Research Problem and Purpose
For Magnan and Norris (2008), the context of plumbing student nurse attitudes in the area of barriers to accommodating patient sexuality and sexual needs is occasioned by the erosion of social mores, the resurgence of teenage pregnancy and abortion rates, and the continued prevalence of sexually transmitted acute and chronic disease. Little is known, they maintain, about how nursing students currently perceive barriers to addressing, among others: a) sexuality issues in the African pandemic that is HIV and the treatment of AIDS patients within America itself; b) the agitation by marginalized homosexuals, cross-dressers and transsexuals for acceptance of their gender “choices” and roles; and, c) sexual harassment and outright rape of women and children. The authors essentially argue from the platform that nurses should be prepared to address sexuality as an intrinsic component of holistic health care.
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Beyond simply social relevance, the research proposed to solve the problem of both nurse and patient being reluctant to engage with each other on assessment of sexuality, taking a sexual history, or offering related counseling. Since nurses have the requisite training, only sheer inhibition on both sides prevents such beneficial practices in a clinical setting.
Review of the Literature
The study at hand goes back a long way to trace the origins of concern with the potentially useful role of nurses in showing empathy for the sexuality-related issues in patients under their care. Magnan and Norris demonstrate that there have been studies about nurses’ attitudes towards human sexuality issues since the 1970s. Coverage extends only to 2005 and 2006 – one that establishes the body of knowledge about accelerated nursing programs, a Potter and Perry book about the fundamentals of nursing, and two more that Magnan had authored with Reynolds concerning precursors to the research covered by this critique – and only because the researchers had submitted the manuscript to the Journal of Nursing Education (JNE) as early as two years before the piece saw light in the pages of the journal.
Employing the heavily-attitudinal Sex Knowledge and Attitudes Test (SKAT), the early investigations were conducted in the hope that patients would benefit more if nurses could acknowledge that conservative attitudes make them prone to “…punitive attitudes, careless statements, and inappropriate reactions” (Magnan and Norris, 2008, p. 261). Even then, comparisons had already been drawn between nursing students on one hand, and RN’s or family planning nurses on the other. Over time, participants evinced swings between liberal and conservative attitudes, presumably reflecting cycles in social mores. When SKAT-based studies were replicated in British settings, one barrier that did emerge was patient reticence about discussing matters of sexuality with nurses. Still, it bears pointing out that the U.K. investigations did not consider it worthwhile to break out the findings for student nurses in the sample.
This inordinate attention to the information gap where student nurses are concerned is explained simply by the fact of submission for publication in the JNE.
In compiling the literature review, the authors consistently focused on readiness for assessing and counseling patients on sexuality matters related to their condition; in effect, this is the criterion variable. On the other hand, the explanatory concepts revolve on liberalism/conservatism, knowledge, sexual myths, and permissiveness with respect to auto-eroticism, heterosexual acts, premarital intercourse and adultery. Finally, the authors evince an interest in sexual health as the critical outcome.
Given the subject matter, it stands to reason perhaps that the authors fall back on no theoretical concepts. Instead, the research is framed by nursing practice becoming more complex for having to empathize with previously-overlooked sexual health issues. In effect, the Magnan and Norris argument for better nursing training and for more tolerant attitudes is based on ideology.
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As a descriptive and correlational study, the Magnan and Norris research focused on the independent variable of attitudes of addressing patient sexuality concerns among nursing students. In effect, the research question investigated whether RN attitudes in the clinical setting have their origins in preexisting attitudes earlier in life. This study therefore relies on the construct that attitudes are enduring predispositions hardly altered by education or early on-the-job training.
Besides age, the explanatory and independent variables consist of gender and educational level. The null and alternative hypotheses are not specifically stated. Suffice it to imply that reticence about addressing sexuality concerns of patients is greater among female, younger, and lower-level nursing students
The dependent variable itself is operationalized in the attitudes measured by the Sexuality Attitudes and Beliefs Survey (SABS) study instrument developed by Reynolds and Magnan (2005) shortly before the study subject of this critique. SABS measures attitudes pertaining to “personal comfort, confidence, meeting patient expectations, and making time to address patient sexuality concerns” (pp. 256-8) in nursing practice and covers not at all the permissiveness operationalized in heterosexual practice and behavior that SKATdid.
Methodology and Research Design
This is a quantitative-type study, employing a convenience sample of 341 students in one school setting. As such it can be argued that the findings are representative solely of that school though other researchers may certainly test reliability by replicating the findings in other schools and settings.
Respondents ranged from sophomores in a baccalaureate nursing program to a 52-year-old in the accelerated, second-degree program. It is not known whether the total sample covered all nursing students in the university or whether there had been an effort to systematically sample from among all available classes (SABS was administered in-classroom). Participation was voluntary to the extent that any student could opt to return the questionnaire unaccomplished or (in the case of seniors) not respond at all to the online invitation. Given the unknown about this having been “census” or systematic sampling, it is impossible to judge the type of sampling done.
The aforementioned absence of theory, the admitted descriptive study approach and the obvious procedure of moving from single observations to generalization and theory are all hallmarks of inductive logic.
Ethical considerations were addressed by asking students to return accomplished (or not) questionnaires in envelopes provided for the purpose, by having the professor handling the particular class leave the room during test administration, and by routing the online responses of seniors to a secure Web site.
As to reliability, the authors report simply an “acceptable” calculated internal consistency reliability of 0.74 (Cronbach’s α). One aspect of internal validity was addressed by incorporating a shortened form of the Marlowe-Crowne Social Desirability Scale in order to test for bias towards socially acceptable responses. Findings were marginal, suggesting that study participants were inhibited by both the natural desire to present an acceptable front and by apprehension that responses might impact their course standing.
Data analysis included simple counting up of scores on SABS (with higher scores of up to 61 indicating greater attitudinal barriers to engaging with patient sexuality), correlation with the Marlowe-Crowne social desirability scores (not statistically significant and therefore ostensibly honest responses), and statistical analysis for differences across participant subgroups. Presentation of data was done exclusively in the form of a cross-tabulation between agreement-disagreement on the 12 SABS items and academic levels: sophomore, junior, senior baccalaureate and senior/second degree.
Owing to the nature of the data (the cumulated SABS scores are effectively an ordinal scale) and item-by-item recoding in the second stage into the categorical form “agree”/”disagree”, Magnan and Norris employed the Mann–Whitney–Wilcoxon (MWW) rank-sum and the Kruskal-Wallis tests as nonparametric equivalents for the t test and ANOVA, respectively. Like the t test, MWW examines whether two sub-samples (e.g. by educational level) come from the same population. For its part, Kruskal-Wallis tests for differences of medians since the distribution of answers (to both SABS and the social desirability scale) was very likely to be skewed instead of exhibiting something akin to a normal curve.
By way of example, the authors report that a greater proportion of sophomores made time to assess sexual health concerns of patients than did juniors and seniors in the traditional baccalaureate program. As well, seniors were more likely to disagree about patients having expectations of their nurses for engaging with sexuality matters.
Summary/Conclusions, Implications & Recommendations
The principal strength of this study is that findings make intuitive sense. Those who had had formal classes in human sexuality in nursing school naturally felt more competent and on surer ground. Hence, they could address sexual health care with fewer barriers. On the other hand, barriers are greater for male students presumably for being more inhibited about attaining empathy, risking accusations of undue intimacy with female patients, and (as elsewhere in real life) avoiding intimations of homosexuality in male-male encounters.
A second strength of the study is that having taken a course on human sexuality makes a difference. This explains why the research was submitted for publication to the JNE in the first place.
The absence of information about sampling design prevents the casual reader from judging whether the findings can be projected to other centers of nursing education. As an RN with a PhD and a handful of published works, Mr. Magnan may even be faulted for lack of objectivity. He does not, for instance, ponder the truth of sophomore nurses claiming to give more time for sexuality assessments when they have no ward duty yet.
Magnan, M. & Norris, D. (2008). Nursing students’ perceptions of barriers to addressing patient sexuality concerns. Journal of Nursing Education, 47(6), 260-8.
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Reynolds, K.E. & Magnan, M.A. (2005). Nursing attitudes and beliefs toward human sexuality: Collaborative research promoting evidence-based practice. Clinical Nurse Specialist, 19: 255-259.