.3% (n = 29) bisexual. Of the 1,259 participants answering a question about their religion, 32.9% (n = 414) were Catholic; 36.6% (n = 461) were Protestant; 3.1% (n = 39) were Evangelical; 3.3% (n = 42) were Jewish; 12.4% (n = 156) were no religion; 2.4% (n = 29) were Muslim, Hindu, Buddhist, or Pagan, and 9.4% (n = 118) were “other.”

Of the participants’ (N = 1,275) reporting educational level (some reported having more than one degree), 43.5% (n = 554) had a master’s degree in nursing, 34.7% (n = 442) had a PhD in nursing, 27.4% (n = 349) had a Doctor of Nursing Science or Doctor of Nursing Practice degree or a doctorate in another field, and 8.5% (n = 108) reported being doctoral students. Of 1,258 participants, 230 (18.3%) have been employed in nursing education for 5 years or less; 320 (25.4%) for 5 to 10 years, 320 (25.4%) for 11 to 20 years, and 388 (30.8%) for 21 years or more. Of those participants responding about geographic area of employment (N = 1261), 63.4% (n = 799) taught in urban environments; 24.5% (n = 309) taught in suburban environments; and 12.1% (n = 153) taught in rural environments. Of 1,257 participants, 75.4% (n = 948) taught in baccalaureate nursing programs, 53.3% (n = 670) taught in masters’ nursing programs, 17.2% (n = 216) taught in PhD programs, 20.5% (n = 258) taught in Doctor of Nursing Practice programs, and 18.4% (n = 231) taught in other types of programs.

Instrument

The ATLG (Herek, 1986, 1988, 1998) consists of 20 statements—10 about attitudes toward lesbians (ATL subscale) and 10 about attitudes toward gay men (ATG subscale). Participants indicate agreement or disagreement with each item on a 9-point Likert scale (1 = strongly agree; 9 = strongly disagree), with possible total scores ranging from 20 (most positive attitudes) to 180 (most negative attitudes). Some items are reverse scored. Coefficient alpha for various samples is consistently greater than 0.90 (Herek, 1987a, 1987b, 1998) for student samples and exceeds 0.80 in adults for self-administration and oral administration via telephone surveys (Herek, 1994; Herek & Glunt, 1991). Test–retest reliability after 3 weeks was 0.90 (Herek, 1998). Discriminant validity was established by administering the ATLG to members of gay and lesbian organizations who scored in the extreme positive range (Herek, 1988). Adults supporting a local gay rights initiative scored significantly lower on the ATLG (more positive attitudes) than adults who opposed the initiative (Herek, 1994). The ATLG correlates with constructs that are theoretically related. Lack of contact with homosexuals, traditional attitudes toward sex roles, high religiosity, high dogmatism, and strong traditional family values correlate with higher scores (more negative attitudes) on the ATLG (Herek, 1987a, 1987b, 1998, 1994; Herek & Capitanio, 1995, 1996). The major factor underlying the ATLG (condemnation–tolerance [Herek, 1998]), intuitively coincides with anecdotal statements about nurse educators’ attitudes toward homosexuality reported in the literature.

Supplementary Data Questionnaire

The supplementary questionnaire contained items requesting demographic, educational, and occupational data from participants presented in Likert-scale format. Occupational items were those that asked for participants’ opinions about how important it is to teach nursing students about homosexuality, as well as how well they considered themselves prepared to teach this subject.

Data Analysis

SPSS® version 18 software was used to manage and analyze the data. Descriptive statistics were calculated for the main study variable and the study sample characteristics. Multiple regression models were developed to evaluate the effect of various independent demographic, educational, and occupational variables on ATLG individual scores as the dependent variable. Pearson correlations and analyses of variance were also calculated to evaluate the relationships among various demographic, educational, and occupational data reported in the supplementary questionnaire.

Results

Descriptive Analyses

The mean score on the ATLG for the sample (N = 1,166) was 47.22 (SD = 27.704; range = 20 to 172), indicating overall positive attitudes toward homosexuality but with a long skew toward negative attitudes. Four hundred eighty-one participants had total ATLG scores ranging from 50 to 172; 252 participants had total scores of 100 to 172. Cronbach’s alpha for the ATLG was 0.917. The Figure shows these results.

Frequency distribution of participants scores on the Attitudes Toward Lesbians and Gay Men Scale (ATLG).

Figure. Frequency distribution of participants scores on the Attitudes Toward Lesbians and Gay Men Scale (ATLG).

Significant differences were noted among mean ATLG scores for participants of various religions. All religions except for Muslim and Evangelical Christian had mean scores not greater than 3 points above the overall sample mean score, and 50.1% of the sample had total scores below the overall mean score. Mean scores on the ATLG also differed significantly by degree of religious observance (F = 10.111; p < 0.000), with each unit increase (1 to 4) in degree of religious observance resulting in significantly greater negative attitudes toward homosexuality. However, despite these significant differences, the overall ATLG mean scores for all levels of religious observances were relatively low. These results are shown in Tables 12.

Mean Scores on the Attitudes Toward Lesbians and Gay Men Scale (ATLG) by Participants’ Religion

Table 1: Mean Scores on the Attitudes Toward Lesbians and Gay Men Scale (ATLG) by Participants’ Religion

Analysis of Variance: Mean Scores on the Attitudes Toward Lesbians and Gay Men Scale (ATLG) by Degree of Religious Observance

Table 2: Analysis of Variance: Mean Scores on the Attitudes Toward Lesbians and Gay Men Scale (ATLG) by Degree of Religious Observance

Multiple Regression Analysis

Up to 10 demographic, educational, and occupational variables were entered as independent variables in three regression models, and the ATLG score was entered as the dependent variable. Participants’ gender, race/ethnicity, and educational level were not significantly related to scores on the ATLG. Participants’ age, sexual orientation, religion, degree of religious observance, degree of spirituality, geographic location of employment, and opinion about importance of teaching students about homosexuality were significantly related to ATLG scores.

A significant inverse relationship was noted between age and ATLG score. For each unit increase in age (each unit = 10 years; 1 = 21 to 30 years, 2 = 31 to 40 years, 3 = 41 to 50 years, 4 = 51 to 60 years, 5 = older than 61 years), scores on the ATLG decreased by 3.039 to 3.469 points, depending on the model (p < 0.000 for all models). A significant inverse relationship was noted between sexual orientation and ATLG score. For each unit increase in sexual orientation, indicated by dummy variables assigned to the categorical variables (1 = heterosexual, 2 = lesbian, 3 = gay male, 4 = bisexual), scores on the ATLG decreased by 2.441 to 3.499 points, depending on the model (p < 0.000 and p < 0.05 for each of two models). Mean ATLG scores by sexual orientation were 48.48 for heterosexuals, 32.4 for lesbians, 36.16 for gay males, and 46.2 for bisexuals, indicating that the overall decreases in ATLG scores by sexual orientation were mainly driven by scores for lesbians and gay males. For each unit increase in religion, indicated by dummy variables (1 to 9) assigned to each religion, ATLG scores decreased significantly by 0.743 to 0.995 points for two models (p < 0.000). For each unit increase in religious observance, indicated by dummy variables (1 to 4), ATLG scores increased significantly by 10.443 points (p < 0.000) in one model. For each unit increase in spirituality, indicated by dummy variables (1 to 4), ATLG scores increased significantly by 6.937 points (p < 0.000) in one model. Each unit increase in geographic location of employment (1 = urban, 2 = suburban, 3 = rural) resulted in a significant increase in ATLG scores from 2.721 (p < 0.01) to 3.689 (p < 0.000) for three models. For each unit increase in opinion about importance of teaching content about homosexuality (1 = not at all important, 2 = somewhat important, 3 = very important, 4 = highly important), there was a significant decrease in ATLG scores from 9.181 to 9.705 points (p < 0.001) for all three models. These results are shown in Table 3.

Multiple Regression Analysis Describing Relationships Between Demographic, Educational, and Occupational Independent Variables and the Attitudes Toward Lesbians and Gay Men Scale Scores (Dependent Variable)

Table 3: Multiple Regression Analysis Describing Relationships Between Demographic, Educational, and Occupational Independent Variables and the Attitudes Toward Lesbians and Gay Men Scale Scores (Dependent Variable)

Correlations

A significant correlation was noted between degree of religious observance and degree of spirituality (n = 1246 and 1239, respectively; r = 0.533; p < 0.000). A small, but significant, negative correlation was seen between participants’ opinion about importance of teaching students about homosexuality and their degree of religious observance (n = 1261 and 1233, respectively; r = −0.082; p < 0.004), but opinion regarding the importance of teaching students about homosexuality and degree of spirituality were not significantly correlated. A significant correlation was noted between participants’ opinion regarding importance of teaching students about homosexuality and their stated level of preparation to teach this content (r = 0.346; p < 0.000; n = 1,254). Most participants (78.6%) stated that teaching nursing students about homosexuality was very important to extremely important, but 71.9% also indicated that they were not at all prepared (56.6%) to somewhat prepared (15.3%) to teach this content. Only 28.1% of participants stated they were very prepared to extremely prepared to teach nursing students about homosexuality.

Discussion

The results of this study confirm and extend previous research findings about attitudes of nurse educators regarding homosexuality. The low mean score of 47.22 on the ATLG for a large nationwide sample that mirrors described demographic characteristics for nurse educators in the United States (Fang & Hu, 2011) supports the conclusion that nurse educators have generally positive attitudes toward homosexuality. However, a long skew toward high ATLG mean scores, with 252 participants having scores of 100 or above, is indicative of a minority of participants that lean toward highly negative attitudes. Participants’ mean scores on the ATLG were significantly affected by a variety of demographic and occupational factors, including age, sexual orientation, religion, degree of religious observance, degree of spirituality, geographic location of employment, length of time employed in nursing education, and opinion about the importance of teaching nursing students about homosexuality.

The positive effect on ATLG scores by sexual orientation and geographic location of employment are consistent with prior evidence about the impact of these factors. Mean scores on the ATLG hovered around the total sample mean for both heterosexuals and bisexuals; mean ATLG scores were 11 points (for gay men) to 14 points (for lesbians) below the total sample mean. The significant decrease in ATLG scores as sexual orientation shifted from heterosexual and bisexual orientation to homosexual orientation is expectable and confirms prior findings that homosexual samples have highly positive attitudes toward homosexuality (Herek, 1988). The finding of more positive attitudes among participants employed in urban areas is also consistent with prior findings. Homosexual people are more prevalent and visible in urban areas. Heterosexual nurse educators employed in urban areas may have greater opportunity for acquaintance and contact with LGB individuals as patients, students, and friends than those employed in suburban and rural areas, with increased contact known to correlate with more positive attitudes toward homosexuality (Finlay & Walther, 2003; Herek & Glunt, 1993).

The finding that increased age and greater length of time employed in nursing education are associated with more positive attitudes toward homosexuality is interesting. Although younger people might be expected to have more liberal or tolerant views about homosexuality than middle aged and older people (Finlay & Walther, 2003), this speculation is neither supported by these study data nor by prior research findings. Prior research shows that students who recently graduated from high school can enter nursing programs with strongly negative attitudes toward homosexuality related to integrating homophobic family and cultural values and lack of exposure or acquaintance with LGB people (Eliason, 1998; Eliason & Raheim, 2000), which improves as they study content modules about sexual minorities (Wells, 1989). This phenomenon has not yet been studied in nurse educators, but the current study’s data demonstrating increasingly positive attitudes toward homosexuality as participants’ age and length of career experience increases suggests this finding might be explained by this group having progressively greater contact with sexual minority individuals as patients and students.

In two of the three regression models analyzed, religion had a highly significant effect on ATLG scores. In model 2, religion was slightly short of being significantly correlated with ATLG scores, probably due to colinearity with the highly significant independent variable of degree of religious observance introduced into that model. Differences in mean scores on the ATLG by religion, although significant, hovered below the overall sample mean for those participants with religions known to be more liberal or unaffiliated. Mainstream Catholics and Protestants tended to have mean ATLG scores that ranged around the overall sample mean, with Protestants scoring slightly higher. Muslims scored higher than the overall sample mean, with Evangelical Christians scoring dramatically higher than the overall sample mean. These data support scientific evidence that particular religious affiliation and increasing degree of religious observance and religiosity are associated with higher levels of homophobia and more negative attitudes toward homosexuals (Finlay & Walther, 2003; Herek & Glunt, 1991). The study data confirm prior findings that people affiliated with more liberal religions or with no religion are more accepting of homosexuality than those professing Christianity (Lottes & Kuriloff, 1992; Wills & Crawford, 2000), with Protestants having more negative attitudes than Catholics (Finlay & Walther, 2003; Wills & Crawford, 2000) and conservative or orthodox Christian groups, such as evangelicals, having strongly negative attitudes toward homosexuality, as previously reported (Finlay & Walther, 2003; Schlub & Martsolf, 1999).

However, the overall effect of religious affiliation on ATLG scores was small compared with effect of degree of religious observance and degree of spirituality. Religious affiliation, although significant, reduced ATLG scores by less than 1 point for each unit in categorical difference. However, scores on the ATLG rose 10.443 points for each of four units of increased religious observance (p < 0.000). For this sample of nurse educators, increased degree of religious observance and degree of spirituality were positively correlated (r = 0.533, p < 0.000) and had a strong association with increasingly negative attitudes toward homosexuality, although each of these factors interacted differently with other independent variables in regression models. In model 3, the effect of degree of spirituality did not keep the independent variable of religion from correlating highly significantly with ATLG scores, although the effect of degree of religious observance in model 2 was great enough to cause the independent variable of religion to be insignificantly correlated with ATLG scores. Although increasing levels of spirituality had a negative effect on ATLG scores, they did not overcome the significantly positive effects of religion on ATLG scores proceeding away from Christian cohorts to more liberal and no religion groups. However, as degree of religious observance increased, effect of religious affiliation on ATLG scores became insignificant. Despite the moderately positive correlation between degree of religious observance and spirituality, this finding indicates probable subtle conceptual differences between participants’ perception of religiosity and religious observance and spirituality. Whereas religiosity and religious observance usually denote affiliation with an established religious denomination having a particular set of teachings and dogmas that could include particular teachings related to homosexuality, spirituality suggests an internal process of self-transcendency, greater connectedness to self and others, and finding life’s meaning and purpose (Love & Talbot, 1999), without necessarily adhering to specific doctrines or denominational teachings.

The majority of participants, or 78.6% of the study sample, stated that teaching nursing students about homosexuality is very important to extremely important. This finding is encouraging in light of current concerns that the health care needs of LGBT individuals and populations are insufficiently addressed in research and health care provider education. Nurse educators’ opinions about the importance of teaching nursing students about homosexuality had a strongly significant inverse effect on ATLG scores, with over 9-point decreases in scores for each of the four levels of opinion, ranging from 1 = not at all important to 4 = extremely important for all three regression models (p < 0.000). This confirms the considerable extent to which increasingly strong opinions about the importance of teaching nursing students about homosexuality is correlated with increasingly positive attitudes toward homosexuality among nurse educators and the vigor with which they endorse teaching this content.

Research data demonstrate that nursing students’ attitudes and sensitivity to the health care needs of LGBT patients improved after being provided with learning modules about sexual minorities (Wells, 1989). However, in the current study only 28.1% of the nurse educator participants stated they were very prepared to extremely prepared to teach this content, a finding critical to understanding the current lack of content about homosexuality in nursing curricula. Although most participants believe this content is very important to teach, many reported a lack of opportunity or available resources in which to learn about and teach the content. One major recurring theme in anecdotal comments submitted by this largely heterosexual (89.3%) participant sample was their sense of ignorance about what content to teach and how to teach it. They also cited a lack of appropriate curricula and teaching materials in this content area.

Limitations

This study has limitations that should be considered when interpreting the data. Direct online invitations to participate in the study were sent to more than 6,000 nurse educators but only 1,282 submitted the study materials. Although the sizable study sample met the criteria for significance for all statistical procedures performed, the attitudes of the more than the 4,700 nursing faculty who failed to notice the study invitation, ignored it, or chose not to participate cannot be known. Also, the study materials were not sent to faculty in associate degree and diploma schools of nursing, which imposes limitations on the generalizability of the study findings. Further, it would have been useful to explore the geographic location of participants by specific regions of the country to capture possible regional differences in attitudes toward homosexuality.

Conclusions and Implications

The study findings indicate that nurse educators have generally positive attitudes toward homosexuality and that their attitudes are significantly correlated with age, sexual orientation, religion, degree of religious observance, degree of spirituality, geographic location of employment, length of time employed in nursing education, and opinion about the importance of teaching nursing students about homosexuality. Most participants have the opinion that teaching nursing students about homosexuality is very important to extremely important but most believe they lack the knowledge, skills, and tools to teach this content. Because other factors could influence nurse educators’ activities related to teaching about homosexuality, further research is needed to investigate how the values and culture of nursing and norms within various nursing educational systems affect educators’ attitudes toward homosexuality and their ability to include this content into nursing curricula. However, the field of nursing education must make the teaching–learning about sexual minority health care a priority in response to glaring health care disparities for these populations and the study findings that a majority of nurse educators wish to gain the ability to address these disparities by teaching this content. National-level educational policies and standards must be developed to ensure that nursing students will be taught about sexual minority health care as a routine part of their educational experience. Nurse educators must gain comfort, cultural competence, and a strong knowledge and skills base to proficiently teach content about sexual minorities and to work with LGB patients and students. Opportunities must be provided for nurse educators to learn about the characteristics and health care needs of sexual minority populations in an effort to improve attitudes toward homosexuality in those individuals whose attitudes are currently negative. Schools and colleges of nursing and nursing education organizations must develop and provide access to programs and materials to facilitate this process, including workshops and seminars addressing LGB health care issues and needs across the lifespan; access to audiovisual materials and informatics, including bibliographic resources and Web sites for centers for research and health care for sexual minorities; and avenues of faculty access to mentorship by LGB colleagues or groups. Accurate, unbiased, and nonjudgmental content about sexual minority identities, cultures, and health care issues and needs must be included in nursing texts used in undergraduate and graduate curricula.

Curriculum guides need to be developed to assist nurse educators to integrate content about LGB health care needs across curricula, with differentiation between undergraduate and graduate knowledge and skills. Such materials should include clinical course-specific content and skill areas, as well as teaching strategies, case studies, assignments, and suggestions for discussion to help students learn the content. Special attention must be given to teaching therapeutic interaction with LGB patients that is tactful, sensitive, and takes into consideration their particular health concerns.

Adoption and application of appropriate educational content and methods to increase nurse educators’ knowledge and ability to teach students about sexual minority health care needs can have a significantly positive effect on students’ development of attitudes toward homosexuality that translates into better, more sensitive, and more comprehensive care for these vulnerable populations.

References

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Mean Scores on the Attitudes Toward Lesbians and Gay Men Scale (ATLG) by Participants’ Religion

Religion (N = 1,259)Frequency (%)aATLG Mean Score
Catholic414 (32.9)45.59
Protestant461 (36.6)50.09
Evangelical39 (3.1)101.89
Jewish42 (3.3)37
Muslim2 (0.2)62
Buddhist21 (1.7)31.55
Hindu1 (0.1)49
Pagan5 (0.4)33
No religion156 (12.4)34.8
Other118 (9.4)45.5

Analysis of Variance: Mean Scores on the Attitudes Toward Lesbians and Gay Men Scale (ATLG) by Degree of Religious Observance

Degree of Religious ObservancenATLG Mean Score (SD)a
Not at all22534.196 (8.43)
Somewhat42940.958 (19.72)
Very28853.909 (30.24)
Highly19066.537 (39.24)
Total113248.150

Multiple Regression Analysis Describing Relationships Between Demographic, Educational, and Occupational Independent Variables and the Attitudes Toward Lesbians and Gay Men Scale Scores (Dependent Variable)

Independent VariableCoefficient (Standard Error)
Model 1Model 2Model 3
Age−3.424*** (0.856)−3.039*** (0.809)−3.469*** (0.841)
Gender2.674 (2.665)3.480 (0.251)3.632 (2.632)
Race/ethnicity1.141 (1.101)0.314 (1.033)0.463 (1.087)
Sexual orientation−3.499*** (1.462)−2.441 (1.403)−3.211* (1.437)
Religion−0.995*** (0.245)−0.010 (0.244)−0.743*** (0.244)
Degree of religious observance10.443*** (0.855)
Degree of spirituality6.937*** (1.087)
Highest educational level attained−0.925 (1.596)−0.889 (1.508)−0.928 (1.567)
Geographic location of employment3.689*** (1.145)2.721** (1.082)3.427*** (1.126)
Importance of teaching content−9.705*** (1.105)−9.181*** (1.040)−9.476*** (1.086)
Constant86.008*** (7.175)56.229*** (7.157)67.480*** (7.644)
F test for model16.925***33.706***19.766***
r20.1230.2410.155
Number of participants1,0911,0721,088

10.3928/01484834-20130320-01

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