Research for Evidence Based Practice

Nurse Education Today 98 (2021) 104665

Available online 12 November 2020 0260-6917/© 2020 Elsevier Ltd. All rights reserved.

Sexual health attitudes and beliefs among nursing faculty: A correlational study

Claudia P. Benton Alumni Capella University, Works at Ventura County Public Health, 2220 East Gonzales Road, Oxnard, CA 93036, United States of America

A R T I C L E I N F O

Keywords: Nursing Nursing faculty Sexual health Sexuality Sexual health attitudes and beliefs Health education Educators Higher education

A B S T R A C T

Background: Sexual health is an integral part of nursing care across the life span. Nurses internal and external factors influenced their knowledge, experiences, and competencies. These impact nursing education and pro- fessional practice. There was no known research regarding the nursing faculty’s sexual health attitudes and beliefs and the relationship with predictive factors. Objectives: The purpose aims to identify any statistical relationships between nursing faculty age, nursing educational level, nursing specialty, years of work, and years of teaching in nursing to predict their sexual health attitudes and beliefs. Design: This is nonexperimental and quantitative research of predictive correlational design with multiple linear regression statistical analyses. Settings: Data gathered from nursing faculty across the United States. Participants: Nursing faculty teaching at the baccalaureate, master, and or advanced practice nursing programs. Methods: Online survey of sexuality attitudes and beliefs (SABS). Results: A convenience sample of 371 nursing faculty. The results showed a statistically significant and a mod- erate correlation (R = 0.35, R2 = 0.12, F(9, 361) = 5.68, p < 0.01) of their sexual health attitudes and beliefs and the predictors. This indicated nursing faculty with a doctorate, women’s health specialty, and increased years for age, nursing practice, and teaching showed lower SABS scores or barriers to addressing sexual health. The social cognitive theory and Benner’s novice to expert model explained the relationship between predictors and sexual health attitudes and beliefs. Conclusions: The findings of this study showed personal, educational, and professional factors as predictors affecting positively or negatively the faculty’s sexual health attitudes and beliefs. Awareness of those findings should promote changes in nursing education, decrease sexual health barriers, and prepare faculty, students, and nurses to provide sexual health care across the life span.

1. Introduction

Sexual health influences the health and wellbeing of people throughout their life. The World Health Organization WHO, (2006) defined sexual health as a state of wellbeing related to sexuality beyond physical, emotional, mental, and social aspects driven by positive atti- tudes and beliefs. In nursing education and professional practice, the topic of sexual health should be an integral part of patient care across the life span (Aaberg, 2016; Das, 2017). However, in the United States and several countries worldwide, there is a deficiency of sexual health ed- ucation and care. This deficiency is evident by limited sexual health curricular content in nursing schools, lack of standards in nursing edu- cation and the professional practice, and the attitudes and beliefs of

nursing students and nurses (Aaberg, 2016; Ayhan et al., 2010; Dias and Sim-Sim, 2015; Fennell and Grant, 2019; Garcia and Lisboa, 2012; Saunamäki et al., 2010; Tsai et al., 2014). The role of nursing faculty is fundamental to improve learning and competencies during the nursing education of students and professionals. The exposure of nursing faculty to different internal and external factors, life, and professional experi- ences may influence their development of sexual health attitudes and beliefs throughout their life. This study explored nursing faculty and the relationship of specific personal, educational, and professional factors as the predictive value of nursing faculty sexual health attitudes and be- liefs. Those factors are age, educational degree, nursing specialty, and years of clinical practice and teaching in nursing. Nursing faculty sexual health attitudes and beliefs and the relationship of these predictive

E-mail address: [email protected].

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https://doi.org/10.1016/j.nedt.2020.104665 Received 25 November 2019; Received in revised form 30 September 2020; Accepted 3 November 2020

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factors affect the delivery of nursing education and practice.

2. Background/literature

From the educator perspective, Long et al. (2011) highlighted the importance of identifying barriers influencing sexual health knowledge and perceptions. According to Aaberg (2016) and Tsai et al. (2014), an individual’s characteristics, attitudes, and behaviors could influence positively or negatively their sexual health nursing education and care. Nurses and nursing students’ attitudes and beliefs were a barrier to conduct quality patient sexual health care (Ayhan et al., 2010; Dias and Sim-Sim, 2015). Thus, the sexual health attitudes and beliefs of nursing faculty could facilitate or hinder their teaching (Huang et al., 2013a; Sirota, 2013; Sung et al., 2015). Magnan and Norris (2008) indicated that nursing students commented on the need for faculty to bring up sexual health education to facilitate their learning. However, nursing faculty expressed uncomfortable feelings when discussing sexual health topics with nursing students (Aaberg, 2016; Tsai et al., 2014). They needed to recognize their sexual health perspective in order to teach (Huang et al., 2013a). These support the need to study nursing faculty and their sexual health attitudes and beliefs. Understanding factors influencing the educational approach could improve the sexual health knowledge and skills of nursing students and the broader nursing force.

The development of nurses and nursing students’ sexual health at- titudes and beliefs is impacted by ranges of internal factors (psycho- logical and biological) and external factors (social, cultural, etc.). Consequently, patient care could be affected by their attitudes and be- liefs. Several authors described factors influencing sexual health atti- tudes and beliefs in education, professional, and clinical practice (Arikan et al., 2015; Magnan et al., 2006; Saunamäki et al., 2010; Tsai et al., 2014). Some of these highlighted factors were age, nursing educational level, nursing specialty, years of practice in the nursing field, and years of teaching in nursing. Age differences influenced positively or nega- tively nurses and nursing students’ sexual health attitudes and beliefs (Magnan et al., 2006; Saunamäki et al., 2010; Tsai et al., 2014) and nursing faculty attitudes and beliefs (Sirota, 2013). However, Areskoug- Josefsson et al. (2016), Lim et al. (2015), and Magnan and Norris (2008) did not find differences between nursing students, nurses, and nursing faculty’s age and sexual health knowledge, and attitudes and beliefs. There are inconsistencies in the literature regarding the impact of age and sexual health attitudes and beliefs in nursing. There are no current studies related to nursing faculty’s age or the nursing faculty population.

Furthermore, there have been more studies regarding nurses’ sexual health attitudes and beliefs with specialties such as cardiology, psychi- atry, oncology, and medical-surgical nursing than other specialty fields (Arikan et al., 2015; Magnan and Reynolds, 2006Quinn et al., 2013a, 2013b). Also, several authors have identified relationships between nurses’ knowledge and an increase in sexual health positive attitudes, beliefs, and skills resulting in higher competencies (Magnan et al., 2006; Saunamäki et al., 2010; Sung and Lin, 2013; Sung et al., 2015). Nurses with more years of experience in nursing practice showed higher com- petencies (Arikan et al., 2015; Magnan et al., 2006; Saunamäki et al., 2010). There is limited research comparing the different specialty fields, years of experience, years of teaching, and the influence of these factors in nursing faculty.

2.1. Theoretical orientation

For this research, two theoretical frameworks were selected. First, Bandura (1977, 1999) described in the social cognitive theory how the interaction of an individual’s environmental factors (social), behavior, and internal factors (affective, biological, and cognitive) impacts the person’s development of competencies across the life span, resources, and perceptions among others. The second framework was Benner’s model of novice to expert on stages of clinical competence (Benner, 1982). Benner explained how nurses advanced from novice to expert

with years of practice and experiences. For this research, the founda- tions of the social cognitive theory and the model of novice to expert on stages of clinical competence could facilitate the explanation of nursing faculty sexual health attitudes, beliefs, and the possible influence of age, education, teaching experiences, years of nursing practice, and spe- cialty. The different factors could reflect nursing faculty attitudes and beliefs toward sexual health and the education of nursing students.

2.2. Statement of the problem

In several countries around the world, there is a scarcity of literature examining sexual health and education among health care providers and educators (Bell and Bray, 2014; Fennell and Grant, 2019; García- Vázquez et al., 2014; Huang et al., 2013a; Huang et al., 2013b; Tsai et al., 2014; Walker and Davis, 2014). The literature showed a few recent sexual health studies related to nursing education and faculty in the United States (Aaberg, 2016; Lim et al., 2015). Understanding the nursing faculty’s sexual health attitudes and beliefs and related factors could demonstrate the positive or negative influence of these factors in nursing education and practice.

2.3. Purpose of the study

The purpose of this study was to identify any statistical relationships between nursing faculty age, educational level, specialty, years of practice, and years of teaching in nursing to predict their sexual health attitudes and beliefs. Nursing faculty sexual health attitudes and beliefs influenced by the different variables could affect how sexual health is addressed in nursing education.

3. Methods

3.1. Research methodology and design

The methodology for this research was quantitative. This nonex- perimental research was developed with a predictive correlational design. The methodological process included multiple linear regression statistical analyses using the sexuality attitudes and beliefs survey (SABS) instrument (Reynolds and Magnan, 2005). The multiple linear regression statistical analysis identified the uniqueness of the relation- ships for predictive value among each independent variable (age, years of nursing practice, years of teaching, education, and specialties) and the dependent variable (sexual health attitudes and beliefs) to answer the research questions.

3.2. Research questions

The research question and subquestions searched for any variances and the prediction of each variable and nursing faculty sexual health attitudes and beliefs. The research question was: Are age, nursing educational level, nursing specialty, years of practice in the nursing field, and years of teaching in nursing predictors of nursing faculty sexual health attitudes and beliefs? Furthermore, the design of the subquestions determined the uniqueness of the prediction of each factor among nursing faculty sexual health attitudes and beliefs. The sub- questions were: (1) Is age a unique predictor of nursing faculty sexual health attitudes and beliefs?; (2) Is nursing educational level a unique predictor of nursing faculty sexual health attitudes and beliefs?; (3) Is nursing specialty a unique predictor of nursing faculty sexual health attitudes and beliefs?; (4) Are years of practice in the nursing field a unique predictor of nursing faculty sexual health attitudes and beliefs?; and (5) Are years of teaching a unique predictor of nursing faculty sexual health attitudes and beliefs?

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3.3. Hypotheses

For the research question, the null (H0) or alternative (H1) hypoth- eses determined any statistically significant relationships between nursing faculty sexual health attitudes and all the predictors. For the subquestions, the H0 or H1 established any statistically significant rela- tionship between nursing faculty sexual health attitudes and beliefs for each predictor. The probability level of significance to predict was 0.05 in order to reject or fail to reject the hypotheses.

3.4. Target population

The target population selected for this study was nursing faculty teaching at the different baccalaureate, master, and or advanced nursing degree programs in the United States. For this study, the inclusion criteria were clinical and didactic nursing faculty, over 18 years of age, who teach at any degree level of the baccalaureate of nursing science (BSN), masters of science in nursing (MSN), and or advanced practice registered nurse (APRN) programs. The baccalaureate degree levels are BSN, registered nurse (RN) to BSN, and accelerated BSN. The bacca- laureate degree is the preferred entry-level of nursing (American Asso- ciation of Colleges of Nursing AACN, 2008). Therefore, the nursing faculty excluded for this study only taught vocational, associate, or doctoral nursing programs.

3.5. Recruitment

Efforts to recruit nursing faculty from most United States universities and territories were performed by emailing the nursing schools’ ad- ministrators (deans, directors, and chairs) from the AACN’s public list for three months. An invitation was sent by email to 698 nursing ad- ministrators out of 808 accredited universities offering baccalaureate and master nursing programs (American Association of Colleges of Nursing AACN, 2017). Some universities (110) did not have electronic contact information, or the administrators were not accessible. Potential nursing faculty participants received an email from their nursing ad- ministrators with the survey link, quick response code, brochure (including eligibility requirements, purpose, objectives, any harm or distress concerns, privacy, anonymity, confidentiality, voluntary participation, researcher’s contact information, and IRB approval noti- fication). The participant spent ten minutes or less completing the survey.

3.6. Sampling

The completion of a power analysis determined the sampling size with the minimum number of participants for 12 variables. The results of the power analysis required a minimal of 157 participants with a sta- tistical power of 0.90, alpha level (probability) of 0.05, and the regres- sion medium effect size of 0.15. However, Pituch and Stevens (2016) recommended sample size for multiple regression of 15 participants per variable resulting in the selection of a minimum of 180 participants for this study.

3.7. Instruments

The instruments consisted of a demographic questionnaire and the SABS instrument. The demographic questionnaire was designed and submitted for peer-review to determine the question’s items (11) per variable. The selection of variables was on significant results from pre- vious nursing studies related to age, nursing educational level, nursing specialty, years of nursing practice, and years of teaching in nursing (Barnason et al., 2013; Lim et al., 2015; Magnan and Norris, 2008; McCabe and Holmes, 2014; Saunamäki et al., 2010; Stroope et al., 2015; Tsai et al., 2014).

The SABS instrument facilitated the investigation of sexual health

attitudes and beliefs variables in nursing faculty. Reynolds and Magnan (2005) developed SABS with 12 items to determine nurses’ sexuality attitudes and beliefs. The questions identified the nurse’s expression of confidence, comfortability, behaviors, and expected perceptions of sexuality. SABS had validity and reliability. The answers to each ques- tion were categorized in a 6-point Likert scale by numbers from 1 (strongly disagree) to 6 (strongly agree). Items 1, 2, 4, 6, 8, 10, and 12 required reverse codings from 1 (strongly agree) to 6 (strongly disagree). The total SABS score could range from 12 to 72. A higher score indicated the participant demonstrated more barriers in addressing patients’ sexuality.

3.8. Data collection

The data was collected from the demographic questionnaire and SABS survey and stored in the SurveyMonkey’s confidential website. The data were numerically categorized, transferred to an Excel file, and into the protected statistical program for the social sciences (SPSS) known as International Business Machines (IBM) SPSS statistics software program, version 24.

3.9. Data analysis

The analysis of the data with descriptive statistics identified the demographic sample, predictive variables, and the results of inferential statistics to test the hypotheses and answer the research question and subquestions for this study. Participants with a higher SABS score indicated more barriers addressing patients’ sexual health based on their attitudes and beliefs. These results were evident by a lack of confidence, comfortability, behaviors, and sexuality perceptions (Reynolds and Magnan, 2005). The correlation and multiple linear regression design were analyzed to identify any statistical relationships between SABS results and all the variables and each separate variable by reviewing Pearson’s correlation coefficient, histogram, normal p-plot, and the scatterplot q-plot.

3.10. Ethical considerations

This study received prior approval from Capella University’s insti- tutional review board (IRB) before recruitment. During the recruitment, some university administrators required a copy of the IRB approval before sending to the faculty. Universities in which the administrators requested their IRB process were not included due to time limitations to complete the process. The survey was confidential and anonymous. The nursing faculty who voluntarily wanted to participate in the study accessed the SurveyMonkey link and consented to participate by completing the survey.

4. Data and Results

4.1. Description of the sample

A total of 404 nursing faculty accessed the survey. From the 404 potential participants, 33 did not complete the survey or were not eligible to be part of the research. The nursing faculty that met the criteria were 371 (92.57%) out of 404 who accessed the survey. The demographics of the sample shown in Table 1 and 2.

4.2. Hypotheses testing

Multiple linear regression was calculated to predict SABS and answer the research question, as seen in Table 3. The results showed a highly significant regression equation. (R = 0.35, R2 = 0.12, F(9, 361) = 5.68, p < 0.01) with a moderate correlation between sexual attitudes and beliefs and the nursing faculty age, nursing educational level, nursing specialty type, years of practice and years of teaching in nursing. The null

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hypothesis was rejected to answer the research question. The simple linear regression analysis to answer the subquestions and

resulting in the rejection of each null hypothesis were as followed:

(1) A highly significant regression equation to predict SABS and age, R = 0.22, R2 = 0.05, F(1, 369) = 18.34, p < 0.01, 95% CI [− 0.23, − 0.08], with a weak correlation.

(2) The educational levels of master (MSN/APRN), R = 0.18, R2 =

0.03, F(1, 369) = 12.38, p < 0.01, 95% CI [1.23, 4.36] and doctorate (Doctor of philosophy [PhD]; Doctor of nursing prac- tice [DNP]; Doctor of nursing science [DNSci]), R = 0.21, R2 =

0.04, F(1, 369) = 16.49, p < 0.01, 95% CI [− 4.75, − 1.65], were highly significant predictors with a weak correlation.

(3) Only women’s health nursing care (Labor and delivery [L&D] and women’s health [WH]) showed significance to predict nursing faculty SABS scores and a weak correlation, R = 0.12, R2 = 0.01, F (1, 369) = 3.24, p < 0.05, 95% CI [− 4.82, − 0.33] based on nursing faculty’ specialty.

(4) The years of work practicing nursing showed a highly significant regression equation with a weak correlation, R = 0.17, R2 = 0.03, F(1, 369) = 10.51, p < 0.01, 95% CI [− 0.18, − 0.45] to predict nursing faculty SABS scores.

(5) The years of teaching showed a highly significant regression equation as a predictor with a weak correlation, R = 0.22, R2 =

0.05, F(1, 369) = 19.62, p < 0.01, 95% CI [− 0.24, − 0.09].

4.3. Reliability and validity of SABS for predictive value

SABS scores with nursing faculty showed an acceptable Cronbach’s α value of 0.781 for internal consistency (Tavakol and Dennick, 2011). The split-half reliability resulted in an acceptable internal consistency of Cronbach’s α values of 0.603 and 0.728. The Spearman-Brown coeffi- cient value was 0.711.

As seen in Table 4, three models were identified with the stepwise method for best predictors. Model 1 showed a highly significant regression with weak correlation equation was found, R = 0.22, R2 =

0.05, F(1, 369) = 19.62, p < 0.01, 95% CI [− 0.24, − 0.09] to predict attitudes and beliefs and nursing faculty years of teaching in nursing. Model 2 demonstrated a highly significant regression equation and weak correlation, R = 0.27, R2 = 0.07, F(1, 368) = 9.59, p < 0.01 predicting SABS and years of teaching, and a PhD/DNP/DNSci education. A. Model 3, a multiple linear indicated a significant regression equation with a moderate correlation, R = 0.30, R2 = 0.09, F(1, 367) = 5.74, p < 0.05 by predicting SABS based on years of teaching in nursing, a PhD/DNP/ DNSci education, and L&D/WH specialty.

For cross-validation, a random sample of 75% of nursing faculty participants (N = 291) was selected to identify the best predictors for attitudes and beliefs. The null hypotheses were rejected for all the an- swers. The cross-validation resulted in three models, as shown in Table 5. Model 1, a highly significant regression equation based on years of teaching was found, R = 0.24, R2 = 0. 06, F(1, 289) = 18.10, p < 0.01, 95% CI [− 0.24, − 0.09]. Model 2, a significant regression equation and a weak correlation based on years of teaching in nursing and a PhD/DNP/ DNSci education was found, R = 0.28, R2 = 0.08, F(1, 288) = 9.59, p < 0.05. Model 3, a significant regression equation and a moderate corre- lation based on years of teaching in nursing, a PhD/DNP/DNSci edu- cation, and L&D/WH specialty type was found, R = 0.31, R2 = 0.09, F(1, 367) = 5.20, p < 0.05.

The results of cross-validation for the subquestions were as followed:

(1) A significant regression equation and a weak correlation to pre- dict SABS based on age was found, R = 0.19, R2 = 0.04, F(1, 289) = 10.65, p < 0.01, 95% CI [− 0.14, − 0.04].

(2) The BSN regression equation with a weak correlation to predict nursing faculty SABS scores based on educational levels was found, R = 0.14, R2 = 0.02, F(1, 289) = 5.75, p < 0.05, 95% CI [1.50, 16.27]. The MSN/APRN regression equation and a weak correlation was found, R = 0.16, R2 = 0.02, F(1, 289) = 7.22, p < 0.01, 95% CI [0.66, 4.24]. The PhD/DNP/DNSci regression equation and a weak correlation was found, R = 0.19, R2 = 0.04, F(1, 289) = 11.07, p < 0.01, 95% CI [− 3.00, − 0.90].

(3) The L&D/WH regression equation with a weak correlation to predict nursing faculty SABS scores based on nursing faculty’ specialty was found, R = 0.13, R2 = 0.02, F(1, 289) = 5.01, p < 0.05, 95% CI [− 5.25, − 0.34].

(4) A significant regression equation with a weak correlation to predict nursing faculty SABS score based on nursing faculty’

Table 1 Nursing faculty demographics.

Characteristics % f

Gender Female 94.34 350 Male 5.12 19 Transsexual 0.54 2

Ethnicity Black/African American 4.04 15 Native American 0.54 2 Asian 1.08 4 Hispanic/Latino 1.89 7 Multi-Ethnic 0.81 3 White nonHispanic 89.76 333 Undeclared/Other 1.89 7

Highest Nursing Degree BSN 2.16 8 MSN/APRN 45.55 169 PhD/DNP/DNSci 52.29 194

Nursing Specialty I/CC/ER/UR 31.81 118 IM/O/S 19.14 71 L&D/WH 14.29 53 P/SN 8.89 33 Psy/G/P/CH/AC 25.88 96

Note. BSN = Baccalaureate of science in nursing; MSN = Master of science in nursing; APRN = Advanced practice in registered nurse; PhD = Doctor of phi- losophy; DNP = Doctor of nursing practice; DNSci = Doctor of nursing science; I/ CC/ER/UR = Intensive/Critical care/Emergency Room/Urgent Care; IM/O/S = Internal Medicine/Oncology/Surgical; L&D/WH = Labor and Delivery/ Women’s health; P/SN = Pediatrics/School Nursing; Psy/G/P/CH/AC = Psy- chiatric/Geriatrics/Public/Community Health/Ambulatory Care.

Table 2 Means for nursing faculty age, education, specialty, and types of nursing practice in years (N = 371).

Variables Years Minimum Maximum M SD

Age 24 74 52.23 10.88 BSN 0 1 0.02 0.14 MSN/APRN 0 1 0.46 0.50 PhD/DNP/DNSci 0 1 0.52 0.50 I/CC/ER/UR 0 1 0.32 0.47 IM/O/S 0 1 0.19 0.39 LD/HH 0 1 0.14 0.35 P/SN 0 1 0.09 0.28 Psy/G/P/CH/AC 0 1 0.26 0.44 Working in nursing 2 60 28.72 11.29 Teaching in nursing 0 42 13.05 10.28

Note. BSN = Baccalaureate of science in nursing; MSN = Master of science in nursing; APRN = Advanced practice in registered nurse; PhD = Doctor of phi- losophy; DNP = Doctor of nursing practice; DNSci = Doctor of nursing science; I/ CC/ER/UR = Intensive/Critical care/Emergency Room/Urgent Care; IM/O/S = Internal Medicine/Oncology/Surgical; L&D/WH = Labor and Delivery/ Women’s health; P/SN = Pediatrics/School Nursing; Psy/G/P/CH/AC = Psy- chiatric/Geriatrics/Public/Community health/Ambulatory Care.

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years of work practicing in the nursing field was found, R = 0.14, R2 = 0.02, F(1, 289) = 5.59, p < 0.05, 95% CI [− 0.18, − 0.16].

(5) A significant regression equation with a weak correlation to predict nursing faculty SABS score based on nursing faculty years of teaching in nursing was found, R = 0.24, R2 = 0.06, F(1, 289) = 18.10, p < 0.01, 95% CI [− 0.27, − 0.10].

A multiple regression analysis was performed for each SABS question and nursing faculty participants’ age, nursing educational level, nursing specialty type, years of practice, and years of teaching in nursing. The results are shown in Tables 6 and 7.

5. Discussion

This correlational study using multiple linear regression aims to identify any statistical relationships between nursing faculty age, nursing educational level, nursing specialty, years of nursing practice, and years of teaching to predict nursing faculty’s sexual health attitudes and beliefs. This research represented nursing faculty and their sexual health attitudes and beliefs influenced by individual characteristics as predictive values. The nursing faculty sample for this study showed similarities with the United States nursing faculty population (see Table 1; National League of Nursing, 2018).

The multiple regression analysis to answer the research question indicated that there were moderate associations with statistical signifi- cance between sexual health attitudes and beliefs and all the nursing faculty predictors for age, education, specialty, years of practice, and years of teaching. The results showed some similarities with Sirota (2013), which identified the influence of occupation, age, years of teaching, and nursing faculty’s homosexuality attitudes and beliefs. The best predictors of nursing faculty attitudes and beliefs were validated for highly and statistical significance. The first predictor was years of teaching, then years of teaching and a doctorate; and lastly, years of teaching, a doctorate, and women’s health specialty. Each variable was analyzed individually to answer each subquestion and determine the unique prediction with nursing faculty sexual health attitudes and be- liefs. The results for each subquestion showed a weak association with the statistical significance of nursing faculty attitudes and beliefs as unique predictors for age, a doctoral degree, the specialty of women’s health, years of work, and teaching in nursing.

Every person develops sexual health views from the interface be- tween internal and external factors across the life span (Bandura, 1977).

Nursing faculty sexual health attitudes and beliefs and the predictive factors could be associated with the theoretical frameworks underpin- ning this study. In the social cognitive theory, for example, age is a biological factor influencing the person’s development through different interactions in life. The findings of this study showed the nursing fac- ulty’s age to be highly statistically significant related to sexual health attitudes and beliefs. These were the result of lower SABS scores with aging. In this study, older nursing faculty showed fewer barriers to discuss sexual health when interacting with patients in health care and education. Saunamäki et al. (2010), Tsai et al. (2014), Huang et al. (2013b), and Sirota (2013) identified the significance between age and the decrease of sexual health barriers. The different researchers sup- ported the results of this study that showed older nursing faculty was highly significantly associated with positive attitudes, beliefs, and comfort to address sexual health in nursing education and practice.

Nursing faculty educational degree determines levels of compe- tencies. According to the Commission on Collegiate Nursing Education (2013, 2018), nursing faculty should have a graduate degree to teach at the baccalaureate or master programs. These results showed a highly significant relationship between educational degree and sexual health attitudes and beliefs. Nursing faculty with a doctoral degree demon- strated a significant negative weight resulting in lower SABS scores. Subsequently, nursing faculty with a doctorate disclosed fewer barriers related to comfort, confidence, knowledge, attitudes, and beliefs to address sexual health with patients and in nursing education.

Similarly, Saunamäki et al. (2010) found significant positive re- lationships between nursing students’ comfort to address sexual health and the higher educational level. Nursing faculty for baccalaureate programs expressed deficiencies in teaching sexual health topics (Echezona-Johnson, 2017; Lim et al., 2015). According to Bell and Bray (2014), Steinke et al. (2016), Sung et al. (2015), and Yingling et al. (2017), their level of education affected the learning and teaching of sexual health. These findings supported the need for more sexual health preparation in nursing faculty across the different programs and the value of a doctorate prepared nursing faculty.

The findings of this study indicated that nursing faculty specialized in women’s health showed a significant positive association in their sexual health attitudes and beliefs. These findings were evident by lower SABS scores of nursing faculty specialized in women’s health than other specialties. As a result, nursing faculty specialized in women’s health demonstrated fewer barriers in their confidence, attitudes, and beliefs to address sexual health with patients and in nursing education. Several

Table 3 Multiple regression coefficients of SABS and variables (N = 371).

Variables B SE B β t p 95.0% CI Collinearity

LL UL VIF

Constant 36.36 2.73 13.28 0.00*** 30.98 41.74 Age − 0.27 0.09 − 0.37 − 2.97 0.00** − 0.44 − 0.09 6.50

Highest nursing education BSN 3.81 2.74 0.07 1.39 0.17 − 1.58 9.20 1.09 MSN/APRN 2.23 0.82 0.14 2.71 0.00** 0.61 3.84 1.14

Nursing specialties IM/O/S − 0.20 1.13 − 0.01 − 1.82 0.85 − 2.42 2.01 1.35 L&D/WH − 3.33 1.22 − 0.15 − 2.73 0.01** − 5.73 − 0.93 1.25 P/SN − 0.86 1.46 − 0.03 − 0.59 0.56 − 3.73 2.01 1.18 Psy/G/P/CH/AC − 1.47 1.02 − 0.08 − 1.43 0.15 − 3.48 0.55 1.38

Years of nursing work 0.21 0.09 0.31 2.44 0.01* 0.04 0.39 6.79

Years teaching in nursing − 0.12 0.05 − 0.16 − 2.38 0.02* − 0.22 − 0.02 1.78

Note. BSN = Baccalaureate of science in nursing; MSN = Master of science in nursing; APRN = Advanced practice in registered nurse; PhD = Doctor of philosophy; DNP = Doctor of nursing practice; DNSci = Doctor of nursing science; I/CC/ER/UR = Intensive/Critical care/Emergency Room/Urgent Care; IM/O/S = Internal Medicine/ Oncology/Surgical; L&D/WH = Labor and Delivery/Women’s health; P/SN = Pediatrics/School Nursing; Psy/G/P/CH/AC = Psychiatric/Geriatrics/Public/Com- munity health/Ambulatory Care; *** Correlation is significant at the 0.000 level (2-tailed) = p < 0.001; **Correlation is significant at the 0.01 level (2-tailed) = p < 0.01; *Correlation is significant at the 0.05 level (2-tailed) = p < 0.05.

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authors have identified the inclusion in the nursing curricula of sexual health content and training among nursing students and nurses in the field of women’s health (Aaberg, 2016; Arikan et al., 2015; Bal and Sahiner, 2015; Magnan and Reynolds, 2006).

Aaberg (2016) recognized a decrease in sexual health content in nursing education in the United States. The baccalaureate nursing pro- grams (72.8%) embedded sexual health curricula content in a few courses, including women’s health. Nevertheless, nurses and nursing students practicing in other specialties different than women’s health showed higher levels of comfort and confidence addressing sexual health in nursing after receiving sexual health training (Akinci et al., 2011; Santos André and Maria, 2014; Steinke et al., 2016). The results suggested that the inclusion of sexual health content across the life span in the nursing curriculum, nursing specialties, nursing programs, and training benefit sexual health care and nursing education.

In this study, nursing faculty that worked long years in the nursing field demonstrated a highly statistically significant relationship with their sexual health attitudes and beliefs. They scored lower SABS, indi- cating fewer sexual health barriers related to knowledge, comfort, confidence, attitudes, and beliefs with patients and in nursing education. Indeed, nursing faculty with longer years of practice indicated positive attitudes and readiness to teach with the lesbian, gay, bisexual, and

transgender patient population (Lim et al., 2015; Sirota, 2013). Ac- cording to Arikan et al. (2015) and Carabez et al. (2015), nurses and advanced practice nurses expressed positive sexual health attitudes and beliefs when practicing nursing for more than six years. From the social cognitive theoretical perspective and Benner’s model of novice to expert competencies, nursing faculty develops sexual health attitudes, beliefs, and skills with more years of experience practicing nursing. These facilitated the nursing faculty’s integration of theory and practice, the decision making and problem-solving skills, and the ability to teach sexual health enhanced by self-efficacy and self-regulation.

This study indicated that nursing faculty with longer years of teaching experience had a highly significant statistical relationship with their sexual health attitudes as a unique predictor. This finding demonstrated lower SABS scores and fewer barriers based on their knowledge, comfort, confidence, and attitudes and beliefs to address sexual health with patients and nursing education with the increase of years of teaching experiences. Lim et al. (2015) indicated that the nursing faculty’s ability to teach was based on their knowledge and expertise to teach sexual health. The nursing faculty role was influential in developing the sexual health education and competencies of nursing students (Rowbotham and Owen, 2015). The findings suggest that nursing faculty with longer years of experience in nursing practice and

Table 4 Multiple regression coefficients for stepwise method models (N = 371).

B SE B β t p 95.0% CI Collinearity

LL UL VIF

Model 1 Constant 29.47 0.63 46.46 0.00*** 28.23 30.72 Years teaching in nursing − 0.17 0.04 − 0.22 − 4.43 0.00*** − 0.24 − 0.09 1.00

Model 2 Constant 30.37 0.69 43.93 0.00*** 29.01 31.73

Years of teaching in nursing − 0.14

0.04 − 0.18 − 3.56 0.00*** − 0.22 − 0.06 1.07 PhD/DNP/DNSci − 2.48 0.80 − 0.16 − 3.10 0.00** − 4.06 − 0.90 1.07

Model 3 Constant 30.77 0.71 43.56 0.00*** 29.38 32.16

Years of teaching in nursing − 0.14 0.04 − 0.19 − 3.63 0.00*** − 0.22 − 0.65 1.07 PhD/DNP/DNSci − 2.46 0.80 − 0.16 − 3.09 0.00** − 4.03 − 0.90 1.07 L&D/WH − 2.64 1.10 − 0.12 − 2.73 0.02* − 4.80 − 0.93 1.00

Note. PhD = Doctor of philosophy; DNP = Doctor of nursing practice; DNSci = Doctor of nursing science; L&D/WH = Labor and Delivery/Women’s health; *** Correlation is significant at the 0.000 level (2-tailed) = p < 0.001. **Correlation is significant at the 0.01 level (2-tailed) = p < 0.01; *Correlation is significant at the 0.05 level (2-tailed) = p < 0.05.

Table 5 Multiple regression coefficients for 75% random sample and stepwise method models (N = 291).

B SE B β t p 95.0% CI Collinearity

LL UL VIF

Model 1 Constant 29.47 0.63 46.46 0.00*** 28.23 30.72 Years teaching in nursing − 0.17 0.04 − 0.22 − 4.43 0.00*** − 0.24 − 0.09 1.00

Model 2 Constant 30.37 0.69 43.93 0.00*** 29.01 31.73

Years teaching in nursing –0.14 0.04 − 0.18 − 3.56 0.00*** − 0.22 − 0.06 1.07 PhD/DNP/DNSci − 2.48 0.80 − 0.16 − 3.10 0.00* − 4.06 − 0.90 1.07

Model 3 Constant 30.77 0.71 − 0.19 43.56 0.00*** 29.38 32.16

Years teaching in nursing − 0.14 0.04 − 0.19 − 3.63 0.00*** − 0.22 − 0.65 1.07 PhD/DNP/DNSci − 2.46 0.80 − 0.16 − 3.09 0.00* − 4.03 − 0.90 1.07 L&D/WH − 2.64 1.10 − 0.12 − 2.73 − 4.80 − 0.93 1.00

Note. PhD = Doctor of philosophy; DNP = Doctor of nursing practice; DNSci = Doctor of nursing science; L&D/WH = Labor and Delivery/Women’s health; *** Correlation is significant at the 0.000 level (2-tailed) = p < 0.001; **Correlation is significant at the 0.01 level (2-tailed) = p < 0.01; *Correlation is significant at the 0.05 level (2-tailed) = p < 0.05.

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teaching, especially those with women’s health experience and doctorate, are key to improve sexual health education. They are skilled in being placed as role models, observe behaviors, promote social in- teractions, educate, and promote sexual health content when teaching theory and clinical courses.

5.1. Limitations

There were several limitations to this study. The topic of sexual health is considered a culturally and sensitive topic that could lead to reporting bias and reluctancy to participate in this study. The method- ological design was of predictive value instead of causality and required a specific number of participants based on a power analysis limiting the numbers of variables. Indeed, there are many nursing specialties, and each specialty is a variable. Groups categorized nursing specialties. The number of participants needed for more variables was unrealistic for this study time frame. Participants selected the closest group to their practice because of the omission of specialties such as informatics.

Moreover, the recruitment efforts were during summer break resulting in a small sample since nursing institutions were closed, or nursing faculty were on vacation or changed jobs. The convenience sample was a limitation. Nursing faculty interested in the topic could be more motivated to participate in the research than others. The random

sample for generalizability was selected from the same population because there were not enough participants to create two groups to have a more robust methodological comparison.

5.2. Implications for practice

The findings of this study identified the relationship between age, nursing educational level, nursing specialty, years of nursing practice, and years of teaching as predictive factors of nursing faculty’s sexual health attitudes and beliefs and the effect in the delivery of nursing education and professional work. There is a stronger relationship when nursing faculty meet all the predictive factors.

Moreover, each factor is a predictor of nursing faculty sexual health attitudes and beliefs in their teaching and professional practice. For example, younger nursing faculty with a baccalaureate and or master’s degree may need more support from older nursing faculty with practical experience in teaching and nursing practice to implement sexual health content in nursing education. These findings support the role of more senior nursing faculty experts in women’s health with a doctorate and years of experience in teaching and nursing practice. These faculty should assess the curricula for sexual health content at the baccalau- reate, master, and advanced nursing practice programs, develop educational and mentoring activities, share different educational and specialty backgrounds, and competency levels (Levesque, 2015). They showed higher levels of competencies in sexual health care across the life span. They should get involved in the development of curricula, training modules, teaching methods, tools, and activities for faculty, students, and nurses (Bell and Bray, 2014; Bosse et al., 2015; Canzona et al., 2018; Echezona-Johnson, 2017; Ellis, 2016; Steinke et al., 2016; Yingling et al., 2017).

The outcomes of this study suggest that collaboration between novice to expert nursing faculty and other healthcare disciplines should be encouraged to enhance the application of theory and practice and promotion of sexual health nursing care and the application of the social cognitive theory. Understanding the predictive factors could support advocacy to implement policy changes, the scope of work, the inclusion of educational content, coordination of practicum sites, preceptors, mentors, and training to prepare nurses. This study could be replicated in the United States and other countries worldwide with different pop- ulations examining the same variables and theoretical frameworks for future comparison.

5.3. Recommendations

Sexual health education and care are needed across the life span to promote sexual health wellbeing and address needs and issues to prevent diseases and social problems. In the United States, the content of sexual health in nursing education curricula has decreased throughout the years due to a lack of time, comfort level, and content priority (Aaberg, 2016). The National Council Licensure Examination (2020) does not require sexual health content except for limited reproductive health. It will be necessary for nursing faculty experts with positive attitudes and beliefs to review nursing curricula for sexual health content from the social cognitive theory framework and beyond women’s health in order to integrate theory and practice and appropriate training for nursing faculty and nursing students.

The lessons learned from the study design provided insightful ways to improve the research methodology and recruitment for future research. The design addressed nursing faculty and predictive factors with significant results. A study with a larger sample could add to the literature and support policy changes to improve sexual health care and education. The recruitment of nursing faculty for research will be more meaningful when schools are in session to outreach more staff. Further research is recommended to explore other individualize predictors in nursing faculty with a larger sample across nursing specialties. Besides, other nursing researchers could investigate other individual

Table 6 Multiple regression analysis per variable and each SABS question.

Questions R R2 Adj R2

F(9, 361)

p

1. Discussing sexuality is essential to patients’ health outcomes.

0.30 0.09 0.07 4.00 0.00***

2. I understand how my patient’s diseases and treatment might affect their sexuality.

0.22 0.05 0.03 2.05 0.03*

3. I am uncomfortable talking about sexual issues.

0.22 0.05 0.03 2.06 0.03*

4. I am more comfortable talking about sexual issues with my patients than most of the nurses I work with.

0.21 0.04 0.02 1.87 0.06

5. Most hospitalized patients are too sick to be interested in sexuality.

0.18 0.03 0.01 1.29 0.24

6. I make time to discuss sexual concerns with my patients.

0.28 0.08 0.05 3.34 0.00***

7. Whenever patients ask me a sexually related question, I advise them to discuss the matter with the physician.

0.26 0.07 0.05 2.95 0.00***

8. I feel confident in my ability to address patients’ sexual concerns.

0.27 0.07 0.05 3.21 0.00***

9. Sexuality is too private an issue to discuss with patients.

0.23 0.05 0.03 2.19 0.02*

10. Giving a patient permission to talk about sexual concerns is a nursing responsibility.

0.23 0.05 0.03 2.18 0.02*

11. Sexuality should be discussed only if initiated by the patient.

0.23 0.05 0.03 2.28 0.01*

12. Patients expect nurses to ask about their sexual concerns.

0.20 0.04 0.02 1.66 0.10

Note. BSN = Baccalaureate of science in nursing; MSN = Master of science in nursing; APRN = Advanced practice in registered nurse; PhD = Doctor of phi- losophy; DNP = Doctor of nursing practice; DNSci = Doctor of nursing science; I/ CC/ER/UR = Intensive/Critical care/Emergency Room/Urgent Care; IM/O/S = Internal Medicine/Oncology/Surgical; L&D/WH = Labor and Delivery/ Women’s health; P/SN = Pediatrics/School Nursing; Psy/G/P/CH/AC = Psy- chiatric/Geriatrics/Public/Community Health/Ambulatory Care; *** Correla- tion is significant at the 0.000 level (2-tailed) = p < 0.001; **Correlation is significant at the 0.01 level (2-tailed) = p < 0.01; *Correlation is significant at the 0.05 level (2-tailed) = p < 0.05. SABS Questions from “Nursing attitudes and beliefs toward human sexuality: Collaborative research promoting evidence- based practice,” by K. Reynolds, and M. Magnan, 2005, Clinical Nurse Specialist, 19(5), p. 258. Permission to publish granted.

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characteristics, such as gender, marital status, religion, ethnicity, and adverse childhood experiences, among others. Worldwide, we need to view the implementation of sexual health from social, economic, and cultural factors, among others, to prevent and protect the health re- percussions of the individual, community, and society.

6. Conclusion

Nursing faculty plays a vital role in nursing education and the development of professional nurses. Their sexual health attitudes and beliefs, influenced by internal and external factors, affect the delivery and promotion of sexual health in nursing education and professional practice. The results of this study found older nursing faculty with a doctoral degree, women’s health specialty, and long years of practicing and teaching in nursing as predictors for better attitudes and beliefs to address sexual health. The lenses of the social cognitive theory and Benner’s novice to expert model of competencies facilitated explaining the significant relationships between nursing faculty and the predictors. The analysis of the results promotes awareness of nursing faculty pre- dictors for barriers impacting comprehensive sexual health care and education across the lifespan. Nursing faculty need to be better prepared to integrate sexual health into the curriculum of theoretical and clinical courses and provide support and guidance to other faculty. The results of this study could facilitate the implementation and promotion of effective and consistent nursing programs, services, and decrease barriers in sexual health education and adverse outcomes at the individual level, in education, and health care. The awareness of nursing faculty predictors

could impact nursing education, policy changes, advocacy, and further research. These will improve sexual health in individuals, communities, and society.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

References

Aaberg, V., 2016. The state of sexuality education in baccalaureate nursing programs. Nurse Educ. Today 44, 14–19. https://doi.org/10.1016/j.nedt.2016.05.009.

Akinci, A.C., Yildiz, H., Zengin, N., 2011. The level of comfort among nursing students during sexual counseling to patients who have chronic medical conditions. Sex. Disabil. 29 (1), 11–20. https://doi.org/10.1007/s11195-010-9185-1.

Areskoug-Josefsson, K., Larsson, A., Gard, G., Rolander, B., Juuso, P., 2016. Health care students’ attitudes towards working with sexual health in their professional roles: survey of students at nursing, physiotherapy and occupational therapy programmes. Sex. Disabil. 34 (3), 289–302. https://doi.org/10.1007/s11195-016-9442-z.

American Association of Colleges of Nursing (AACN), 2017. Mailing list rental. Retrieved from. http://www.aacn.nche.edu/membership/mailing-list-rental.

American Association of Colleges of Nursing (AACN), 2017. Mailing list rental. Retrieved from. http://www.aacn.nche.edu/membership/mailing-list-rental.

Arikan, F., Meydanlioglu, A., Ozcan, K., Canli Ozer, Z., 2015. Attitudes and beliefs of nurses regarding discussion of sexual concerns of patients during hospitalization. Sex. Disabil 33 (3), 327–337. https://doi.org/10.1007/s11195-014-9361-9.

Ayhan, H., Iyigun, E., Tastan, S., Coskun, H., 2010. Turkish version of the reliability and validity study of the sexual health attitudes and belief survey. Sex. Disabil. 28 (4), 287–296. https://doi.org/10.1007/s11195-010-9157-5.

Table 7 Multiple regression coefficient and p value per each SABS question and variables.

Variables Constant Age Highest nursing education

Nursing specialties

BSN MSN/ APRN

IM/O/S L&D/WH P/SN Psy/G/ P/CH/ AC

Years of nursing work Years of teaching in nursing

Question 1 B 2.39 − 0.03 1.15 0.16 0.37 0.02 0.09 0.05 0.03 − 0.01 p 0.00*** 0.02* 0.00** 0.12 0.01* 0.88 0.63 0.74 0.01* 0.04*

Question 2 B 2.35 − 0.02 − 0.01 0.10 0.05 − 0.06 0.14 − 0.03 0.01 − 0.00 p 0.00*** 0.05* 0.97 0.28 0.69 0.65 0.39 0.76 0.42 0.54

Question 3 B 4.92 − 0.06 0.26 0.02 − 0.23 − 0.79 − 0.40 − 0.25 0.04 − 0.00 p 0.00*** 0.01** 0.69 0.93 0.39 0.01** 0.25 0.29 0.07* 0.86

Question 4 B 3.77 − 0.03 − 0.38 0.15 − 0.16 − 0.29 − 0.05 − 0.19 0.02 − 0.02 p 0.00*** 0.14 0.46 0.35 0.45 0.21 0.85 0.32 0.19 0.02*

Question 5 B 3.25 − 0.03 0.44 0.17 − 0.02 − 0.21 − 0.22 − 0.11 0.04 − 0.01 p 0.00*** 0.02 0.33 0.22 0.90 0.29 0.36 0.52 0.01 0.50

Question 6 B 3.70 − 0.02 0.32 0.38 − 0.25 − 0.61 − 0.08 − 0.53 0.01 − 0.01 p 0.00*** 0.29 0.53 0.01* 0.24 0.01** 0.76 0.01** 0.44 0.19

Question 7 B 2.70 − 0.03 0.18 0.18 0.16 − 0.24 0.07 0.09 0.03 − 0.02 p 0.00*** 0.02* 0.64 0.13 0.30 0.16 0.75 0.55 0.02 0.01**

Question 8 B 3.46 − 0.03 0.12 0.19 − 0.32 − 0.47 − 0.35 − 0.17 0.03 − 0.01 p 0.00*** 0.01* 0.77 0.12 0.06 0.01* 0.11 0.26 0.05 0.05

Question 9 B 2.22 − 0.02 0.05 0.04 0.08 − 0.08 − 0.08 − 0.02 0.01 − 0.01 p 0.00*** 0.05 0.87 0.67 0.53 0.55 0.63 0.86 0.22 0.05

Question 10 B 1.66 0.00 0.40 0.07 − 0.05 − 0.11 0.04 − 0.20 − 0.00 − 0.01 p 0.00*** 0.95 0.18 0.45 0.71 0.39 0.84 0.08 0.84 0.04

Question 11 B 2.64 − 0.01 0.79 0.28 0.17 − 0.34 0.17 − 0.01 0.01 − 0.01 p 0.00*** 0.36 0.09 0.04* 0.36 0.10 0.49 0.97 0.34 0.16

Question 12 B 3.31 0.01 0.50 0.50 − 0.01 − 0.16 − 0.18 − 0.09 − 0.01 0.01 p 0.00*** 0.66 0.31 0.00*** 0.96 0.47 0.50 0.62 0.55 0.52

Note. BSN = Baccalaureate of science in nursing; MSN = Master of science in nursing; APRN = Advanced practice in registered nurse; PhD = Doctor of philosophy; DNP = Doctor of nursing practice; DNSci = Doctor of nursing science; I/CC/ER/UR = Intensive/Critical care/ Emergency Room/Urgent Care; IM/O/S = Internal Medicine/ Oncology/Surgical; L&D/WH = Labor and Delivery/Women’s health; P/SN = Pediatrics/School Nursing; Psy/G/P/CH/AC = Psychiatric/Geriatrics/Public/Com- munity Health/Ambulatory Care; *** Correlation is significant at the 0.000 level (2-tailed) = p < 0.001; **Correlation is significant at the 0.01 level (2-tailed) = p < 0.01; *Correlation is significant at the 0.05 level (2-tailed) = p < 0.05. SABS Questions 1. Discussing sexuality is essential to patients’ health outcomes; 2. I understand how my patient’s diseases and treatment might affect their sexuality. 3. I am uncomfortable talking about sexual issues; 4. I am more comfortable talking about sexual issues with my patients than most of the nurses I work with; 5. Most hospitalized patients are too sick to be interested in sexuality; 6. I make time to discuss sexual concerns with my patients; 7. Whenever patients ask me a sexually related question, I advise them to discuss the matter with the physician; 8. I feel confident in my ability to address patients’ sexual concerns; 9. Sexuality is too private an issue to discuss with patients; 10. Giving a patient permission to talk about sexual concerns is a nursing responsibility; 11. Sexuality should be discussed only if initiated by the patient; 12. Patients expect nurses to ask about their sexual concerns. SABS Questions from “Nursing attitudes and beliefs toward human sexuality: Collaborative research promoting evidence-based practice,” by K. Reynolds, and M. Magnan, 2005, Clinical Nurse Specialist, 19(5), p. 258. Permission to publish granted.

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9

Bal, M.D., Sahiner, N.C., 2015. Turkish nursing students’ attitudes and beliefs regarding sexual health. Sex. Disabil. 33 (2), 223–231. https://doi.org/10.1007/s11195-014- 9388-y.

Bandura, A., 1977. Social Learning Theory. Prentice Hall, Englewood Cliffs, NJ. Bandura, A., 1999. Social cognitive theory: an agentic perspective. Asian J. Soc. Psychol.

2 (1), 21–41. https://doi.org/10.1111/1467-839X.00024. Barnason, S., Steinke, E., Mosack, V., Wright, D.W., 2013. Exploring nurses’ perceptions

of providing sexual health counseling for patients with cardiac disease: implications for evidence-based interventions. Dimensions of Critical Care Nursing 32 (4), 191–198. https://doi.org/10.1097/DCC.0b013e31829980d1.

Bell, A., Bray, L., 2014. The knowledge and attitudes of students’ nurses towards patients with sexually transmitted infections: exploring changes to the curriculum. Nurse Educ. Pract. 14 (5), 512–517. https://doi.org/10.1016/j.nepr.2014.05.002.

Benner, P., 1982. From Novice to Expert: Excellence and Power in Clinical Nursing Practice. Prentice-Hall, Upper Saddle River, NJ.

Bosse, J.D., Nesteby, J.A., Randall, C.E., 2015. Integrating sexual minority health issues into a health assessment class. Journal of Professional Nursing: Official Journal of the American Association of Colleges of Nursing 31 (6), 498–507. https://doi.org/ 10.1016/j.profnurs. 2015.04.007.

Canzona, M.R., Ledford, C.W., Fisher, C.L., Garcia, D., Raleigh, M., Kalish, V.B., 2018. Clinician barriers to initiating sexual health conversations with breast cancer survivors: the influence of assumptions and situational constraints. Families, Systems, and Health 36 (1), 20–28. https://doi.org/10.1037/fsh0000307.

Carabez, R., Pellegrini, M., Mankovitz, A., Eliason, M., Ciano, M., Scott, M., 2015. Never in all my years...” Nurses education about LGBT health. J. Prof. Nurs 31 (4), 323–329. https://doi.org/10.1016/j.profnurs.2015.01.003.

Commission on Collegiate Nursing Education, 2013. Standards for accreditation of baccalaureate and graduate nursing programs. Retrieved from. https://www.aacnn ursing.org/CCNE-Accreditation/Resource-Documents/CCNE-Standards-Pr ofessional-Nursing-Guidelines.

Commission on Collegiate Nursing Education, 2018. Standards for accreditation of baccalaureate and graduate nursing programs. Retrieved from. https://www.aacnn ursing.org/CCNE-Accreditation/Resource-Documents/CCNE-Standards-Pr ofessional-Nursing-Guidelines.

Dias, H.M.d.S., Sim-Sim, M.M.S.F., 2015. Validation of the sexuality attitudes and beliefs survey (SABS) for the Portuguese population. [Validação para a população Portuguesa do sexuality attitudes and beliefs survey (SABS)]. Acta Paulista de Enfermagem 25 (3), 196. Retrieved from. https://www.proquest.com/.

Das, A., 2017. Dyadic configurations of sexual problems among older U.S. adults: A national study. J. of Sex and Marital Therapy 43 (5), 4791208128–4791208495. https://doi.org/10.1080/0092623X.2016.

Echezona-Johnson, C., 2017. Evaluation of lesbian, gay, bisexual, and transgender knowledge in basic obstetrical nursing education. Nurs. Educ. Perspect. 38 (3), 138–142. https://doi.org/10.1097/01.NEP.0000000000000136.

Ellis, D.M., 2016. The role of nurse educators’ self-perception and beliefs in the use of learner-centered teaching in the classroom. Nurse Education in Practice 16 (1), 66–70. https://doi.org/10.1016/j.nepr.2015.08.011.

Fennell, R., Grant, B., 2019. Discussing sexuality in health care: a systematic review. J. Clin. Nurs. 28, 3065–3076. https://doi.org/10.1111/jocn.14900.

García-Vázquez, J., Ordóñez, A.L., Arias-Magadán, S., 2014. Educación sexual: Opiniones y propuestas del alumnado y profesorado de los institutos de secundaria de Asturias, España. [Sexual education: Opinions and proposals regarding students and teachers of secondary education institutes in Asturias, Spain]. Global Health Promotion 21 (4), 74. https://doi.org/10.1177/1757975914528727.

Garcia, R.Z., Lisboa, C.d.S., 2012. Nursing consultation concerning sexuality: An instrument for women’s nursing healthcare at the level of primary healthcare. Texto and Contexto Enfermagem 21 (3), 708–716. https://doi.org/10.1590/S0104- 07072012000300028.

Huang, C., Lee, S., Yen, W., Li, C., Tsai, L., 2013a. Nursing intervention on sexual health: a multilevel behavioral survey of senior nursing students in clinical practice. Int. J. Sex. Health 25 (4), 273–280. https://doi.org/10.1080/19317611.2013.815298.

Huang, C., Tsai, L., Tseng, T., Li, C., Lee, S., 2013b. Nursing students’ attitudes towards provision of sexual health care in clinical practice. J. Clin. Nurs. 22 (23/24), 3577–3586. https://doi.org/10.1111/jocn.12204.

Levesque, P., 2015. Meeting the needs of the transgender nursing student. Nurse Educ. 40 (5), 244–248. https://doi.org/10.1097/NNE.0000000000000163.

Lim, F., Johnson, M., Eliason, M., 2015. A national survey of faculty knowledge, experience, and readiness for teaching lesbian, gay, bisexual, and transgender health in baccalaureate nursing programs. Nurs. Educ. Perspect. 36 (3), 144–152. https:// doi.org/10.5480/14-1355.

Long, C.G., Krawczyck, K.M., Kenworthy, N.E., 2011. Assessing the sexual knowledge of women in secure settings: the development of a new screening measure. Br. J. Learn. Disabil. 41, 51–65. https://doi.org/10.1111/j.1468-3156.2011.00722.x.

Magnan, M., Norris, D.M., 2008. Nursing students’ perceptions of barriers to addressing patient sexuality concerns. J. Nurs. Educ. 47 (6), 260–268. https://doi.org/10.3928/ 01484834-20080601-06.

Magnan, M., Reynolds, K., 2006. Barriers to addressing patient sexuality concerns across five areas of specialization. Clin. Nurse Spec. 20 (6), 285–292. https://doi.org/ 10.1097/00002800-200611000-00009.

Magnan, M.A., Reynolds, K.E., Galvin, E.A., 2006. Barriers to addressing patient sexuality in nursing practice. Medsurg Nurs. 14, 282–289. https://doi.org/10.1097/ 00002800-200611000-00009.

McCabe, J., Holmes, D., 2014. Nursing, sexual health and youth with disabilities: a critical ethnography. J. Adv. Nurs. 70 (1), 77–86. https://doi.org/10.1111/ jan.12167.

National Council Licensure Examination Online, 2020. Topics. Retrieved from. https: //www.nclexonline.com/topics/.

National League of Nursing, 2018. Nurse educator demographics: 2014–2015. Retrieved from. http://www.nln.org/newsroom/nursing-education-statistics/nurse-educator-d emographics.

Pituch, K.A., Stevens, J.P., 2016. Applied Multivariate Statistics for the Social Sciences: Analysis with SAS and IBM’s SPSS, 6th ed. Taylor & Francis, New York, NY.

Quinn, C., Happell, B., Welch, A., 2013a. The 5-As framework for including sexual concerns in mental health nursing practice. Issues in Mental. Health Nursing 34, 17–24. https://doi.org/10.3109/01612840.2012.711433.

Quinn, C., Happell, B., Welch, A., 2013b. Talking about sex as part of our role: making and sustaining practice change. Int. J. Ment. Health Nurs. 22, 231–240. https://doi. org/10.1111/j.1447-0349.2012.00865.x.

Reynolds, K., Magnan, M., 2005. Nursing attitudes and beliefs toward human sexuality: collaborative research promoting evidence-based practice. Clin. Nurse Spec. 19 (5), 255–259. https://doi.org/10.1097/00002800-200509000-00009.

Rowbotham, M., Owen, R.M., 2015. The effect of clinical nursing instructors on student self-efficacy. Nurse Educ. Pract. 15 (6), 561–566. https://doi.org/10.1016/j. nepr.2015. 09.008.

Santos André, F.D., Maria, V.L.R., 2014. Sexuality of postinfarction patients: diagnosis, results and nursing intervention. J. Clin. Nurs. 23 (15/16), 2101–2109. https://doi. org/10.1111/jocn.12345.

Saunamäki, N., Andersson, M., Engström, M., 2010. Discussing sexuality with patients: nurses’ attitudes and beliefs. J. Adv. Nurs. 66 (6), 1308–1316. https://doi.org/ 10.1111/j.1365-2648.2010.05260.

Sirota, T., 2013. Attitudes among nurse educators toward homosexuality. J. Nurs. Educ. 52 (4), 219–227. https://doi.org/10.3928/01484834-20130320-01.

Steinke, E.E., Barnason, S., Mosack, V., Hill, T.J., 2016. Baccalaureate nursing students’ application of social-cognitive sexual counseling for cardiovascular patients: a web- based educational intervention. Nurse Educ. Today 44, 43–50. https://doi.org/ 10.1016/j.nedt. 2016.05.015.

Stroope, S., Mcfarland, M.J., Uecker, J.E., 2015. Marital characteristics and the sexual relationships of U.S. older adults: an analysis of national social life, health, and aging project data. Arch. Sex. Behav. 44 (1), 233–247. https://doi.org/10.1007/s10508- 014-0379-y.

Sung, S., Lin, Y., 2013. Effectiveness of the sexual healthcare education in nursing students’ knowledge, attitude, and self-efficacy on sexual healthcare. Nurse Educ. Today 33 (5), 498. https://doi.org/10.1016/j.nedt.2012.06.019.

Sung, S., Huang, H., Lin, M., 2015. Relationship between the knowledge, attitude, and self-efficacy on sexual health care for nursing students. J. Prof. Nurs. 31 (3), 254. https://doi.org/10.1016/j.profnurs.2014.11.001.

Tavakol, M., Dennick, R., 2011. Making sense of Cronbach’s alpha. Int. J. Med. Educ. 2, 53–55. https://doi.org/10.5116/ijme.4dfb.8dfd.

Tsai, L., Huang, C., Shih, F., Li, C., Lai, T., 2014. Undergraduate nursing education to address patients’ concerns about sexual health: the perceived learning needs of senior traditional four-year and two-year recurrent education (RN-BSN) undergraduate nursing students in Taiwan. Nagoya J. Med. Sci. 76 (3–4), 273–284. Retrieved from. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4345689/.

Walker, S.H., Davis, G., 2014. Knowledge and reported confidence of final year midwifery students regarding giving advice on contraception and sexual health. Midwifery 30 (5), e169–e176. https://doi.org/10.1016/j.midw.2014.02.002.

Yingling, C.T., Cotler, K., Hughes, T.L., 2017. Building nurses’ capacity to address health inequities: incorporating lesbian, gay, bisexual and transgender health content in a family nurse practitioner programme. J. Clin. Nurs. 26, 2807–2817. https://doi.org/ 10.1111/jocn.13707.

World Health Organization (WHO), 2006. Defining sexual health: Report of a technical consultation on sexual health 28–31 january 2002, Geneva. Retrieved from. http ://www.who.int/reproductivehealth/publications/sexual_health/defining_sexual _health.pdf.

C.P. Benton