Nursing Students’ Comfort with Lesbian, Gay, Bisexual, and Transgender (LGBT) Patient Care: The Role of Self-efficacy and Socio-demographic Factors

Jeresse Jeah R. Recaforte, Jovel D. Chiva, Chelsea Coleen T. Cayabyab, Glayza H. Clarito, Brylle Isidore B. Rapio, Kirk Russell O. Rojo, Ryan Michael F. Oducado*

College of Nursing, West Visayas State University, Iloilo City, 5000 Iloilo, Philippines

*Corresponding Author’s Email: rmoducado@wvsu.edu.ph

ABSTRACT

Background: Providing high-quality and culturally competent care to Lesbian, Gay, Bisexual, and Transgender (LGBT) patients is essential in nursing. However, there are still reports of challenges in feeling comfortable and confident in delivering care to this population. Understanding the factors influencing nursing students' comfort levels in caring for LGBT patients, such as self-efficacy and socio-demographic variables, is crucial for nursing education and practice. This study assessed the association of socio-demographic factors and self-efficacy with senior nursing students' comfort levels when providing care to LGBT patients. Methods: This study employed a quantitative, descriptive-correlational, cross-sectional survey design. A total of 179 out of 186 nursing students from two selected universities in the Philippines participated in the online survey conducted between April and May 2023. Data were collected using a self-administered questionnaire comprising three sections. Descriptive statistics, along with the Mann-Whitney U test, Spearman’s rho, and Kruskal-Wallis test, were used for data analysis. Results: The study demonstrated that senior nursing students were highly comfortable caring for LGBT patients. There were significant differences in the comfort levels based on the type of university, gender identity, sexual orientation, religiosity, and presence of LGBT family member/s. There was a significant, moderately positive correlation between the self-efficacy and comfort levels of senior nursing students caring for LGBT patients. Conclusion: Nursing education programs should actively enhance students' self-efficacy in providing care to LGBT patients, fostering greater comfort and competence in delivering culturally responsive and inclusive healthcare.

Keywords: Cross-Sectional Studies; Nursing, Self-Efficacy; Sexual and Gender Minorities; Students

INTRODUCTION

Societal attitudes toward the social acceptance of the lesbian, gay, bisexual, and transgender (LGBT) community have demonstrated both advancement and challenges (Galanza et al., 2024). Nevertheless, despite significant strides and notable advancements in laws and shifting attitudes toward greater inclusivity, discrimination against the LGBT community has persisted and remains widespread (Centre for American Progress, 2020; Arora, Bhujang & Sivakami, 2022).

In the Philippines, the situation offers a complex narrative. The country is often viewed as more LGBT-friendly compared to its Southeast Asian neighbours, yet gender and sexual minority Filipinos continue to face stigma, prejudice, and discrimination within society, including LGBT staff nurses (Galanza et al., 2024; Manalastas & Torre, 2016; Philippine Psychological Association of the Philippines, 2020).

Notwithstanding government efforts to address these issues, including laws designed to combat discrimination, significant challenges persist, particularly in healthcare access and equity. This is particularly concerning as LGBT individuals face a disproportionate burden of physical and psychological health challenges (Butial et al., 2024). Unfortunately, many LGBT community members avoid seeking medical care due to fears of discrimination in healthcare settings (Falck & Bränström, 2023; Kcomt et al., 2020). Moreover, the National Institute on Minority Health and Health Disparities identified the LGBT community as a “health disparity population” since those who identify as such have less access to health care (Gillespie, 2020).

The Philippine Commission on Women sees gender mainstreaming as the strategy for achieving the goals of gender equality in the Philippines (Philippine Commission on Women, 2020). As a response, the Philippine Commission on Higher Education issued a Memorandum Order, which mandates the active promotion of gender and developmental initiatives. This directive can expectantly shape future professionals into gender-responsive individuals, especially those interacting with diverse people in their workplace, such as health workers and nurses. Enhancing the educational curriculum can be one approach, given that nurses play a pivotal role in delivering care at the forefront. Nursing schools may enhance or expand the contents of the curriculum to equip future nurses with the skills and knowledge to provide unbiased, culturally competent, and gender-responsive care. Particular attention should be given to undergraduate nursing students as they will enter the nursing profession very soon. Nursing students should be equipped to provide care to a wide range of patient demographics, including individuals who identify as sexual and gender minorities (Hand & Gedzyk-Nieman, 2022). However, a study found that 12.31% of nurses were uncomfortable providing care to LGBT patients; their discomfort with practicing may adversely affect patient care (Carabez et al., 2015). Another study conducted elsewhere reported that nursing students experienced discomfort when offering support to sexual minorities (Richardson, Ondracek & Anderson, 2017).

Although there have been efforts to evaluate the comfort levels of nursing students in other countries, there is a notable lack of research assessing the comfort of nursing students in the Philippines, who are expected to be influenced by the country's Gender and Development inclusion strategies. In addition, the self-efficacy of nursing students in the care of LGBT patients has not been widely explored. Many of the recent studies focused on nursing students’ knowledge and attitudes in caring for LGBT patients (Fradelos et al., 2022; Oducado, 2023; Sherman et al., 2021; Wang, Miao & You, 2022). This necessitates conducting studies on the comfort levels of the nursing students and the factors that influence them, such as self-efficacy and certain socio-demographic factors. These factors may interact in complex ways to shape efficiency levels, and the aim is to uncover potential barriers or facilitators to providing affirming nursing care to LGBT patients.

This study aimed to determine the comfort level in the care of LGBT patients among senior nursing students in Iloilo City, Philippines, and selected associated factors, such as self-efficacy and socio-demographic variables. Such a study stems from the crucial need to ensure that future healthcare providers must be equipped to deliver broad and competent care to all patients, regardless of sexual orientation or gender identity. As the healthcare landscape continues to evolve towards greater recognition of diversity and inclusivity, it becomes imperative to investigate factors that may influence nursing students' self-assurance in providing care for LGBT patients.

METHODOLOGY

Design

This study applied a quantitative, descriptive-correlational, cross-sectional survey research design.

Participants

This study selected all senior nursing students from a public university (n=155) and a private university (n=61). Of the 186 individuals invited, 179 responded and were included in the analysis, resulting in a response rate of 96.24%.

The inclusion criteria involved fourth-year nursing students who were officially enrolled in both schools during the academic year 2022–2023, whether they went to school full-time or part-time, and who had completed Related Learning Experience (RLE) or clinical duties, regardless of whether they had cared for LGBT patients or not.

Nursing students from other universities, those from different year levels, participants in the pilot survey, those on a leave of absence, and those absent on the scheduled survey date were excluded.

Instruments

The data collection process involved conduction a self-administered questionnaire with three sections developed specifically for this research.

The first section consisted of personal profile enquiries covering demographic information such as age, gender, sexual orientation, type of university, presence of LGBT family member/s, and presence of LGBT friend/s. Their self-reported level of religiosity was assessed with the question, “How would you rate your religiosity?” and was answerable by “Strong,” “Somewhat strong,” “Not very strong,” and “Do not know.”

The second part of the survey questionnaire was the LGBT Nursing Care Self-Efficacy Scale (LGBT-NCSES). LGBT-NCSES is composed of 15 statements from the studies of Bidell (2017) and Kennedy et al. (2015), adapted to better match the context of the present study.

A Likert-type scale was used to measure each statement, ranging from “1-not very well” to “5-extremely well.” Higher scores indicate higher levels of self-efficacy. The third part of the survey questionnaire was the 10-item LGBT Nursing Care Comfort Scale (LGBT-NCCS). The LGBT-NCCS is a Likert-type scale adapted from the studies of Richardson, Ondracek and Anderson (2017) and Hand and Gedzyk-Nieman (2022) to assess the comfort level in caring for LGBT individuals. A 5-point Likert-type scale was used to measure each statement, ranging from “1-strongly disagree” to “5-strongly agree”. Higher scores indicate higher levels of comfort.

Four experts specialising in gender and sexuality, each holding at least a master’s degree in health or allied health-related fields, validated the questionnaire. Reliability testing was conducted using Cronbach's Alpha of the Internal Consistency Method, scoring 0.968 for self- efficacy and 0.841 for the comfort scale.

Data Collection

Data collection was done from April to May 2023. The researchers secured permission from the Office of the Dean, the respective division Chairpersons of Senior Nursing Students, and the Ethics Review Committee from the two selected schools. After this, the researchers arranged a convenient time to conduct the survey and informed the participants about the study and their rights. On the survey day, the participants were given sufficient time to complete the self-administered questionnaire, and their responses were processed.

Data Analysis

This study used IBM Statistical Package for Social Science (SPSS) version 26.0 software. Frequency count, percentage, mean, and standard deviation were used for descriptive statistics. The mean score level was interpreted as 1.00-2.33 as "low," 2.34-3.67 as "moderate," and 3.68-5.00 as “high.” The Kolmogorov-Smirnov test revealed that the data was not normally distributed. Mann-Whitney U test (Z), Spearman’s rho, and Kruskal-Wallis (H) with Dunn’s Post Hoc test pairwise comparison were used for inferential statistics. The alpha level of significance was set at 0.05.

Ethical Consideration

This paper was approved by the Unified Research Ethics Review Committee of West Visayas State University, Philippines with reference number WVSU.URERC-2022.CONS_001 on 29th March, 2023. The respondents' informed consents were obtained before the data were collected.

RESULTS

Table 1 presents socio-demographic data from the 179 participants analysed in this study. The majority of respondents hailed from the public university (68.2%). Their average age was 22 years old, with a predominant representation of females (72.1%), cisgender women (62.0%), and heterosexual individuals (70.9%). Additionally, a significant portion expressed somewhat strong religiosity (40.2%). Most participants reported having LGBT friends (97.2%) and LGBT family members (51.4%). Furthermore, the average self-efficacy score among nursing students was 4.13 (SD=0.64).

Table 1: Socio-Demographic Characteristics and Self-Efficacy Level of Nursing Students

Table 2 shows that a large proportion (77.7%) of nursing students were highly comfortable caring for LGBT patients, with a mean score of 4.08 (SD=0.64).

Table 2: Descriptives of Comfort Levels

Table 3 displays the bivariate analysis of factors associated with comfort levels. Statistical analysis revealed that there were significant differences in the comfort level based on the type of university (Z=4.293, p=0.000), gender identity (Z=10.435, p=0.015), sexual orientation (H=10.549, p=0.032), religiosity (H=8.252, p=0.041), and presence of LGBT family member/s (Z=2.633). In addition, Table 3 shows a moderate degree of significant positive correlation (rho=0.651, p=0.000) between senior nursing students' self-efficacy and comfort levels in caring for LGBT patients.

Table 3: Bivariate Analysis of Factors Associated with Comfort Level

NOTE: aMann-Whitney U, bKruskal-Wallis, cSpearman rho, *p<0.05

DISCUSSION

This study assessed the self-efficacy and socio-demographic factors associated with senior nursing students’ comfort with LGBT patient care. In this study, the majority of nursing students were highly comfortable caring for LGBT patients. A prior study in the Philippines evaluating nursing students' attitudes wherein comfort was a domain similarly revealed positive attitudes among nursing students toward LGBT patients (Oducado, 2023). The high comfort levels of Filipino nursing students may be attributed to the Philippines being recognised as one of the more LGBT-friendly countries in Southeast Asia (Manalastas & Torre, 2016). Filipino culture also emphasises "pakikisama" or "pakikipagkapwa-tao," a sense of mutual respect for or humanising others (Saito, 2010). This cultural trait can foster empathy and cultural sensitivity, potentially enhancing students' comfort in caring for LGBT patients when nurtured.

Additionally, the country has proposed legislation to protect sexual minority individuals from discrimination (Eng & Yang, 2020). Such legislation may foster a more inclusive and supportive environment, helping nursing students feel more comfortable providing care without fear of backlash. Besides, nursing students are trained to adhere to professional and ethical standards guided by the code of ethics for nurses that emphasises patient advocacy, respect, dignity, and non-judgemental care for all patients, regardless of their sexual orientation or gender identity (American Nurses Association, 2001; Professional Regulation Commission Board of Nursing, 2004). This commitment to professionalism and ethical practice can contribute to students' comfort in caring for LGBT patients.

However, a study conducted elsewhere showed that while graduating nursing students expressed adequate comfort in delivering care to sexual minority patients, they did not attribute this comfort to their academic nursing education (Hand & Gedzyk-Nieman, 2022). Factors other than academic nursing education may contribute to their comfort in delivering such care that must be explored. It is also noteworthy that, despite many nursing students being highly comfortable with this study, some were still only moderately comfortable. A study conducted abroad also disclosed that nursing students felt discomfort in providing support to LGBQ adolescents (Richardson, Ondracek & Anderson, 2017).

The imposition of norms favouring cisgender heterosexuality, along with stereotypes and prejudices against the LGBT community, poses challenges and difficulties in delivering tailored care to individuals in this population (Medina-Martínez et al., 2021). This study shows how important it is to create targeted interventions or educational programs to help nursing students who are having different levels of comfort when caring for LGBT patients. This will improve their cultural competence and sensitivity towards diverse patient populations and make it easier for them to provide inclusive and affirming care to sexual and gender minority groups. Additionally, incorporating sexual minorities' healthcare needs into the nursing curriculum could be considered (Alibudbud, 2024).

Self-efficacy aids nursing students in feeling capable of fulfilling the demands of entry-level clinical positions and embracing this demanding role, serving as a favourable predictor of nursing students' performance in clinical practice (Alavi, 2014). This study found a high level of self-efficacy in caring for LGBT patients among nursing students. Furthermore, the current study discovered a moderate positive correlation between senior nursing students' self-efficacy and comfort levels when caring for LGBT patients. This correlation suggests that as nursing students’ self-efficacy increases, so does their comfort level. Essentially, higher self-efficacy tends to correspond with greater comfort in providing care for LGBT patients, while lower self- efficacy correlates with reduced comfort levels in this aspect of nursing practice. High self- efficacy instills confidence and enables individuals to easily navigate unfamiliar or difficult circumstances, as they trust their capacity to handle challenges successfully (Karlen et al., 2019; Shorey & Lopez, 2021). Conversely, low self-efficacy may lead to hesitancy and diminished confidence, resulting in decreased performance (Shorey & Lopez, 2021). A study by Pedrazza et al. (2015) among nurses evaluating comfort and self-efficacy constructs supports this study finding. Moreover, this finding of the study has important implications for nursing education, particularly in bolstering the self-efficacy of nursing students. By enhancing students' beliefs in their abilities to provide competent care to diverse patient populations, including LGBT individuals, nursing programs can potentially improve students' comfort levels in this aspect of nursing practice.

This study also discovered significant differences in comfort based on socio-demographic variables. Firstly, a significant difference in comfort level was found depending on the type of university. Public university students had significantly higher comfort levels than private university students. Public universities have a more diverse demographic because they are more accessible to most of the population. In contrast, some private universities have more barriers to admission, such as financial and religious affiliation (Franklin, 2013). Diversity in cultural backgrounds can play a valuable role in addressing the needs of an increasingly varied population (Muronda, 2016). The diversity within the student population may provide nursing students with exposure and interaction with sexual and minority groups, potentially fostering their comfort levels in interacting with such communities. Increased interaction with LGBT individuals may foster a sense of comfort (McNeill, Mc Ateer & Jepson, 2023). It is, therefore, not surprising to note that students in this study with LGBT family members were significantly more comfortable in caring for LGBT individuals than those without LGBT family members. This may be due to the familiarity and understanding that comes from having LGBT family members. Individuals who interacted with or who had contact with lesbian women and gay men tended to hold more favourable attitudes toward gay males and lesbian females (Unlu,Beduk & Duyan, 2016). A prior study also disclosed that nursing students who knew someone identifying as LGBTQ+ showed significantly higher comfort levels than those who did not (Hand & Gedzyk-Nieman, 2022).

This study found a significant difference in comfort according to the degree of religiosity. The post hoc test revealed a significant difference when comparing those with strong to not very strong religiosity, with those with not very strong religiosity being more comfortable caring for LGBT patients. A study also found that healthcare students with higher religiosity and less exposure to diverse religious views on sex expressed less favourable attitudes towards LGBT individuals (Wilson et al., 2014). It must be considered that Roman Catholicism is the dominant religion in the country. Pew Research Centre surveys conducted in recent years indicate that Catholics worldwide exhibit varying levels of support for same-sex marriage and acceptance of homosexuality in general (Diamant, 2020). However, religious affiliation and religiosity, in general, create negative attitudes toward LGBT, especially among Christian individuals with a literal interpretation of the Bible (Westwood, 2022; Worthen, Lingiardi & Caristo, 2017). Moreover, individuals may experience moral and sexual distress when confronting or considering a new sexual identity, leading to internalised homophobia (Rodríguez & Murtagh, 2022).

Finally, significant differences were observed in the comfort level of nursing students based on their gender identity and sexual orientation. Post Hoc analysis of comfort level and gender identity revealed that there was a significant difference between those who identify themselves in the other gender spectrum, which includes transgender, gender fluid, gender nonbinary, genderqueer, and gender fluid, and those who prefer not to say. Cisgender men and women were significantly more comfortable compared to the respondents who answered that they preferred not to say. As for sexual orientation, Post Hoc comparison revealed that those who belonged to other sexual orientations, which include pansexual and asexual, were more comfortable than those who preferred not to say so. It was also noted that the other sexual orientation category had significantly higher comfort levels compared to heterosexuals, and homosexuals were significantly more comfortable than heterosexuals. The gender identities of cisgender men and women may be relatively more stable (Orenstein & Lewis, 2022), making them more comfortable in social situations and taking the initiative to engage with other. Conversely, nursing students who choose to remain silent may harbour uncertainties about their gender identity and sexual orientation, potentially leading to internalised homophobia (Lee et al., 2019). This can cause introvert reactions and discomfort when interacting with open LGBT members. Openly identifying individuals may have overcome questioning and come to terms with their identities, providing a sense of shared identity that facilitates positive attitudes and relationship building, unlike those who prefer not to say. Sexual orientation was found to be associated with attitudes towards LGBT in earlier research among students (Wilson et al., 2014).

Limitation

This study focused on comfort levels in caring for LGBT patients, excluding other identities within the spectrum. The scope was limited to senior nursing students from two schools in the Philippines, restricting its relevance. Despite these limitations, the study provides valuable insights into LGBT patient care and highlights the need for further research across diverse nursing populations. Future studies must explore broader gender identities, employ longitudinal designs, and integrate qualitative approaches to deepen understanding and improve inclusive nursing education.

CONCLUSION

The study emphasises the crucial role of self-efficacy in shaping students' comfort levels, with higher levels of self-efficacy correlating with increased comfort levels. Additionally, factors such as gender identity, sexual orientation, university type, religiosity, and the presence of LGBT family members significantly influence nursing students' comfort levels in caring for LGBT patients. By learning about these factors, the teaching process will improve and will help nursing students become better prepared to treat LGBT people with kindness, respect, and care, which will promote health equity and lead to better patient outcomes in this group. Also, healthcare institutions can better prepare future nurses to handle the challenges of providing holistic care to diverse patient populations by addressing any differences or discomfort early in nursing education. This will help make healthcare more beneficial and supportive for everyone. Nursing schools should continuously build the confidence of nursing students in caring for LGBT patients, promoting comfort in delivering nursing care that meets the cultural needs of the LGBT community.

This study provides a valuable foundation for understanding nursing students’ comfort in caring for LGBT patients. To build on these findings, future research should expand the scope by including larger, more diverse samples across national or multicountry settings and different academic year levels. Further exploration of comfort levels among underrepresented subgroups, such as asexual, pansexual, or non-binary individuals, would enhance inclusivity. Additionally, investigating factors influencing self-efficacy in LGBT patient care presents a promising direction. Strengthening the psychometric properties of the LGBT Nursing Clinical Self-Efficacy Scale would also enhance its reliability and applicability in future studies.

Conflict of Interest

The authors declare that they have no competing interests.

ACKNOWLEDGEMENT

The authors would like to thank the participants and Deans of the schools included in the study.

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