Nursing Students’ Attitudes Toward Lesbian, Gay, Bisexual,

and Transgender Persons: An Integrative Review

Fidelindo A. Lim and Richard Hsu

Abstract
AIM The aim of this study was to critically appraise and synthesize findings from studies on the attitudes of nursing students
toward lesbian, gay, bisexual, and transgender (LGBT) persons.
BACKGROUND There is paucity of research to assess the attitudes of nursing students toward LGBT persons.
METHOD An electronic search was conducted using PubMed, Medline, Web of Science, EbscoHost, PsycInfo, and the
Cumulative Index to Nursing and Allied Health Literature using medical subject headings terminologies. Search terms used
included gay, lesbian, transgender, bisexual, LGBT, nursing students, baccalaureate nursing, undergraduate nursing,
homophobia, homosexuality, sexual minority, attitudes, discrimination, and prejudice.
RESULTS Less than 50 percent of the studies (5 out of 12) suggested positively leaning attitudes of nursing students toward
LGBT persons; six studies reported negative attitudes, and one study reported neutral attitudes.
CONCLUSION There are some indications that student attitudes may be moving toward positively leaning. Studies published
before 2000 reported a preponderance of negative attitudes.
KEY WORDS Nursing Students – Attitudes – LGBT – Homosexuality – Health Disparities

H
ealth inequity continues to affect the lesbian, gay, bisexual,
and transgender (LGBT) population. However, in the last sev-
eral years, the health care needs of this population have re-
ceived significant attention from policy makers. The Institute of
Medicine (IOM), Healthy People 2020, and the Agency for Healthcare
Research and Quality have all highlighted best practices in dealing
with the unique health issues of LGBT persons.
Health inequity is closely tied to sexual and social stigma (IOM,
2011), with sexual stigma defined as the negative regard, inferior sta-
tus, and relative powerlessness that society collectively accords to
any nonheterosexual behavior, identity, relationship, or community
(Herek, 2007). The heteronormative construct of society (Röndahl,
2009) has created social barriers resulting in legal discrimination in
access to health care, lack of appropriate social programs for LGBT
persons, and a shortage of culturally competent health care pro-
viders and educators who are knowledgeable in LGBT health
(HealthyPeople.gov, 2016).
Despite the increasing social acceptance of homosexuality (Pew
Research Center for People and the Press, 2011), the evidence sug-
gests that LGBT persons have significant health disparities as com-
pared to heterosexuals that are slowly gaining exploration from
researchers (Lim, Brown, & Kim, 2014). The challenge for nursing ed-
ucation is to synthesize the growing evidence of LGBT health issues
into meaningful curricular integration that will result in positive health
outcomes for patients, for their families, and for society.
About the Authors Fidelindo A. Lim, DNP, CCRN, is a clinical assistant
professor at College of Nursing, New York University. Richard Hsu, BS,
is a graduate of New York University’s Global Institute of Public Health
and currently works for AmeriCorps.
Copyright © 2016 National League for Nursing
doi: 10.1097/01.NEP.0000000000000004
BACKGROUND AND SIGNIFICANCE
At the height of the AIDS (acquired immune deficiency syndrome) ep-
idemic, studies demonstrated high levels of homophobia, fear of con-
tagion, avoidance, and stigmatization of LGBT person among nurses
(Forrester & Murphy, 1992; Meisenhelder, 1994). Analysis of such
studies indicates that it is difficult to separate attitudes about
AIDS from attitudes about LGBT populations (Eliason, Dibble, &
DeJoseph, 2010). Although the last decade has seen a growing ac-
ceptance of LGBT identities and expressions, recent metasyntheses
indicate that negative attitudes toward sexual minorities persist
among nurses (Dorsen, 2012; Eliason et al., 2010). These findings
may be an indication of the lack of meaningful inclusion of LGBT
health in nursing education across all levels (Sirota, 2013) and the lim-
ited exposure to LGBT persons during clinical practice in prelicensure
education (Lim, Brown, & Jones, 2013).
The call to integrate LGBT health into the nursing curriculum has
been the subject of discussion among nurse experts in LGBT health
(Chinn, 2013; Eliason et al., 2010; Keepnews, 2011). A survey to ap-
praise LGBT health knowledge, experience, and readiness to teach
LGBT health among faculty in baccalaureate nursing programs (n =
1,231) revealed that the median time devoted to teaching LGBT
health was 2.12 hours (Lim, Johnson, & Eliason, 2015). Knowledge,
experience, and readiness for teaching LGBT health among faculty
were limited. However, LGBT faculty reported greater awareness,
knowledge, and readiness compared with heterosexual nursing fac-
ulty (Lim et al., 2015).
Although various studies explored sexual attitudes among nurs-
ing students and other health professions students (Papaharitou
et al., 2008), there is a paucity of research to assess the attitude of
nursing students toward LGBT persons. Most studies included in this
review are several years old; therefore, there is a need to reevaluate
their relevance, particularly because social attitude changes over
time. On the basis of the notion that students with negative attitudes

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may be less likely to provide patient-centered care or advocate
for vulnerable populations (Chapman, Watkins, Zappia, Nicol, &
Shields, 2012), understanding health provider attitudes remains
vital in addressing the health care inequities that affect the
LGBT population.
CONTEXT FOR UNDERSTANDING STUDENT
ATTITUDES
Real or perceived LGBT phobia among nursing students may have a
lasting impact on their professional practice. Negative attitudes of
health workers have been known to affect service utilization by sex-
ual minorities and the provision of patient-centered care (U.S.
Department of Health and Human Services, Agency for Healthcare
Research and Quality, 2012). As with most health care professions,
it can be proposed that nursing students enter the profession with
a degree of altruism to practice the idealized standards of care (The
Joint Commission, 2008).
The historical underpinnings of nursing are largely based on
Christian values exemplified by the example of Florence Nightingale.
This notion has rendered a durable impact on the attitudes of those
joining the profession. As a result, some students “may struggle to
reconcile their personal attitudes and beliefs about LGBT persons
with their professional responsibility to provide care” (Dorsen, 2012,
p. 20).
Providing patient-centered care and evidence-based practice
are among the core ideals in the education of health professionals
(IOM, 2003). To guide curricular programming, an informed under-
standing of educational gaps (instructional and experiential) needs
to take place. The aim of this integrative review is to critically analyze
and synthesize extant information and knowledge regarding nursing
students’ attitudes toward LGBT persons.
METHOD AND LITERATURE SEARCH STRATEGY
Critical appraisal of the studies in this review used the guidelines for
integrative reviews described by Whittemore and Knafl (2005). In
nursing science, integrative reviews play an important role in
evidence-based practice. This form of review allows for broad ap-
praisal and simultaneous inclusion of experimental and nonexperi-
mental studies in order to enhance the depth of analysis of a
phenomenon of interest (Whittemore & Knafl, 2005).
An electronic search was conducted using PubMed, Medline,
Web of Science, EbscoHost, Google Scholar, PsycInfo, and the Cu-
mulative Index to Nursing and Allied Health Literature using medical
subject headings terminologies. Search terms used included gay,
lesbian, transgender, bisexual, LGBT, GLBT, nursing students, bac-
calaureate nursing, undergraduate nursing, homophobia, homo-
sexuality, sexual minority, attitudes, discrimination, and prejudice.
Various combinations of the search terms were matched to broaden
coverage of the body of literature. For inclusion in the present re-
view, studies had to be published in English with no specified time
frame or geographic location. All studies involving prelicensure nurs-
ing students as participants were included for appraisal. Qualita-
tive, quantitative, and mixed-methods studies that met the criteria
were included.
The following exclusion criteria were used to sort through the
positive search results: unpublished manuscripts, dissertations, the-
ses, and abstracts; articles pertaining to graduate nurses and staff
nurses; and studies exclusively on students’ attitudes toward AIDS.
The reason for this latter exclusion criterion is that in these studies,
Nursing Education Perspectives
Copyright © 2016 National League for Nursing. Unauthorized reproduction of this article is prohibited.
Nursing Student Attitudes Toward LGBT
“it is difficult to disentangle attitudes about AIDS from attitudes about
homosexuality” (Eliason, 1996, p. 127).
Search Results
A total of 211 articles from the various databases were initially consid-
ered for this review as identified by their title. From this result, 53 ab-
stracts (one found through hand review) were evaluated. After
reviewing the full texts, 33 studies were deemed ineligible for inclu-
sion. Of the remaining 20 articles, eight articles were excluded. Al-
though one study involves students and faculty, it is included in the
review because a separate tool was used to analyze scores for stu-
dent subjects.
Ancestry and descendancy searches (Polit & Beck, 2012) did
not yield any other studies meeting the inclusion criteria. The final
sample comprised 12 papers on nursing students’ attitudes toward
LGBT patients, representing nine qualitative, descriptive, and correla-
tional studies and three interventional studies (pre- and posttest).
Data Evaluation and Analysis
Table 1 displays the summary of findings. The Critical Appraisal Skills
Program was used to assess the quality of the papers (Polit & Beck,
2012). All of the studies were judged to be of sufficient quality for the
review. Noblit and Hare’s approach (Atkins et al., 2008) was used to
analyze, compare, and synthesize study findings. A systematic
method of extraction was conducted to analyze salient findings and
patterns.
RESULTS
The earliest published paper is from 1981. The acronym LGBT, more
commonly used in current discussions, does not appear in this arti-
cle. All studies utilized a descriptive design to elicit nursing students’
attitudes toward LGBT.
The general attitude from studies published before 2000 sug-
gested that attitudes toward LGBT tended to be negative or very
negative. In one study that reported a positively leaning outcome,
the authors interpreted this as a sign of neutrality, considered as
a “subtle form of discrimination…more about what is not said
than overt actions and behavior” (Dinkel, Patzel, McGuire, Rolfs, &
Purcell, 2007, p. 9). Some studies equated individual or population
instrument mean scores to overall levels of students’ attitudes toward
LGBT persons, whereas others simply reported descriptive frequen-
cies, with a discussion on their meaning and implications. This pat-
tern has been similarly noted in an extensive review of staff nurses’
attitudes toward LGBT (Dorsen, 2012).
Of the 12 papers reviewed, two used the same tool (Index of At-
titudes Toward Homosexuals, also referred to as Index of Homopho-
bia), and another two used the Attitudes Toward Lesbians and Gay
Men (ATLG) Scale. All the others used different instruments in combi-
nation or developed their own tools (e.g., survey questionnaire).
The earliest paper reviewed used an experimental design. The
Survey of Attitudes Toward Deviance-Homosexuality Scale was
used to assess participants’ attitudes before and after a two-hour
workshop on homosexuality (Anderson, 1981). Because the Survey
of Attitudes Toward Deviance-Homosexuality Scale applies only to
male homosexuality, attitudes toward lesbians, bisexuals, and trans-
gender cannot be discerned. The tool’s validity was not mentioned,
but the author noted a reliability coefficient of .94 based on a test-
retest of the control group. Posttest scores revealed a 35-point
change in the positive direction (p < .001). However, attitudes relating
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Lim and Hsu

Table 1: Summary of Findings of Studies of Student Nurses’ Attitudes Toward LGBT Persons

Summary of Findings/
Author/Year Purpose Design Setting/Sample Limitations

Anderson To examine the attitudes Partially randomized, University (Midwest, USA) A stable, more positive attitude
(1981) of female nursing experimental, – 64 female BSN oward homosexuality after a
students toward correlational students two-hour workshop (p < .001).
homosexuality and Attitudes relating to morality
the effects of a workshop and social distance were
on these attitudes unchanged.
Limitations: Convenience
sample. Uneven sampling
between control/experimental
groups. No male nursing
students included. Self-selecting
bias by control group
participants.

Eliason & To identify students’ Descriptive University (Midwest, USA) Half the subjects indicated that
Randall (1991) attitudes toward lesbians correlational; – 120 female BSN lesbian lifestyle is not acceptable;
and assess correlation questionnaire-based students (all levels) 15% that there should be a law
with students’ age, survey against lesbian sexual behavior;
sex-role identity, 28% that lesbians are high-risk
familiarity with lesbian group for AIDS. No demographic
lifestyles variables were related to
lesbian phobia.
Limitations: Convenience
sample. No p values were
offered on the results. Male
students were excluded from the
study; majority of subjects
(94%) were Caucasian with 76%
middle class/6% upper class.

Eliason (1998) To examine racial Descriptive; University (Midwest, USA) Negative attitudes toward
awareness and attitudes questionnaire-based – 116 White, heterosexual LGBT persons and feeling
toward sexual survey BSN students “uncomfortable” working with
minorities sexual minorities; higher level of
comfort with racial minorities.
Limitations: Convenience
sample and omission of data
from students of color and
nonheterosexual students.

Schlub & To assess relationship Descriptive University (Midwest, USA) Low-grade nonhomophobia in
Martsolf (1999) between religious beliefs correlational; – 87 sophomore and 87 50% of subjects; 93% of
and attitudes related questionnaire-based senior BSN students subjects have orthodox Christian
to homophobia survey (total 174) beliefs; Christian religion
correlates with increased level of
homophobia. Frequency of
church attendance correlates with
homophobia (p > .01,
two-tailed).
Limitations: Convenience
sample. Of subjects, 94% were
Caucasian. Findings apply only to
Christian religion.
Continued

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Table 1: Summary of Findings of Studies of Student Nurses’ Attitudes Toward LGBT Persons, Continued
Author/Year Purpose
Stewart (1999) To asses attitudes toward
AIDS and sexual
orientation changes over
time in a 3-year
nursing program
Eliason & To assess the relationship
Raheim (2000) between students’
exposure to 14 culturally
diverse groups and their
anticipated or actual level
of comfort in working
with clients, including
LGBT persons
Rondahl et al. To assess emotions of
(2004) nursing staff and nursing
students, and possible
relations to cultural
background and gender,
toward homosexual
patients
Dinkel et al. To assess homophobia
(2007) among nursing students
and faculty
Nursing Education Perspectives
Copyright © 2016 National League for Nursing. Unauthorized reproduction of this article is prohibited.
Nursing Student Attitudes Toward LGBT
Summary of Findings/
Design Setting/Sample Limitations
Descriptive University (England)–192 Positive attitudes toward sexual
correlational; nursing students orientation and significant
questionnaire-based in all levels prejudice toward AIDS patients
survey (higher levels of blame and
responsibility).
Limitations: Convenience
sample. Comparison of attitudes
may not be valid as students
were surveyed in various stage of
the program.
Descriptive, University (Midwest, USA) Lack of knowledge and
questionnaire-based – 196 BSN students in experience working with LGBT
survey prerequisite course persons and those who are human
immunodeficiency virus-positive
correlates with feeling uncomfortable.
Of subjects, 44% would be
uncomfortable working with
lesbians; 43% with bisexuals; 42%
with human immunodeficiency
virus-positive persons (fear of
infection); and 35% with gay men.
Subjects include 78% who have
friends who are openly LGBT.
Limitations: Convenience
sample. All respondents were
Caucasian. Survey included
variables other than sexual
orientation.
Descriptive, comparative School type unknown Students expressed homophobic
design; questionnaire- (Sweden) – 79 nursing anger, homophobic guilt, and
based survey students delight. Non-Swedish respondents
expressed more homophobia;
9% of students expressed
agreement to refrain from
nursing homosexual patients if
given the option.
Limitations: Small sample size,
self-selection, and nonrandomized.
Descriptive, questionnaire- University (Midwest, USA) Low levels of homophobia noted
based survey – 126 BSN students from both faculty and students.
enrolled in clinical courses Low scores may indicate neutrality.
Limitations: Convenience sample,
investigators known to the
subjects. “Students may have
chosen to participate simply to
please the researchers.”
Continued
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Lim and Hsu

Table 1: Summary of Findings of Studies of Student Nurses’ Attitudes Toward LGBT Persons, Continued

Summary of Findings/
Author/Year Purpose Design Setting/Sample Limitations

Chapman et al. To assess medical and Descriptive, comparative; University (Western Nursing students had mean score
(2012) nursing students’ questionnaire-based Australia) – 100 third-year of 30.2 (SD = 10.8) on Attitudes
attitudes, knowledge, survey nursing students/161 Toward Lesbians and Gay Men
beliefs, and medical students who Scale (possible range 20–80;
gay-affirmative practices completed pediatric higher score = more negative
related to LGBT parents clinical placement attitude). On Gay Affirmative
seeking health care for Practice Scale, nursing students
their children scored 55 (SD = 8.6) (possible
range 15–60; higher score = more
gay affirmative actions).
Non-Caucasians had more
negative attitudes.
Limitations: Convenience sample.
Data specific to nursing students’
beliefs about LGBT parents
seeking health care for their
children were combined with
medical students’ data.

Carabez et al. To examine the effects of Descriptive correlational; University (Western USA) Nearly 40% felt unprepared to
(2015) a public health nursing pre- and postinterview – 122 BSN students provide nursing care to LGBT
course assignment on the questionnaire-based enrolled in community patients. Majority (70%) expressed
attitudes and knowledge survey health nursing course; 92% being comfortable using a
of nursing students response rate (n = 112) transgender client’s preferred
regarding LGBT pronoun. When asked if gender
health care needs identity and sexual orientation
mattered to patients, 13% said
“not at all”; 16% said “very little”;
42% said it “mattered sometimes”;
28% said it “matters a lot.”
Limitations: Small convenience
sample. Some data reported
unclear whether pre- or
postinterview.

Strong & Folse To determine if nursing Descriptive cross- University (Midwest, Majority (89%) indicated that
(2015) students’ knowledge and sectional; questionnaire- USA) – 58 BSN students attitudes of family or friends were
attitudes toward LGBT based survey (various levels) most influential on their attitudes
patient care can be about LGBT persons. More
improved after an positive attitudes were reported
educational intervention after educational intervention,
except on the item about refusal
to care for an LGBT patient.
Limitations: Small convenience
sample. Suboptimal reliability of
survey tools used.

Cornelius & To examine nursing Descriptive, questionnaire- University (Southwest, RN to BSN students reported
Carrick (2015) students’ knowledge of based survey USA) – 190 nursing more positive attitudes toward
and attitudes toward students (121 providing care to LGBT clients
providing care of LGBT undergraduate students) compared with other undergraduate
individuals and graduate students.
Limitations: Nonrandomized
selection of participants and small
sample from one university.

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to morality and social distance remained unfavorable, indicating that
enduring attitudes cannot be readily changed by a single educational
activity or may require activities other than a classroom activity
to change.
Eliason and Randall (1991) developed their own questionnaire
(test-retest reliability = .79) and used the Bem Sex Role Inventory (co-
efficient alpha = .82 to .86; Bem, 1974) to examine lesbian phobia
among 120 female nursing students. Four statements regarding so-
cial contact with lesbians were intercorrelated, suggesting an all-or-
none effect rather than a continuum. Of participants, 26 percent
(n = 32) indicated that they would not initiate social contact with les-
bians; 50 percent (n = 60) indicated a lesbian lifestyle is not accept-
able and considered lesbians to be of high risk for AIDS. This study
only explored lesbian phobia, and the enduring stereotypes of those
whom subjects considered would most likely be lesbian (e.g.,
feminists, athletes).
The Eliason and Randall (1991) findings are consistent with re-
sults from a study by Eliason (1998), which described correlates of
prejudice in nursing students. The Oklahoma Racial Attitude Scale
was used in the latter study; correlation coefficients of the Oklahoma
Racial Attitude Scale provided by the author indicated that higher so-
cial awareness in the scale meant more positive attitudes toward
LGBT persons. The survey revealed that nursing students had higher
levels of comfort and positive attitudes about people from racial mi-
norities than individuals from sexual minority groups. Male gender,
younger age, and conservative religion were all noted to be predic-
tors of low racial awareness and negative attitudes toward LGB per-
sons. Although 51 percent to 53 percent expressed that the LGB
lifestyle was against their religion, 81 percent to 86 percent agreed
that LGB persons deserve equal protection and rights. According
to the author, this pattern might be a reflection of social desirability
bias and emotional ambivalence of the participants about issues
where they have limited experiences.
Schlub and Martsolf (1999) assessed the relationship between
religious beliefs and attitudes related to homophobia using the Index
of Homophobia scale. This instrument was designed to measure
homonegativism (Ricketts & Hudson, 1980). Statistically significant
correlation was shown between Index of Homophobia scores and
the Christian Orthodoxy Scale (r = .248, p < .001), indicating that
the Christian belief system correlated with increased levels of homo-
phobia (Schlub & Martsolf, 1999). Frequency of church attendance
also correlated with homophobia (r = .332, p > .01, two-tailed). Sim-
ilar patterns were noted by Eliason (1998).
Although the Schlub and Martsolf (1999) study showed low-
grade nonhomophobia in 50 percent of subjects (n = 43), 93 percent
of participants (n = 81) had orthodox Christian beliefs. This disparity
is explained by making a distinction between intrinsic (spiritual as-
pects) and extrinsic (material needs) motivations. Those who were
intrinsically motivated tend to be less homophobic (Schlub &
Martsolf, 1999).
All of the papers reviewed were studies conducted in the United
States, except three (Chapman et al., 2012; Röndahl, Innala, &
Carlsson, 2004; Stewart, 1999). Stewart used the Prejudicial Evalua-
tion and Social Interaction Scale (PESIS) to assess attitudes of nurs-
ing students enrolled in a three-year program in the United Kingdom
toward AIDS and sexual orientation and to note changes in attitude
over time. Cronbach’s alpha was found to be .58 for the PESIS prej-
udicial evaluation scale and .88 for the PESIS social interaction scale
(Forrester & Murphy, 1992). The scale was administered to four
Nursing Education Perspectives
Copyright © 2016 National League for Nursing. Unauthorized reproduction of this article is prohibited.
Nursing Student Attitudes Toward LGBT
cohorts of nursing students who were one year apart in their educa-
tional level. Overall, the results showed that nursing students held
positive attitudes toward homosexual patients. Students were willing
to interact with patients regardless of diagnosis or sexual orientation.
However, they reported significantly greater prejudice toward per-
sons with AIDS. The results suggest that the positive attitudes of
the students may be more indicative of fairly stable personality fac-
tors than knowledge developed by education or progression in
nursing training.
Eliason and Raheim (2000) developed their own instrument to as-
sess the relationship between students’ exposure to 14 culturally di-
verse groups and their anticipated or actual level of comfort in working
with clients, including LGBT persons. Pilot testing showed a test-retest
correlation of .94; validity indicators were not mentioned. Findings indi-
cated that 35 percent to 44 percent of students (70-86 students) re-
ported that they would be uncomfortable working with LGBT clients;
42 percent (n = 82) would be uncomfortable working with human im-
munodeficiency virus-positive persons. These findings provided evi-
dence on the intractable association between LGBT persons and
AIDS that may linger to this day. Lack of experience working with
AIDS patients and LGBT persons was noted to be inversely corre-
lated with fear of contagion (Cornelius, 2006) and level of comfort in
working with these populations (Eliason & Raheim, 2000).
In a descriptive, comparative study to explore the emotions of
Swedish nursing staff and students toward caring for homosexuals,
Röndahl et al. (2004) used the author-developed Nursing Behavior
Questionnaire (Cronbach’s alpha not provided). In response to the
question, “If I had the option to choose, I would not nurse homosex-
ual patients,” 36 percent (n = 28) of nursing staff agreed to the state-
ment but only 9 percent (n = 7) of student participants agreed,
indicating a positively leaning attitude that may have been influenced
by social desirability bias.
Dinkel et al. (2007) used the Index of Attitudes Toward Homo-
sexuals (Cronbach’s alpha = .90) and the Homophobic Behavior Stu-
dents Scale (Cronbach’s alpha = .81) to assess homophobia among
students and faculty. The Homophobic Behavior Students Scale is a
10-item Likert-type scale that allows the rating of intention on five
levels from definitely false to definitely true. The tool also contains
questions about behaviors that would be seen as acting supportively
for LGBT rights. The low homophobia scores noted were attributed
by the authors to reflect neutrality and heterosexism, a subtle form
of discrimination (Dinkel et al., 2007). Personal or professional con-
tact with LGBT persons correlated with positive attitudes toward
sexual minorities, reporting a p value of < 0.5.
Another report of more positive attitudes toward gays and les-
bians was reported by Chapman et al. (2012) using the ATLG Scale
and Gay Affirmative Practice (GAP) Scale. The GAP is a 30-item scale
designed to assess practitioners' beliefs and behaviors in practice
with LGBT individuals (Cronbach’s alpha > .93; Crisp, 2006). Al-
though nursing students demonstrated high GAP scores, suggesting
support for cultural competent practice with LGBT clients, only 30.1
percent (79 combined medical and nursing students) reported that
they encouraged disclosure of possible LGBT parenting roles. Con-
sistent with findings from an earlier study by Eliason (1998), men
expressed more negative attitudes toward gay men compared with
female respondents (Chapman et al., 2012).
Two recent studies that examined nursing students’ attitudes
and perception of their knowledge of LGBT issues and cultural com-
petence provided an educational intervention and measured their
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Lim and Hsu
effects (Carabez, Pellegrini, Mankovitz, Eliason, & Dariotis, 2015;
Strong & Folse, 2015). Strong and Folse assessed students’ atti-
tudes using a modified ATLG Scale (Cronbach’s alpha = .95). In ad-
dition, the LGBT Health Care Scale, a 6-item Likert scale encouraging
a written response on perceptions of cultural competence, and the
LGBT Knowledge Questionnaire, a 15-point, true-or-false question-
naire, were also used in the study. Results that showed more positive
attitudes toward LGBT persons were reported after a 45-minute ed-
ucational intervention. Of note, 80 percent of participants in this study
(n = 88) reported having a friend who identified as LGBT (Strong &
Folse, 2015). This is important to consider based on the notion that
lack of exposure with sexual minorities correlates with feelings of dis-
comfort in working with these groups (Eliason & Raheim, 2000).
As part of a community health nursing course, Carabez et al.
(2015) conducted a two-hour presentation on LGBT health issues
and had students interview two nurses regarding LGBT policies.
The interviews were based on the four domains of LGBT health care
equality (e.g., nondiscrimination, visitation rights, employment non-
discrimination, and training in LGBT patient care) contained in the
Health Care Equality Index (Human Rights Campaign, 2014). Partic-
ipants completed a pre- and postinterview questionnaire to assess
knowledge, comfort level, and attitudes toward LGBT persons. Of
the students interviewed (n = 112), 40 percent felt unprepared to pro-
vide nursing care to LGBT clients. Although a majority, 70 percent, re-
ported being comfortable using a transgender’s preferred pronoun,
only 28 percent reported that gender identity and sexual orientation
matter a lot to the patient and family. It is not specified if these results
reflected findings before or after the two-hour presentation on LGBT
health or before or after the students interviewed the staff nurses.
Using the Nursing Students’ Knowledge and Attitudes of LGBT
Health Concerns survey tool (Cronbach’s alpha = .77), Cornelius
and Carrick (2015) reported that RN to BSN students (n = 11)
expressed more positive attitudes toward caring for LGBT clients
compared with traditional undergraduate and graduate students.
The authors also reported a significant relationship between students’
knowledge of LGBT health issues and their comfort level in caring for
LGBT clients (p = .042). In contrast to Eliason’s early findings (1998),
Cornelius and Carrick reported that religion was not significantly related
to students’ attitudes.
In summary, less than 50 percent of the studies (5 of 12) sug-
gested positively leaning attitudes of nursing students toward LGBT
persons; six studies reported negative attitudes, and one study re-
ported neutral attitudes. One study indicated cognitive and emotional
dissonance, reflecting socially desirable thoughts but expressing
negative emotional attitudes toward sexual minorities.
DETERMINANTS OF NEGATIVE ATTITUDES
For this present review, the most commonly examined variables were
age, gender, race, degree of religiosity, education level, personal or
professional contact with LGBT persons, and fear of AIDS. Physical
stereotypes of lesbian appearance and lifestyle (Eliason & Randall,
1991), conservative religion (Dinkel et al., 2007; Eliason, 1998),
non-Caucasian ethnicity (Chapman et al., 2012), limited experience
with diverse populations (Eliason & Raheim, 2000), and extrinsic
Christian belief (Schlub & Martsolf, 1999) were noted to be predictors
of negative attitudes. Low racial awareness, male gender, and youn-
ger age were also associated with negative attitudes (Chapman
et al., 2012; Eliason, 1998). Although in one study the frequency
of church attendance, regardless of denomination, correlated with
150 May/June 2016
Copyright © 2016 National League for Nursing. Unauthorized reproduction of this article is prohibited.
homophobic attitudes (Schlub & Martsolf, 1999), religious affilia-
tion by itself did not have an impact on students’ knowledge and
attitudes in a later study (Cornelius & Carrick, 2015). Conversely,
the predictors of positive attitudes toward sexual minorities were
emotional stability, objectivity, greater support for sexual equality,
and more liberal attitudes toward sex-appropriate behavior
(Anderson, 1981).
SYNTHESIS AND DISCUSSION
The finding of this review indicated that studies conducted before
2000 reported more negative attitudes compared with studies per-
formed after the turn of the 21st century. Negative attitudes have
been reported to have positive correlation with lack of willingness to
care for LGBT persons (Anderson, 1981; Eliason, 1998; Eliason &
Raheim, 2000; Röndahl et al., 2004). Because of lack of outcomes
research on how student attitudes translate to real-life provider ac-
tions, it is not possible to ascertain how negative attitudes impact be-
havior at the bedside (Dorsen, 2012). However, the literature
indicated that negative attitudes may adversely affect treatment of
LGBT patients (IOM, 2011).
Outcomes research is much needed in the field of LGBT-
affirmative practices. Because all of the studies were conducted in
a single-site university setting, one needs to question whether the
positive findings reflected the more tolerant atmosphere of academia
or the effects of social desirability of responding positively when par-
ticipating in a research project at one’s school or place of employ-
ment (Dorsen, 2012). Because tools used in all of the studies rely
on self-report, social desirability bias is of prime concern. In addition,
some of the investigators were openly lesbian and known to the sub-
jects (Dinkel et al., 2007). This may have influenced responses toward
a more accepting attitude.
It is noteworthy to mention that 7 of the 12 studies were con-
ducted in the American Midwest, a geographic area known to be
unsupportive of LGBT equality and conservative religion (Dinkel
et al., 2007). This may partly explain why four of the six studies
reporting negative attitudes all came from this region. It would be of
interest if more studies were conducted in cities well known for large
LGBT populations, such as New York City or San Francisco.
The subjects of all the studies in the current review were over-
whelmingly female, Caucasian, Christian, and middle- to upper-
class students. The lack of representative sampling from diverse
groups such as ethnic minorities and male students might limit the
applicability of the findings to the general nursing student popula-
tions. It must be noted, however, that although the nursing profession
is comprised mostly of White females, in cities that have larger LGBT
representation, the nursing staff also tends to be diverse. Use of ran-
domization, stratified, or matched sampling for future studies would
be called for in order to reduce systematic bias (Polit & Beck, 2012).
The last decade has seen a slow but steady increase in racial
(Black, Asian, and Hispanic) and gender (male) minority students en-
rolling in prelicensure nursing programs (American Association of
Colleges of Nursing, 2014). Nationally, about 30 percent of nursing
students belong to minority populations, with numbers as high as
56 percent to 75 percent in California and Hawaii (American
Association of Colleges of Nursing, 2014). This is noteworthy based
on the notion that certain demographic features correlate with preju-
dice and impact the delivery of culturally competent care. Collectively,
the attitudes of nurses and nursing students mirror the larger culture
www.neponline.net
 Nursing Student Attitudes Toward LGBT

of which they are a part. Therefore, heterosexism and heteronorma- populations. The available evidence is confounded by missing or in-
tive beliefs abound in nursing (Gray et al., 1996). consistent definitions of key constructs (e.g., homophobia and
This review found a lack of consistency among instruments used LGBT), lack of theoretical frameworks, inconsistent use of instru-
to explore attitudes toward LGBT persons. Of the 12 articles re- ments and use of instruments with unknown validity and reliability, in-
viewed, a total of 23 different tools were used to examine attitudes consistent examination of possible predicting or consequential
and beliefs. Cross-comparative analysis and generalizability is difficult variables, and exclusion of measures of bisexual and transgender
when there is lack of measurement consistency (Polit & Beck, 2012). persons. The need for a more rigorous and robust qualitative and
A majority of the tools used provided validity and reliability scores; outcomes studies related to nursing students’ attitudes toward
however, content validity indexes were not provided on the three LGBT is definitely warranted.
author-developed survey questionnaires (Carabez et al., 2015; LGBT health content must be made explicit and fully integrated in
Cornelius & Carrick, 2015; Strong & Folse, 2015). the nursing curricula. Cognitive, affective, and psychomotor domains
Although changing social values have led to increasing accep- of cultural competency must be dealt with equal vigor. Minority stress
tance of LGBT expressions (Pew Research Center for People and model, life course perspective, intersectionality, and social ecology
the Press, 2011), the nursing profession has been slow in adopting are conceptual frameworks that can be applied to develop a situated
and advocating for these changes (Eliason et al., 2010). As a result, understanding of LGBT health issues (IOM, 2011). The need for con-
nursing education stakeholders must take an active role in the mean- tinuing education on LGBT health beyond the basic generalist educa-
ingful inclusion of LGBT health topics into nursing education across tion is implied from the studies reviewed. Cultural competence is a
all levels. Interestingly, the National Student Nurses Association process that needs to be supported by faculty professional develop-
(2012) has issued a resolution endorsing the Joint
Commission’s directive to advance effective
communication and cultural competence in the The need for continuing education on LGBT health
care of LGBT clients.
When confronted with the challenge of caring beyond the basic generalist education is implied from the
for diverse patient populations, nursing students studies reviewed. Cultural competence is a process
may feel the need to state that they are capable
of treating everyone alike, invoking a socially de- that needs to be supported by faculty professional
sirable response of “treating everybody alike.” development activities to sustain its cultivation.
However, given their lack of experience and lack
of contextualized understanding of sexual minor-
Increased time devoted to LGBT health disparities in
ities, they may be mistaken or harbor a false nursing education is needed.
sense of cultural competency (Eliason, 1998). Ex-
periential learning in nursing education will remain a solid model in ment activities to sustain its cultivation. Increased time devoted to
teaching cultural competence in caring for vulnerable populations. LGBT health disparities in nursing education is needed.
In one study, 62 percent of students reported that they have the Interactions with LGBT populations may allow those students
knowledge to work with LGBT clients, but 85 percent said that their with negative attitudes to be moved from prejudice to empathy, an
education had not prepared them, suggesting that students come to important first step in patient-centered care (Chapman et al., 2012).
nursing programs with baseline knowledge of LGBT populations or Nurse educators have identified the need to teach LGBT issues but
they had acquired knowledge from other venues other than nursing feel unprepared to do so (Lim et al., 2015; Sirota, 2013). In this era
education (Carabez et al., 2015). of competing priorities, educators must strive for balance to explore
meaningful inclusion of LGBT health disparities into research, educa-
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