WLHR_A_309477.dvi Belief in the “Free Choice” Model of Homosexuality: A Correlate of Homophobia in Registered Nurses Christopher W. Blackwell ABSTRACT. A great amount of social science research has supported the positive correlation between heterosexuals’ belief in the free choice model of homosexuality and homophobia. Heterosexuals who believe gay, lesbian, bisexual, and transgender (GLBT) persons consciously choose their sexual orien- tation and practice a lifestyle conducive to that choice are much more likely to possess discriminatory, homophobic, homonegative, and heterosexist beliefs. In addition, these individuals are less likely to support gay rights initiatives such as nondiscrimination policies or same-sex partner benefits in the workplace or hate crime enhancement legislation inclusive of GLBT persons. Although researchers have demonstrated this phenomenon in the general population, none have specifically assessed it in the nursing workforce. The purpose of this study was to examine registered nurses’ overall levels of homo- phobia and attitudes toward a workplace policy protective of gays and lesbians. These variables were then correlated with belief in the free choice model of homosexuality. Results indicated that belief in the free choice model of homosexuality was the strongest predictor of homophobia in nurses. Implications for nursing leadership and management, nursing education, and future research are discussed. KEYWORDS. Discrimination, free choice model of homosexuality, gay, homophobia, homosexual, lesbian, nurse, nursing INTRODUCTION AND LITERATURE REVIEW Discrimination Against Gays and Lesbians in the Workplace The purpose of this study was exploration of registered nurses’ beliefs about homosexu- ality in conjunction with examining attitudes to- wards the protection of gays and lesbians in the workplace through a nondiscrimination policy. Research suggests that discrimination against homosexuals is pervasive in America’s work- places; homosexuals experience disparities in wages and earning, continual harassment and homophobic treatment, and lack many essen- tial employment rights (Anastas, 2001; Croteau, 1996; Irwin, 2002; Klawitter, 1998; Morrow, Christopher W. Blackwell, PhD, ARNP-C, is Assistant Professor, UCF College of Nursing, P.O. Box 162210, Orlando, FL 32816-12210 (E-mail: cwblackw@mail.ucf.edu). 2001). Discrimination that gays and lesbians experience in the workplace is considered both indirect and direct. Indirect forms include the ad- ditional disparity of lesbian couples secondary to overall lower pay for women (Cohn, 1992; Frum, 1992; Melymuka, 2001; Quittner, 2003; Van Soest, 1996; Yared, 1997). Examples of direct discrimination are often central features of qualitative studies of participants’ experi- ences with discrimination at work (Croteau, 1996). Croteau (1996) identified both formal (di- rect) and informal (indirect) discrimination practices in the workplace. Formal are insti- tutionalized procedures that restrict officially conferred work rewards, and informal are the loss of credibility, acceptance, or respect by coworkers and supervisors based on a workers’ Journal of LGBT Health Research, Vol. 3(3) 2007 Available online at http://jlhr.haworthpress.com C© 2007 by The Haworth Press. All rights reserved. doi: 10.1080/15574090802093117 31 32 JOURNAL OF LGBT HEALTH RESEARCH sexual orientation. Formal discrimination was typically associated with employer decisions to terminate or not hire an individual due to their sexual orientation (Croteau, 1996). I also noted other formal discriminatory practices including the exclusion of homosexuals from promotions, pay raises, or increased responsibility at their jobs. Fear of having one’s sexual orientation discovered is predictive of how an individual chooses to present his or her sexual orienta- tion identity in the work environment (Croteau, 1996). This finding may be of significance to this in- quiry because supporters of nondiscrimination policies protective of gays and lesbians in the workplace often claim that such guidelines cre- ate equity and fairness (Economist, 1995), which could help alleviate fears of possible discrimi- nation and antigay retaliation for homosexuals who choose not to hide their sexual identity at work. Anticipation of discrimination, especially if an individual’s sexual orientation is disclosed or discovered, is of great concern to gay and les- bian workers (Croteau, 1996). Individuals have reported the belief that discrimination would oc- cur if their sexual orientation was discovered by management; research has indicated that this fear or anticipation of discrimination is the ma- jor factor in workers closeting lesbian, gay, or bisexual identities (Croteau, 1996). Research regarding the socioeconomic status of gays and lesbians as a minority suggests that working gay, lesbian, and bisexual people are no better off, and in some ways are disadvan- taged economically, in relation to comparable heterosexual people (Anastas, 2001; Badgett, 2000; Cahill & Jones, 2002; Klawitter, 1998). Data suggest that gay males appear to earn less than their heterosexual counterparts. A compre- hensive analysis conducted by Black, Makar, Sanders, and Taylor (2003) estimated earnings among gay men to be between 14% and 16% lower than for heterosexual men; the researchers considered differences in career specialization and labor market choices between heterosexual men and homosexual men and hypothesized the etiology for lower earnings in gay men went beyond these forces and were related to deep and pervasive antigay attitudes of employers. Some studies have found specific examples of such disparity in females as well (Badgett, 2000; Klawitter, 1998). Because of the overall wage discrimination that females experience, lesbian couples have an overall lower combined income than heterosexuals (Anastas, 2001; Klawitter, 1998). Belief in the “Free-Choice” Model of Homosexuality as a Correlate with Homophobia Controllability of one’s sexual orientation, be- lief in the free choice model of homosexuality, and support for psychological versus biological explanations of sexual orientation development have been supported as predictors of homo- phobia (Herek, 2000, 2002; Herek & Capi- tanio, 1995; Landen & Innala, 2002; Sakalli, 2002). Individuals who believe that a homo- sexual orientation results from social learning and/or a conscious choice that remains within one’s control statistically have higher levels of homophobia than those who believe that a ho- mosexual orientation results from biological and psychosocial influences (Herek, 2000, 2002; Herek & Capitanio, 1995; Landen & Innala, 2002; Sakalli, 2002). There are also differences in heterosexual opinions regarding choice of homosexuality of either gay men or lesbians; males and females both considered lesbianism to be more of a choice than male homosexuality (Herek, 2002). In addition, heterosexuals who believe that ho- mosexuality is not a choice overwhelmingly en- dorse the idea that it is innate and not determined by environmental factors (Herek, 2002). People who believe in a biological explanation as the eti- ology of homosexuality are much less restrictive towards homosexuals; i.e., these individuals are much more accepting and more willing to sup- port protections and human rights for gays and lesbians than those who believe in a psycholog- ical explanation (Landen & Innala, 2002). Sim- ilarly, the belief that homosexuals can control their homosexuality has also been correlated to high levels of homophobia (Herek & Capitanio, 1995). Some of the data researching the belief in the free choice model of homosexuality is connected to the body of social science that examines the Christopher W. Blackwell 33 belief that obese individuals choose their obesity (Crandall & Martinez, 1996; Sakalli, 2002). Comparable to the finding that individuals who believe that obesity is a controllable behavioral trait are more prejudiced towards overweight in- dividuals, individuals who believe that homo- sexuality is a controllable behavioral trait have more prejudicial attitudes toward gay men and lesbians than those who think that homosexual- ity is uncontrollable (Herek & Capitanio, 1995; Sakalli, 2002). Clinicians’ personal beliefs regarding the cause of clients’ illnesses can have profound ef- fects on care delivery and discrimination in the workplace. For example, Ortloff’s (1995) work found that homosexuals infected with HIV or di- agnosed with AIDS were more likely to receive discriminatory healthcare and be discriminated against in the workplace than nonsexual mi- norities. HIV/AIDS-associated stigma has been supported as a cause of depression in clients with HIV/AIDS (Swendemen, Rotheram-Borus, Comulada, Weiss, & Ramos, 2006). These is- sues highlight the need for critical assessments of homophobia in the healthcare setting. Discrimination Against Gays and Lesbians in Healthcare Although many inquires have supported the existence of discrimination against gays and lesbians in the workplace, there are very little data examining the amount of homophobia and prevalence of discrimination in the healthcare setting. There is even further scant data exam- ining the responsiveness to deal with homopho- bia within the workplace of healthcare workers (Saunders, 2001). Some studies do examine physician attitudes and discriminatory belief patterns. Examples of such studies include those conducted by Tellez, Ramos, Umland, Palley, and Skipper (1999); Lock (1998); O’Hanlan, Cabaj, Schatz, Lock, and Nemrow (1997); Olsen and Mann (1997); and Muller and White (1997). However, none of this research pertains to the homophobia of regis- tered nurses. In addition, all of these researchers explored the negative impacts of homophobia on the gay and lesbian patient population; none specifically assessed the impacts of physician homophobia in the workplace or attitudes re- garding a protective workplace policy for homo- sexuals. Studies assessing the effects of homopho- bia in the workplace of healthcare professionals are also dearth. Review of the current literature found only a very few studies detailing the well- being of homosexual physicians as related to homophobia in the workplace. Those reviewed concentrated on the overall feelings of gay and lesbian medical doctors about the amount of homophobia thatthey perceived in their places of employment and within their profession. The scarcity of empirical research about homopho- bia in the workplaces of the nursing profession was even greater, as evidenced by the finding of only one study, authored by Theresa Stephany (1992) for Sexuality and Disability. Stephany’s (1992) work was a qualitative es- say and explored the author’s own personal work experiences as a lesbian nurse. Although the work of Douglas, Kalman, and Kalman (1985) did investigate some homophobia in nursing and medicine, it had no emphasis on discrimination in the workplace and, instead, made correlations with homophobia and AIDS patients. Burke and White (2001) conducted research examining the wellbeing of gay, lesbian, and bisexual med- ical doctors and discussed many correlations between well-being and workplace-related dis- crimination issues but, again, were void on the topic of protective policies in the workplace. Purpose of Study The paucity of data assessing registered nurses’ homophobia and attitudes towards gays and lesbians in the workplace have led to a lack of contribution from nursing scholars on how to solve discriminatory dilemmas in the work- place. The purpose of this study is to examine registered nurses’ homophobia and overall at- titudes toward the protection of gays and les- bians in the workplace. The dependent variables of this study were the homophobia scores rep- resented by the Attitudes Toward Lesbians and Gay Men (ATLG) scale and support or nonsup- port of a workplace nondiscrimination policy that protects gay men and lesbians. The inde- pendent variable assessed for this discussion was 34 JOURNAL OF LGBT HEALTH RESEARCH belief in the free choice model of homosexuality, operationalized as: “The belief that gay and les- bian individuals consciously choose their ho- mosexuality and practice a lifestyle conducive to that choice rather than the belief of biologi- cal and psychosocial influences in the develop- ment of sexual orientation” (Blackwell, 2005, p. 16). The findings will augment the literature per- taining to social justice and discrimination is- sues encountered by homosexuals and will also provide direction for administrative decisions re- garding the addition of such policies in the work environment of nurses. Research Hypotheses The research hypotheses of this study pre- dicted a positive correlation between belief in the free choice model of homosexuality with homo- phobia and nonsupport for a nondiscrimination policy protecting gays and lesbians in the work- place. METHODOLOGY Sample A randomized stratified sample of registered nurses licensed in the State of Florida was selected. Using the electronic database of reg- istered nurses through the State of Florida De- partment of Health Board of Nursing, potential participants were chosen by selecting every third name in the Stats database under each letter of the alphabet until 20 names were picked per letter, yielding a total of 520 potential partici- pants. Only individuals with mailing addresses within the United States were included. If an individual living outside the United States was selected, the very next name in the database was selected; every third name was then chosen us- ing the newly selected individual as the starting point. In alphabet letters where the sample of 20 could not be arrived at by selecting every third registered nurse, the deficient amount was made- up by sampling every third name from the end of the alphabet forward. Of the 520 study packets mailed to the sample, 40 were returned as unde- liverable, lowering the potential sample to 480. One-hundred sixty-five (34%) of the 480 surveys were returned and included in the analyses. Instruments One instrument was used in this study, the ATLG Scale developed by Gregory Herek (1984, 1987a, 1987b, 1988, 1994). This 20-question psychometric instrument is designed as a 5-point likert scale on which respondents rate their at- titude regarding a specific statement about ho- mosexual men or women. The ATLG consists of two subscales: the Attitudes Toward Lesbian (ATL) Scale and the Attitudes Toward Gay Men (ATG) Scale. Combined as the ATLG, this tool measures heterosexuals’ attitudes toward homo- sexuals. Scoring is evaluated by summing numerical values (1 = strongly disagree, 5 = strongly agree) across items for each subscale. Reverse scoring is used for select items; reverse scoring is corrected in the statistical analyses. The possible range of scores varies depending on the response of the study sample. With the 5-point response scale used in this inquiry, total scale scores can range from 20 (extremely positive attitudes) to 100 (extremely negative attitudes), with ATL and ATG subscale scores each ranging from 10 to 50. In addition to the ATLG, a demographic data collection sheet to gather information about the participants’ age, gender, race/ethnicity, educa- tion level, belief in the free choice model of ho- mosexuality, exposure to homosexuals through friends and/or family associations, and attitudes towards workplace nondiscrimination policies protective of gays and lesbians was used. Atti- tudes toward the protection of gays and lesbians in the workplace were determined by evaluat- ing responses to two opposing statements about workplace nondiscrimination policies, which were scored employing the same 5-point lik- ert scale used on the ATLG and data collection sheets. Data Collection Research proposals were submitted for ap- proval to the Institutional Review Board at the University of Central Florida. To collect data in a random fashion, a mathematical approach was used to obtain the sample. To stratify, every third Christopher W. Blackwell 35 nurse under each letter of the alphabet was se- lected until each letter had a total of 20 possible participants. Using 20 per letter, a total of 520 registered nurses were mailed a study packet. Forty were returned as undeliverable and 165 of the remaining 480 (34%) were included in the analyses. The study packet included directions for com- pleting the study, a 2-page questionnaire (includ- ing the demographic data collection sheet and the ATLG Scale), and a postage paid envelope for return of the survey. As explained in the di- rections included in the study packet, comple- tion and return of the survey indicated informed consent for participation. The survey instrument was specifically designed to assess attitudes to- ward gays and lesbians only among heterosex- uals (Herek, 1984, 1987a, 1987b, 1988, 1994). Thus, disclosure of a homosexual or bisexual orientation was exclusionary for the study. The respondents’ identities were kept anonymous; no identifiers were used during the data col- lection or analyses. Participants could choose to withdraw from the study at any time with- out consequence. Individual raw data were read only by the researcher. Confidentiality was main- tained by locking the questionnaires in a research office. Treatment of the Data To determine relationships among indepen- dent and dependent variables structural equation modeling (SEM) and linear regression (also re- ferred to as ordinary least squares) were used. Confirmatory factor analysis was used to support the internal consistency of the ATLG Scale. RESULTS Sample Demographics Five-hundred-twenty registered nurses within Florida were selected using a stratified system- atic sampling method and mailed a study packet. Forty of the 520 were returned as undeliver- able, bringing the potential sample to 480. One- hundred-sixty-five (34%) were returned and included in the analyses. The typical respondent was a Caucasian heterosexual women (only 11 of the respondents were men), between the ages of 40–49 years, with an Associate Degree in Nursing. With regard to religiosity, the major- ity were moderate Christians who attend church weekly. Seventy-three percent of participants have at least one friend or family member who is a gay man or lesbian, and 62% indicated that they would support a nondiscrimination policy in their workplace that protects gay men and lesbians. Hypotheses Testing To test the study’s hypotheses, SEM was used. The independent variables of the study, belief in the free-choice model of homosexuality and sup- port or nonsupport of a nondiscrimination policy protective of gay men and lesbians in the work- place, were placed on the left side of the model and were correlated with the latent construct of homophobia, which was then correlated with the 20-item ATLG scale. To measure belief in the free choice model of homosexuality, respondents were asked to gauge the degree to which they agreed or dis- agreed with the statement: “Gay men and les- bians consciously choose their homosexuality and practice a lifestyle conducive to that choice.” To suggest overall correlation between this in- dependent variable, the researcher analyzed the data using a critical ratio (CR) score of >1.96 (Garson, 2005) to indicate statistical signifi- cance. The CR value for this independent vari- able was 5.9, which was the highest CR score of all the variables in the structural equation model. As the strongest correlate of all the indepen- dent variables, belief in the free-choice model of homosexuality, was strongly correlated with homophobia. To assess the correlation between the nurses’ homophobia and support/nonsupport for a work- place nondiscrimination policy protective of gays and lesbians, respondents were asked to gauge the degree to which they agreed or dis- agreed with the statements “I would support a nondiscrimination policy in my workplace that protects gay men and lesbians” and “I would not support a nondiscrimination policy in my work- place that protects gay men and lesbians.” Next, the researcher included the answers to both of 36 JOURNAL OF LGBT HEALTH RESEARCH TABLE 1. Summary of Study Findings and Interpretations Variable Critical Ratio Value Interpretation Belief in the “free choice” model of homosexuality 5.9∗ Strongest predictor: Nurses believing homosexuality was a conscience lifestyle choice had the highest levels of homophobia. Support for a nondiscrimination policy protecting gays and lesbians in the workplace −4.1∗ Strong reverse correlation: Nurses supporting a nondiscrimination policy in the workplace had lower levels of homophobia. Nonsupport for a nondiscrimination policy protecting gays and lesbians in the workplace 3.3∗ Strong correlation: Nurses who would not support a nondiscrimination policy in the workplace had higher levels of homophobia. ∗Statistically significant at p ≤ .05. these as independent variables in the SEM and analyzed the CR value using >1.96 to indicate statistical significance. Support of the nondiscrimination policy was a significant negative correlate with homopho- bia with a CR value of −4.1. Thus, it can be suggested that those nurses who indicated that they would support such a policy were less ho- mophobic than those who indicated that they would not support such a policy. In addition, the second question had a positive correlation CR value of 3.3, suggesting a positive correlation between nonsupport of a nondiscrimination pol- icy and overall homophobia. Findings and their interpretations are provided in Table 1. DISCUSSION Belief in the Free Choice Model of Homosexuality, Homophobia, and Support/Nonsupport of a Workplace Nondiscrimination Policy Data supported a positive correlation between belief in the free choice model of homosex- uality and homophobia. This finding echoes that of the literature, which suggests individuals who believe gay men and lesbians consciously choose to be homosexual are more homopho- bic than those individuals who believe biologi- cal and psychosocial influences are responsible for the development of a person’s sexual orien- tation (Herek, 2000, 2002; Herek & Capitanio, 1995; Landen & Innala, 2002; Sakalli, 2002). Although outside of the scope of this study, research has also demonstrated differences in heterosexual attitudes regarding choice; lesbians are more often thought as choosing their homo- sexuality rather than gay men (Herek, 2000). Similarly, Herek and Capitanio (1995) pos- itively correlated belief in controllability with homophobia. Study participants who believed that homosexuals had control over their homo- sexuality were more homophobic than those in- dividuals who believed that sexual orientation was outside of one’s control. Some of the data researching the belief in the free choice model of homosexuality is connected to the body of so- cial science that examines the belief that obese individuals choose their obesity (Crandall & Martinez, 1996; Sakalli, 2002). Comparable to the finding that individuals who believe that obesity is a controllable be- havioral trait are more prejudiced towards over- weight individuals, individuals who believe that homosexuality is a controllable behavioral trait have more prejudicial attitudes toward gay men and lesbians than those who think that homo- sexuality is uncontrollable (Herek & Capitanio, 1995; Sakalli, 2002). Treated as an independent variable in the structural equation model, support for the nondiscrimination policy was significantly reverse-correlated with homophobia. Thus, those nurses who supported the workplace policy were significantly less homophobic than those who did not support the policy. Nurses are taught a holistic approach to healthcare (Potter & Perry, 2005). Holism emphasizes respect for the person as a whole Christopher W. Blackwell 37 physical and spiritual being. Because of the em- phasis of this in nursing, perhaps nurses believe that workplace protection policies help provide respect for homosexual persons by maintaining their integrity and individuality. However, the study of the precise relationship between workplace policies and overall homo- phobia is nonexistent. Perhaps the relationship between homophobic attitudes and workplace policies is explained by attitude itself. In other words, heterosexuals who believe that homo- sexuals constitute a disadvantaged population in general society might also extrapolate this idea into workplace discrimination issues. The reverse might also be true. If hetero- sexuals believe homosexuals do not comprise an oppressed group in American society, then workplace policies could be deemed unneces- sary and counterproductive. Perhaps homopho- bic thought can lead to the belief that gays and lesbians are not oppressed in American life, and thus, lead to lack of support for a nondiscrimi- nation policy in the workplace. Implication for Future Research This critical inquiry could possibly serve as a basic infrastructure for future research related to registered nurses’ attitudes towards homo- sexuals in the workplace. During the course of this study, no specific studies that explored the attitudinal differences among registered nurses towards workplace discrimination of gay men and lesbians were found. In addition, a re- search method of reverse correlating support of a nondiscrimination policy in the workplace protective of gay men and lesbians with higher levels of homophobia and positively correlating support of such a policy with decreased levels of homophobia in a sample of registered nurses has never been completed before. A more national (and even possibly global) study could explore the overall homophobia and attitudes of nurses towards a nondiscrimination policy in the workplace that protects gay men and lesbians from a much grander scope. This type of research design might also highlight im- portant geographical differences in homophobia among nurses. Gay marriage was recently legal- ized in Massachusettes, and Vermont has civil union laws granting many of the essential rights of marriage to gay couples; California has some extensive equality laws protective of gay men and lesbians in such areas as domestic partner- ship, mandatory benefits for same-sex couples at work, and nondiscrimination in employment (Segal Group, 2004). Florida, on the other hand, has no legislation that protects gay men and lesbians from work- place discrimination, lacks criminal enhance- ment penalties for homosexual victims of hate crimes, and outlaws any form of adoption by gay men or lesbians (Equality Florida, 2004). Differences in these policies from state to state may cause speculation that, overall, homopho- bia levels and attitudes towards gays and les- bians at work vary by location of the country; research with a larger aggregate of nurses from various geographic boundaries could highlight diverse sociopolitical climates for gays and les- bians throughout the United States. In addition to national studies, future research could also cross international borders and explore differ- ences in homophobia and attitudes towards a nondiscrimination policy in the workplace of various countries, and contrast these beliefs with those of western populations similar to Lim’s (2002) research. Future research studies should shift focus from finding differences in populations to expla- nation of the differences and the evolution of ho- mophobic thought processes in a profession and in society as a whole. Perhaps the application of a qualitative research design would yield richer data. Perhaps future research based in qualita- tive designs could begin to more closely explain causality in homophobia, compare and contrast differences in attitudes and beliefs in the nursing population, and bridge the current gap between phenomenon and explanation. Implications for Nursing Education This study has yielded a vast amount of ed- ucational implications for nursing. Because the sample of this study was comprised of regis- tered nurses licensed in the State of Florida, per- haps the educational implications for nursing are most condign. Registered nurses are taught to treat the client as an entire being, encompassing 38 JOURNAL OF LGBT HEALTH RESEARCH not only physical health, but mental, spiritual, and psychosocial health as well (Potter & Perry, 2005). Whether or not a registered nurse can fully commit to this vital component of care is an important consideration based on the analysis of the data that reflects the presence of homopho- bia within the profession. Many psychologically-driven theories of the 1950s, including psychoanalysis, held highly- homophobic views of homosexuality. Coupled with this pathologizing of homosexuality comes the belief that gay men and lesbians con- sciously choose their homosexuality and prac- tice a lifestyle conducive to that choice. A highly debated issue in the sociopolitical arena, the question of homosexuality as a choice is con- verged with religious belief of homosexuality as a sin, labeling of civil rights for gays and lesbians as “special rights” designed to protect sexually- deviant individuals, and nature versus nurture theories of sexual orientation development (Van Wormer, Wells, & Boes, 2000). Although the contest between nature versus nurture as the etiology of a homosexual orienta- tion continues, it is essential to examine the rel- evant biological and psychosocial research that is scrutinizing this subject. Recent research has suggested a strong biological component to the development of sexual orientation; differences in postmortem brain morphology between het- erosexual and homosexual males,genetic pre- disposition and genotyping of heterosexual versus homosexual samples, and early con- siderable differences in associative gender de- velopment have all been supported in the literature as at-least partial causative agents (Bai- ley & Pillard, 1991; Bailey, Pillard, Neale, & Agyei, 1993; Bell, Weinberg, & Hammersmith, 1981; Comperio-Ciani, Corna, & Capiluppi, 2004; LeVay, 1991; Zastrow & Kirst-Ashmon, 1997). Research supporting an element of social- ization in the development of sexual orienta- tion focuses on the scarce data derived from prison samples (Van Wormer et al., 2000). This data suggests that some homosexual sexual be- haviors first learned in the prison environment perpetuate into life outside of prison; males who received anal sex during incarceration were much more likely to continue this sexual activity once returned to the general population than those males who actually penetrated other males (Van Wormer et al., 2000). The current dominant theory of causality in the social science literature is termed interaction theory, which proposes that a homosexual orientation results from both bi- ological and psychosocial input variables (Van Wormer et al., 2000). To overcome the infusion of homophobia in nursing education, topics and lectures regarding sexual orientation development might include information about interaction theory and could also stress the wider scientific belief that homo- sexuality is at least partly determined through biological factors beyond one’s control. If a nursing student holds strong to the belief that homosexuality is a personal lifestyle decision, instructors might reiterate the principle of au- tonomy, which mandates that registered nurses respect the decisions made by clients, regardless of the personal attitudinal beliefs of the nurse (Potter & Perry, 2005). Limitations Perhaps the greatest limitation of this study is generalizability. Study participants were se- lected from a randomized sample of registered nurses licensed in the State of Florida. Thus, the results of this study are generalizable only to reg- istered nurses licensed in the State of Florida. Another threat to the study that must be con- sidered is whether or not respondents honestly reported their sexual orientation. Although par- ticipant anonymity was ensured, the existence of social stigma and fear of repercussions from dis- closing a homosexual orientation (Schoenewolf, 2004) might have resulted in some homosex- ual or bisexual nurses selecting heterosexual as their orientation on the demographic survey instrument. Finally, the overall size of the sample (n = 165) is small. The smaller sample size threat- ens generalizability of the study and also poses a threat to the integrity of the structural equation model. With an increased sample size, the con- struct validity could be strengthened by splitting the total sample into two groups and performing multiple group analysis with equality constraints of the measurement model. Christopher W. Blackwell 39 Summary and Conclusion The purpose of this study was to examine reg- istered nurses’ overall levels of homophobia and attitudes toward a workplace policy protective of gays and lesbians. 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