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Genitalia-related nursing embarrassment and its associated factors among female nurses in mainland China: a nationwide cross-sectional study

Background Genital-related care is a common nursing procedure and may cause embarrassment for nurses. However, nurses’ level of embarrassment and the factors associated with embarrassment have been scarcely studied. Therefore, a cross-sectional study was conducted to investigate genitalia-related care’s embarrassment and its associated factors among Chinese female nurses. Methods Online questionnaires regarding the frequency of genitalia-related care and the embarrassment level were distributed to female nurses from the gynecology and urology departments between October and December 2019. Participants also completed the Chinese version of the professional identity scale for nurses and the Jefferson scale of empathy. Mantel-Haenszel chi-square and ordinal logistic regression were used to explore factors associated with the level of embarrassment. Results In total, 648 female nurses from 54 hospitals in 31 cities in China were recruited. Among these respondents, approximately 67% provided genitalia-related care at least three days per week, and about 70% of nurses felt slightly embarrassed to extremely embarrassed when providing genitalia-related care. Compared to nurses from gynecology departments, nurses from urology departments felt more embarrassed during genitalia-related care (P<0.001). Ordinal regression analysis showed that the odds of nurses from gynecology and urology departments with total empathy scores greater than 100 experiencing higher levels of embarrassment than nurses with total empathy scores less than 100 were 0.47 and 0.45, respectively. Nurses from gynecology departments with higher professional identity scores, higher education levels, more frequent genital-related care experienced less embarrassment, while nurses from the urology department with prior sexual experience experienced less embarrassment. Conclusions Feeling embarrassed during genitalia-related nursing was common among Chinese female nurses, especially those from urology departments. Embarrassment during genitalia-related nursing was related to professional identity, empathy, educational level, genitalia-related care frequency, and sexual history. These findings highlight the importance of professional identity, empathy, and education among nurses.


Introduction
Medical procedures that are intimate, such as colonoscopies and pelvic/prostate examinations, can cause discomfort and embarrassment for patients. Previous studies have reported that the embarrassment experienced during these situations can prevent patients from engaging in medical examinations (1,2).
Medical staff such as nurses also face this sensitive situation, especially when providing genitalia-related nursing, which are nursing procedures that necessitate exposure and/or physical contact with the external genitalia (perineum, penis, or orchis). Such care includes genital hygiene, urinary catheterization, meatal cleansing, genital wound care, pubic area shaving, and taking sexual histories on admission to the wards (3). Embarrassment, which is a negative emotion defined as feeling flustered because of poor performance (4), is also experienced by patients when their bodily privacy (5) is invaded.
Although many studies have focused on medical embarrassment and its influence on patients, few studies have examined embarrassment among female nurses. Existing studies on attitudes toward intimate care have mainly involved nursing students and male nurses. Crossan et al. (6) interviewed 166 nursing students in New Zealand to explore their attitudes about providing intimate care to patients of the opposite sex. The results showed that student nurses face many challenges when providing intimate care to patients. Meanwhile, a study by Turk et al. (7) involving 300 female nursing students found that many students had negative attitudes towards providing genital area-related care to male patients. Inoue and colleagues (8) used semistructured, open-ended interviews to reveal that male nurses in Western Australia often experience negative feelings when providing intimate care for female patients.
In China, nursing is a female-dominated occupation. Nurses are susceptible to negative emotions such as shyness, embarrassment, and resistance when caring for male patients' bodily private parts (9). This may lower the quality of healthcare, cause nurse-patient disputes, and affect nurses' mental health. Therefore, it is crucial to investigate the embarrassment felt by female nurses when providing genitalia-related care.
A national cross-sectional study among Chinese female nurses was conducted to investigate the feeling of embarrassment when providing genitalia-related care and the factors associated with embarrassment. This article is presented following the STROBE reporting checklist (10) (available at http://dx.doi.org/10.21037/atm-20-5154).

Study design, setting, and participants
A national cross-sectional survey was conducted from October to December 2019 to evaluate the state of embarrassment among Chinese female nurses during genitalia-related care and the factors associated with the levels of embarrassment. Female nurses from gynecology and urology departments were recruited online via convenience sampling and invited to complete an online survey powered by www.wjx.cn, a platform providing services equivalent to Amazon Mechanical Turk. Registered female nurses who voluntarily participated were included in this study.

Data collection
The online survey collected socio-demographic and jobrelated information including age, educational level, marital status, hospital of employment, department, years working, frequency of genitalia-related care per week, personal attitude towards genital contact, and level of embarrassment when providing genitalia-related care. The question, "How embarrassing assessed the latter is providing genitaliarelated care?" The embarrassment level was rated from 1 to 5, with responses ranging from 1 being "extremely embarrassing" and 5 being "not embarrassing at all." The online survey also included a professional identity scale and the Chinese version of the Jefferson scale of empathy. The professional identity scale (11) was used to measure a nurse's professional identity: the clear recognition of one's career goals, abilities, personal interests, and personal values (12). The scale consists of 30 items categorized into five dimensions: self-reflection, dealing with professional frustration, professional social skills, professional social support, and professional identity evaluation. The items were rated on a 5-point Likert scale, with 1 indicating that the item was "very inconsistent," 2 indicating that it was "inconsistent," 3 indicating that it was "sometimes consistent," 4 indicating that it was "consistent," and 5 indicating that it was "very consistent". The total score ranged from 30-150. Typically, 30-60 points indicated very low professional identity levels, 61-90 points indicated low levels of professional identity, 91-120 points indicated medium levels of professional identity and 121-150 points indicated high professional identity levels. Reliability and validity were determined to be satisfactory (Cronbach's α =0.938, χ 2 /df =1.85). The scale's acceptable reliability has been confirmed in previous studies (13).
The Chinese version of the Jefferson scale of empathy (14,15) was used to assess the nurse's level of empathy, that is, the ability to understand others (16). The scale contains 3 dimensions: taking perspective, compassionate care, and understanding of others' perspectives. The 20 items on the scale were rated on a Likert scale ranging from 1 (strongly agree) to 7 (strongly disagree), with a total score of 7-140 points. A single item score ≥3.5 indicates a relatively ideal level, while total scores ≤60, 61-99, and ≥100 indicate low, medium, and high empathy levels, respectively. The Chinese version scale had sound reliability and validity. The Cronbach's α coefficient of the overall scale was 0.797, and the split-half reliability coefficient was 0.788. The overall scale's content validity index was between 0.2-1, suggesting good reliability and validity. The scale's acceptable reliability and validity in the Chinese context have been confirmed in a previous study (17,18).

Statistical analysis
Categorical data were presented as numbers, and percentages and continuous data were presented as mean and standard deviation or median and interquartile range (IQR). The t-test or Mann-Whitney U test was used to compare continuous data, depending on the continuous data distribution. The Shapiro-Wilk test was used to examine the normality of the data. The Mantel-Haenszel chi-square test was used to compare the level of embarrassment and personal attitude towards genital contact between the nurses in the gynecology and the urology departments. Ordinal logistic regression was used to identify the factors associated with the level of embarrassment among nurses, with the dependent variable being the level of embarrassment and the independent variables being total professional identity score, total empathy score, age, working years, educational level, genital-related care frequency per week, and prior sexual experience. The independent variables were included based on the opinions of nursing specialists. SPSS 26.0 (SPSS Inc., Chicago, IL, USA) was used to conduct all statistical analyses. The P values in this study were twotailed. Alpha was set at 0.05 for statistical significance.

Ethical statement
All procedures performed in this study involving human participants were following the Declaration of Helsinki (as revised in 2013). The Ethical Committee approved the study protocol of the Peking University People's Hospital (No. 2020PHB182-01). The online survey was anonymous. Participant consent was obtained during the online survey.

Participants' characteristics
A total of 648 nurses (311 from gynecology departments and 337 from urology departments) from 54 hospitals in 31 cities were enrolled in this study. The majority of nurses (91.20%) were under 40 years old, 71.60% were married, and 78.55% had an undergraduate or higher degree. Approximately 67% of participants reported that they provided genitalia-related care at least 3 days per week. There were no differences in the age, working years, and nurses' educational level between these two departments. Nurses from the gynecology departments had higher genital-related care frequency and were more likely to be married or have had sexual intercourse ( Table 1).

Embarrassment among female nurses
About 70% of nurses felt a little embarrassed to extremely embarrassed when providing genitalia-related care. Compared to nurses from the gynecology departments, nurses from the urology departments experienced more embarrassment when providing genitalia-related care (P<0.001), but none felt extremely embarrassed when facing female patients. As for the attitude towards genital contact, 44.37% and 39.46% of nurses from the gynecology and urology departments, respectively, agreed that genital contact should only occur between a married couple ( Table 2).

Factors associated with the level of embarrassment
Ordinal logistic regression was used to identify the factors associated with embarrassment among nurses from the gynecology and urology departments. After adjusting for age and working years, the results showed that nurses from the gynecology departments with professional identity scores less than 90 had 0.53 times the odds of having a higher level of embarrassment than nurses with professional identity scores of 90 or less. Gynecology nurses with empathy scores of 100 or greater had 0.47 times the odds of having a higher level of embarrassment than nurses with empathy scores less than 100. A higher level of education (OR =0.53, 95% CI, 0.30-0.93) and higher frequency of genital-related care (OR =0.52, 95% CI, 0.32-0.85) were both associated with lower levels of embarrassment. Prior sexual experience was not associated with the level of embarrassment.
As for nurses from the urology departments, professional identity score was not associated with embarrassment, while nurses with a total empathy score of 100 or greater had 0.45 times the odds of having a higher level of embarrassment than nurses with empathy scores less than 100. Nurses who had no previous sexual experience had 1.75 times the odds of having a higher level of embarrassment than nurses with previous sexual experience ( Table 3).

Discussion
Genitalia-related care is a common nursing procedure in medical practice, especially for nurses in gynecology and urology departments. Our study demonstrated that 73.31% and 61.42% of nurses in gynecology and urology departments, respectively, provided genital-related care at least three times per week. Nurses experienced various levels of embarrassment while providing genital-related care. Nurses from gynecology departments experienced embarrassment despite being the same gender, while nurses from urology departments experienced embarrassment when caring for patients of a different gender. Our study showed that female nurses felt more embarrassed when providing genitalia-related care to male patients. None of the nurses from the gynecology departments felt extreme embarrassment when providing genital-related care, whereas about 15% of nurses from the urology departments felt extreme embarrassment. More than half of the gynecology department's nurses did not feel any embarrassment, while 10.68% of nurses from the urology departments felt some form of embarrassment. This was consistent with previous research showing that nursing the sexual health of patients of the opposite sex was more embarrassing (19,20). Sexuality issues and embarrassment surrounding intimate genital care are common, particularly between male patients and female nurses (21). China's strong traditional conservative culture may explain this kind of embarrassment on sex. Traditionally, in China, one of the core "rites" in Confucianism is that physical contact between adults of different genders outside marriage is prohibited. Physical contact with any sexual implication, for example, exposure of or physical contact with the penis, is often regarded as the most private matter for Chinese individuals (22). The observation supports this that more than 60% of nurses in this study agreed moderately to extremely that genital contact should only occur between a married couple. The factors associated with the level of embarrassment were investigated. Nurses from gynecology departments who had higher professional identification scores and higher genital-related care frequency felt less embarrassment when providing genital-related care. Meanwhile, nurses from urology departments and those who had never had sexual intercourse tended to experience more embarrassment. This suggested that female nurses providing genital-related care to male patients may experience increased embarrassment. Previous studies have shown that medical embarrassment is not unidimensional but has two distinct components: bodily embarrassment and unwanted intimacy during examinations (23,24). Nurses with a strong desire to help and a strong sense of responsibility could function effectively outside their comfort zone and address sexual issues with patients (5). These results provided preliminary evidence that professional identity and empathy were correlated with a nurse's ability to cope with medical embarrassment.
Empathy is one of the major factors influencing a nurse's attributes (25). Nurses with a high level of empathy may better understand a patient's situation (26). Enhancing the understanding of others' perspectives may be beneficial in modulating embarrassment.
This study also identified that female nurses with higher education levels felt less embarrassed when providing genital-related care. Nurses with higher education may have had more opportunities for sex education, leading to a more positive attitude towards providing intimate care. Furthermore, coping with genitalia-related care situations requires nurses to possess certain skills and higher levels of experience. Their level of education generally influences these skills and experiences. Previous reports have suggested that student nurses require an effective curriculum to increase their ability and willingness to address a patient's sexual health (27). Therefore, additional courses related to genital care, especially regarding coping with embarrassment, and encouragement from nursing managers to receive continuous training, are essential to reduce a nurse's embarrassment.

Limitations and future research directions
Several limitations of this study must be acknowledged. First, female nurses included in this study were recruited using convenience sampling. Most participants were under 40 years of age and may indicate potential selection bias. Second, owing to the nature of the cross-sectional design, causal relationships could not be established. Third, the current research was descriptive and merely provided preliminary results of factors associated with medical embarrassment. Further research is needed to explore how culture, professional identity, and empathy influence the degree of medical embarrassment.

Conclusions
Experiencing embarrassment during genitalia-related nursing was common in Chinese female nurses, especially when caring for male patients. Our findings demonstrated that this embarrassment was related to professional identity, empathy, educational level, frequency of genitalia-related care, and personal sexual history. These findings highlight the importance of professional identity, empathy, and education among nurses.