Background
Workplace sexual harassment (WSH) remains a serious issue across various industries, including healthcare [1]. WSH is known as unpleasant and annoying sexual behaviors, including verbal, physical, psychological, and visual types that are common in the workplace [2]. Societal gender perceptions, creating power imbalances and normalizing behaviors that victimize women, are directly linked to the prevalence of sexual harassment [3]. Sexual harassment in healthcare can lead to a range of severe psychological and physical consequences for victims, including depression and anxiety, low self-esteem, burnout, Sleep disturbance, and somatic symptoms [4, 5]. Nurses, particularly women, are disproportionately affected due to factors like gender imbalance, lack of legal protection, and power dynamics within the healthcare hierarchy [6, 7]. Studies have shown that over half of nurses worldwide have experienced WSH ranging from 10 to 87.3% in different contexts [8, 9]. This form of harassment can have serious negative psychological, physical, and occupational consequences for victims [5, 9, 10].
Despite the negative consequences of WSH, many victims, especially those who experience less severe forms of harassment, hesitate to disclose their experiences [11]. Previous studies show that only 2–15% of WSH incidents are formally reported [12, 13]. Several factors contribute to this underreporting, including cultural norms, negative consequences, pressure from colleagues, disbelief, potential career damage, fear of retaliation, fear of rejection, lack of support from management [12].
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A person’s attitude toward disclosing WSH is significantly influenced by factors such as confidence in the reporting process, concerns about reputation, self-perception, and the perceived severity of the harassment [14, 15]. Freedman-Weiss et al. (2019) revealed that many surgical residents at Yale University who experienced WSH did not report it due to various reasons, including perceiving the harassment as harmless, believing it was a waste of time, feeling too busy, or uncertainty about whether the behavior constituted WSH. Most respondents cited multiple reasons for their failure to report [12]. Underreporting or inadequate reporting hinders efforts to quantify the true prevalence of harassment, impedes organizational change, and undermines justice and accountability. Addressing the barriers to reporting is crucial to preventing WSH and its negative consequences for nurses, patients, and organizations [16].
Cultural, religious, and social factors significantly influence attitudes toward WSH disclosure. In Iran’s socio-cultural context, discussing WSH is often stigmatized, leading victims to avoid disclosure due to fear of labeling, shame, and social stigma [17]. This underreporting hinders efforts to define the problem and implement effective prevention strategies accurately. The concept of sexual harassment and attitudes toward its disclosure are inherently context-dependent, carrying specific meanings within the relevant cultural framework. The religious, cultural, and social contexts of Iranian health organizations differ significantly from those in many Western countries. Given the absence of a standardized tool to assess nurses’ attitudes toward the disclosure of sexual harassment, both in Iran and globally, alongside the cultural misalignment of existing tools, there is a clear need for a tailored instrument in this area [18]. Consequently, this study aimed to develop a scale specifically designed to evaluate nurses’ attitudes toward the disclosure of WSH.
The questions of this study were as follows:
1.
What are the items of “nurses’ attitudes toward disclosure of sexual harassment in the workplace” scale?
2.
How is the content and face validity of the scale?
3.
How is the construct validity of the scale?
4.
What is the reliability of the total scale and subscales?
5.
How is the optimal length and interpretability of the total scale and subscales?
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Methods
Study design and setting
This study, conducted in Kerman, Iran, represents the second phase of a mixed methods study. The study consists of two main phases: (1) qualitative exploration of nurses’ WSH experiences and theme identification through conventional content analysis, and (2) development and validation of the NADWSH-S using a methodological approach. The scale development process, guided by DeVellis’ framework and Classical Test Theory involved eight stages: (1) determine clearly what it is you want to measure, (2) generate an item pool, (3) determine the format for measurement, (4) have the initial item pool reviewed by experts, (5) consider inclusion of validation items, (6) apply items to a development scale, (7) evaluate the items, and (8) optimize scale length [19].
Determine clearly what it is you want to measure: interviews and qualitative analysis
At this stage, conventional content analysis was used to analyze data from in-depth, semi-structured interviews with 22 Iranian nurses (18 women and 4 men). Purposive and snowball sampling were used to recruit participants with maximum variation (education level, work experience, organizational position, and work experience). Graneheim and Lundman’s (2020) method was used for data analysis [20], while Guba and Lincoln’s criteria (1994) were used to ensure data quality and trustworthiness [21]. A summary of the results of this section is presented in supplementary file 1.
Generate an item pool
The scale item pool was developed based on themes, categories, codes, and excerpts derived from qualitative data analysis, combined with a comprehensive literature review. Our previous scoping review (2024) identified various scales related to reporting WSH [14]. Additionally, we conducted a thorough search of various databases such as Science Direct, ProQuest, PubMed, Web of Science, Scopus, Google Scholar, and Iranian resources like SID and Magiran, using keywords related to sexual harassment, workplace, questionnaires/scales/instruments, psychometrics, content analysis, and qualitative studies.
Determine the format for measurement
Due to the widespread use of the Likert scale, we decided to use this scale. It requires respondents to rate their level of agreement or disagreement with each statement on a 5-point scale.
Have the initial item pool reviewed by experts
Content validity
To assess content validity, we employed both qualitative and quantitative methods involving 14 experts. Qualitative feedback focused on content coverage, grammar, wording, and item placement. Quantitatively, we calculated the content validity ratio (CVR) and content validity index (CVI). The CVR assesses item necessity using a three-point Likert scale: necessary, useful but not essential, and not essential. The Lawshe table was utilized to calculate a minimum acceptable CVR threshold of 0.51, leading to the retention of items with a CVR exceeding this value [22]. To assess content validity index (CVI), a four-point ordinal scale was employed to evaluate item relevance, ranging from not relevant to highly relevant. The item-level content validity index (I-CVI) for each item was calculated by dividing the number of experts who rated the item as either quite relevant or highly relevant by the total number of experts [23]. The S-CVI was calculated to assess the overall scale’s content validity. Items with an I-CVI of 0.8 or higher and an S-CVI of 0.9 or higher were considered acceptable [24].
Face validity
To assess face validity, both qualitative and quantitative approaches were employed. Fifteen nurses who experienced WSH were interviewed to evaluate item difficulty, relevance, and clarity. Additionally, the Item Impact method was applied to quantitatively assess item significance. Items with an impact score of 1.5 or higher were retained for further analysis [25].
Consider inclusion of validation items
The initial scale was pilot-tested on 50 nurses using convenience sampling. SPSS version 22 was used for data analysis. Various metrics were evaluated, including response rate, missing data, central tendency, dispersion, variability skewness, kurtosis, and floor/ceiling effects [26]. Items with more than 15% missing data, extreme skewness, or kurtosis, or exhibiting floor/ceiling effects were removed [27, 28]. According to some references, kurtosis values for items are acceptable within the range of ± 8 [29]. Both effects are calculated for the entire instrument as well as individual items, with unacceptable levels indicated by more than 80% of samples achieving the maximum or minimum scores [30]. Cronbach’s alpha was used to assess the initial reliability of the scale, while Inter-Item Correlation and Item Total Correlation were used to identify items that negatively impacted the scale’s internal consistency. Items with a Corrected Item Total Correlation below 0.3 were removed.
Administer the items to a development sample
Following the pilot study, a larger sample of 330 nurses was recruited through convenience sampling to complete the scale.
Evaluate the items
Construct validity
The study evaluated construct validity using both structural validity and convergent validity methods. SPSS version 22 was used for data analysis.
Structural validity
To assess structural validity, convergent and divergent correlation matrices were employed. Exploratory and confirmatory factor analyses were conducted using SPSS version 22. A sample size of 330 nurses was used [19], and the Kaiser-Meyer-Olkin (KMO) statistic was calculated to evaluate sample adequacy, with a value of 0.8 or higher deemed acceptable [31]. During the exploratory factor analysis, the type of rotation applied is crucial for simplifying and clarifying the factor structure [32]. In this study, Promax rotation was selected to simplify the factor structure, and items with factor loadings ≥ 0.4 were retained. The number of factors was determined based on eigenvalues ≥ 1 and the scree plot. Missing data were replaced with the median [33].
Convergent validity
Convergent validity refers to the extent to which a measure correlates with other measures or tasks that assess the same construct [19]. In this study, the Nurses Sexual Harassment Scale (NSHS) was utilized, with 330 nurses completing both scales. The NSHS, developed by Zeighami et al. (2024), was chosen as the most suitable instrument for assessing convergent validity due to its comprehensive coverage of sexual harassment types and its cultural relevance to the Iranian context. The NSHS, a 15-item scale, comprises two components: latent sexual harassment (9 items) and manifest sexual harassment (6 items). This scale explains 68.4% of the total variance and exhibits strong reliability, with Cronbach’s alpha coefficient of 0.94, Omega coefficient of 0.94, and ICC of 0.92 [34].
Reliability
We report both types of reliability, including relative and absolute. To evaluate the relative reliability, internal consistency, test-retest reliability, and McDonald’s Coefficient Omega were utilized. In this study, internal consistency was assessed in two phases: before and after factor analysis. A Cronbach’s alpha coefficient above 0.9 is considered excellent, 0.7–0.9 is good, 0.5–0.7 is average, and below 0.5 is unacceptable. McDonald’s Omega, a more robust measure of reliability, was calculated for the main sample of 330 participants [35]. Test-retest reliability was assessed using the Intraclass Correlation Coefficient (ICC). Thirty nurses completed the scale twice, two weeks apart, and Intra Class Correlation (ICC) was computed for all dimensions and the overall scale. An ICC value greater than 0.8 indicates favorable reliability [19]. Furthermore, to determine the absolute reliability, we used the formula (SEM = SD×\(\:\surd\:\)1 − r) [36], where r is the Cronbach’s alpha and SD is the standard deviation. Its interpretation will be based on the confidence interval around the sum for each score using the following formula: CI = Observed Score ± (Z×SEM) [37].
Optimize scale length and interpretability
At this stage, the final version of the scale was developed. It is important to consider that shorter scales tend to be more favorable for respondents, while longer scales generally offer greater reliability. Maximizing one aspect often results in a decrease in the other [19]. The final scale length was determined by considering the percentage of unanswered questions and the average response time from the samples.
For the quantitative interpretability of this scale, we use the Minimal Important Change (MIC), which is the smallest change in the construct score that is considered important for patients, using the formula (MIC = 0.5 × SD) [38]. Additionally, the Minimal Difference Change (MDC) was also calculated. It is the smallest change in a measurement that can be detected by a given instrument or test, indicating a true change in a patient’s status rather than a result of measurement error. MDC is often calculated using the Standard Error of Measurement (SEM) and can vary based on the specific instrument and population. Accordingly, it was calculated based on the formula MDC = SEM×Z×\(\:\surd\:\)2 [39].
Results
Define the measurement goal: the qualitative part of the study
From the data of the qualitative phase, 762 codes, one main theme, three sub-themes, eight categories, and thirty-three subcategories were extracted. The results of the qualitative data analysis indicated three themes: perception of the uneven work environment, internal perceptions of the victim, and ambivalent attitudes toward seeking family support.
Generate an item pool
A comprehensive literature review, including a scoping review and the examination of 6 international scales, was conducted to identify relevant items [14, 18, 40‐44]. Twenty articles were selected, and no scales were found in Iranian studies. Based on the qualitative findings and the reviewed literature, 22 new items were developed, and some existing items were revised. The initial item pool comprised 54 items, categorized into three themes: perception of the adverse work environment (23 items), internal beliefs of the victim (26 items), and skeptical view of family (5 items).
Determine the format for measurement
A 5-point Likert scale (strongly agree, agree, neutral, disagree, strongly disagree) was used to measure participants’ responses. However, a pilot study on 50 nurses showed that 15.83% of the responses were assigned to the “no idea” option. Therefore, a 5-point Likert scale (with a middle answer option) was selected for the present scale.
Have the initial item pool reviewed by experts
Content validity
Qualitative content validity
Fourteen experts, including two MSc and PhD in psychiatric nursing, five nursing faculty members specializing in scale development, six nursing faculty members, and one clinical instructor, reviewed the scale. According to their feedback, some items were merged, seven items (item 17, 25, 29, 30, 38, 39, 44) were removed due to vagueness or overlap, and items 1, 2, 50, and 51, were combined. The experts deemed the revised scale to be sufficiently comprehensive.
Quantitative content validity
Fourteen experts assessed the CVR and CVI of the scale. Based on the CVR, 14 items (item 1, 4, 7, 10, 15, 18, 23, 27, 30, 34, 37, 38, 39, 44) with a coefficient below 0.509 were removed. All items had a CVI above 0.8, except for one item with a CVI below 0.8. The CVI of the entire scale was 0.906. After the content validity stage, 18 items were removed, leaving 36 items in the scale stage (Supplementary file 2).
Face validity
Qualitative face validity
Fifteen nurses were interviewed face-to-face. Some of the items were rearranged in terms of their order in the scale (items 4, 5, and 26), and item 19 was rewritten for better clarity.
Quantitative face validity
Fifteen nurses participated to determine quantitative face validity. While three items had an impact score below 1.5, the research team decided to retain them for the pilot stage. Therefore, the scale proceeded to the pilot stage with 36 items.
Consider inclusion of validation items
Following the assessment of face and content validity, 50 nurses completed the scale. The pilot sample had an average age of 33.2 years and an average work experience of 12.5 years. Most of the participants were female (76%), married (71%), held a bachelor’s degree (78%), worked as nurses (89%), and were permanent personnel (72%). During this phase, items exhibiting floor/ceiling effects exceeding 75%, Corrected Item-Total Correlation below 0.2, Inter Item Correlation above 0.8, and skewness/kurtosis ≥ ± 2 were identified and removed based on the research team’s judgment (Table 1).
Table 1
Results of item analysis based on a pilot study on 50 nurses (pilot test)
Item | Corrected item-total correlation | Cronbach’s alpha in case of item deletion | Ceiling effect (%) | Floor effect (%) | Skewness | Kurtosis | Changes |
|---|---|---|---|---|---|---|---|
1. If sexual harassment is disclosed in the workplace, the victim suffers more than the harasser. | 0.192 | 0.825 | 0 | 54 | 1.4 | 1.55 | Remained with the opinion of the research team |
2. If the harasser holds a higher job position, disclosing and proving sexual harassment becomes difficult. | 0.591 | 0.814 | 2 | 30 | 1.28 | 1.81 | Remained |
3. Victimized women are blamed due to their unconventional clothing and makeup. | 0.393 | 0.819 | 6 | 18 | 0.6 | -0.36 | Remained |
4. Male victims are more inclined to remain silent due to the fact that disclosure contradicts their sense of masculinity. | -0.038 | 0.831 | 2 | 16 | 0.46 | 0.63 | Deleted |
5. A patriarchal culture makes male harasser less likely to be punished. | 0.053 | 0.829 | 4 | 20 | 0.69 | -0.29 | Remained with the opinion of the research team |
6. Disclosure of sexual harassment in the workplace creates rumors and slander against the victim. | 0.35 | 0.822 | 0 | 20 | 0.291 | -0.61 | Remained |
7. Confidentiality of colleagues and officials is an important principle in disclosing sexual harassment. | 0.033 | 0.835 | 30 | 2 | -1.09 | 2.16 | Remained |
8. Reporting sexual harassment is an example of whistleblowing. | 0.133 | 0.828 | 24 | 4 | -0.33 | -0.95 | Remained with the opinion of the research team |
9. The existence of an atmosphere of empathy and support in the workplace facilitates the disclosure of sexual harassment. | 0.036 | 0.83 | 22 | 6 | -1.07 | 1.17 | Remained with the opinion of the research team |
10. People who witness WSH have a moral obligation to report it. | 0.297 | 0.822 | 14 | 6 | -0.95 | 0.65 | Remained |
11. Reporting sexual harassment in the workplace is an effective way to stop the problem. | 0.187 | 0.825 | 18 | 2 | -0.79 | 0.44 | Remained with the opinion of the research team |
12. Existence of the law and specific guidelines on dealing with sexual harassment will facilitate its disclosure. | 0.083 | 0.829 | 40 | 0 | -0.86 | -0.26 | Remained with the opinion of the research team |
13. The process of disclosing WSH is time-consuming. | 0.224 | 0.825 | 10 | 22 | 0.58 | -0.61 | Remained |
14. Some people believe that harassers with powerful connections may avoid consequences. | 0.534 | 0.816 | 2 | 38 | 1.23 | 1.57 | Remained |
15. WSH can only be disclosed if there is sufficient and solid evidence. | 0.25 | 0.823 | 0 | 36 | 1 | 0.7 | Remained |
16. Some authorities exonerate harassers based solely on their outward behavior, appearance, and reasonable attire. | 0.441 | 0.818 | 4 | 26 | 0.88 | 0.87 | Remained |
17. Some authorities neglect WSH complaints to avoid challenges and trouble. | 0.44 | 0.819 | 0 | 32 | 0.519 | -0.3 | Remained |
18. The fear of losing a job reduces the motivation to disclose WSH. | 0.705 | 0.813 | 0 | 34 | 1.155 | 1.429 | Remained |
19. It is better to remain silent about WSH because victims may be blamed. | 0.481 | 0.815 | 20 | 14 | -0.08 | -1.38 | Remained |
20. Disclosing workplace sexual harassment can lead to fear and anxiety, as victims may worry about retaliation from the harasser. | 0.642 | 0.812 | 4 | 16 | 1.17 | 1.21 | Remained |
21. Fear of stigmatization reduces the motivation to disclose WSH. | 0.572 | 0.815 | 0 | 30 | 0.88 | 0.87 | Remained |
22. Disclosure of WSH causes victims to be stigmatized. | 0.731 | 0.811 | 0 | 32 | 0.76 | 0.58 | Remained |
23. Instead of disclosing WSH, victims should deal with the harasser directly and decisively. | -0.009 | 0.832 | 6 | 26 | 0.71 | -0.43 | Deleted |
24. Victims of WSH should examine their own behavior to avoid future harassment | -0.179 | 0.838 | 20 | 36 | 0.27 | -1.46 | Deleted |
25. Walking away from harassers puts an end to WSH and there is no need to disclose. | 0.314 | 0.822 | 36 | 4 | -0.89 | -0.3 | Remained |
26. To avoid the continuation of WSH, it is better to change the hospital, department or shift instead of revealing it. | 0.505 | 0.814 | 32 | 0 | -0.36 | -1.17 | Remained |
27. Shame makes it difficult to report incidents of WSH. | 0.444 | 0.817 | 2 | 0 | 0.6 | -0.29 | Remained |
28. Extroverted people are more willing and courageous to disclose WSH. | 0.292 | 0.822 | 20 | 0 | 0.12 | -0.89 | Remained |
29. Disclosure of WSH can lead to negative perceptions or judgement from others. | 0.526 | 0.816 | 0 | 24 | 0.44 | -0.4 | Remained |
30. Disclosure of WSH can damage the reputation of the profession. | 0.653 | 0.809 | 4 | 0 | 0.79 | -0.16 | Remained |
31. Disclosure of WSH causes a sense of peace for victims. | 0.271 | 0.823 | 8 | 6 | -0.45 | -0.1 | Remained |
32. Disclosure of WSH causes victims to feel guilty. | 0.334 | 0.821 | 10 | 14 | -0.19 | -0.66 | Remained |
33. The threat of family blame and punishment discourages WSH disclosure. | 0.504 | 0.816 | 0 | 20 | 0.71 | -0.43 | Remained |
34. Disclosing WSH can lead to spousal distrust and relationship breakdown. | 0.682 | 0.81 | 4 | 26 | 0.86 | 0.61 | Remained |
35. Disclosure of WSH causes restrictions on the part of the spouse. | 0.648 | 0.812 | 2 | 24 | 0.83 | 0.84 | Remained |
36. Ensuring family empathy and support facilitates disclosure of WSH. | 0.122 | 0.827 | 32 | 2 | 5.28 | 38.84 | Remained with the opinion of the research team |
Reliability: internal consistency (pilot stage)
Cronbach’s alpha of the whole scale with 37 items was 0.826. After removing three items, Cronbach’s alpha coefficient reached 0.854. Finally, the scale with 33 items was prepared for the construct validity.
Administer the items to a development sample
Construct validity
In the current study, structural validity and convergent validity were used to measure construct validity.
Structural validity
A total of 330 nurses working in hospitals affiliated with Kerman University of Medical Sciences participated in this stage of the study. Since the scales with 20% or more missing data should be removed [45], none of them were removed, and all 330 data were entered for item analysis and factor analysis. The mean age of the participants was 34.27 years, with an average work experience of 9.91 years. Most of the samples were female (80%), married (68.18%), had a bachelor’s degree (79.4%), worked as nurses (91.2%), were permanent personnel (50.6%), and worked rotating shifts (89.09%) (Table 2).
Table 2
Demographic characteristics of the nurses participating in the research (N = 330)
Quantitative variables | Mean ± standard deviation |
|---|---|
Age (years) | 34.27 ± 17.7 |
Work experience (years) | 9.91 ± 31.6 |
Qualitative variables | Frequency (%) |
Gender | |
Female | 264 (80) |
Male | 66 (20) |
Marital Status | |
Married | 225 (68.18) |
Singe | 82 (24.84) |
Divorced | 18 (5.45) |
Widowed | 5 (1.53) |
Education | |
BSc | 262 (79.4) |
Msc | 59 (17.9) |
PhD | 9 (2.7) |
Position | |
Nurse | 301 (91.21) |
Head Nurse | 23 (6.97) |
Supervisor | 6 (1.81) |
Recruitment Status | |
Contract recruiters | 163 (49.4) |
Permanent | 167 (50.6) |
Wards | |
Emergency Room | 35 (10.60) |
Psychiatrics | 34 (10.30) |
CCU/ICU/NICU/PICU | 75 (22.73) |
Surgery | 58 (17.57) |
Neurology | 16 (4.85) |
Pediatrics | 30 (9.09) |
Orthopedics | 10 (3.03) |
Internal Medicine | 53 (16.06) |
Oncology | 6 (1.82) |
Supervisory Office | 6 (1.82) |
Ophthalmology | 5 (1.51) |
Dialysis | 2 (0.60) |
Shifts | |
Fixed | 36 (10.909) |
In Rotation | 294 (89.09) |
Hospitals | |
A | 154 (46.66) |
B | 92 (27.87) |
C | 50 (15.15) |
D | 34 (10.30) |
Evaluate the items
At this stage, the items with ceiling/floor effects of more than 75%, missing values of more than 15%, and skewness/kurtosis exceeding ± 2 were identified. None of the items had a ceiling/floor effect. One Item (item 5) was removed due to a kurtosis of 120.8 and a skewness of 8.9, item 19 was removed due to excessive missing data (24%), and items 4, 6, 8, 11, 12, 25, and 33 were removed due to correlation below 0.2. Items 31 and 32 had a correlation of 0.76 and item 32 was removed.
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Exploratory factor analysis
Missing data were replaced with the median value. All factor extraction methods were tested along with various rotation methods. Among them, the PCA method with Promax rotation was considered due to better interpretability and better placement of items (Table 3). Factor loading above 0.4 was considered as a criterion for item retention. In cases where items had cross-loadings or did not load on any component were also deleted. Four factors were extracted, explaining 54.27% of the total variance. These factors were concerns about personality consequences (6 items), concerns about processes and organizational outcomes (5 items), tendency toward alternative strategies (4 items), and ethical beliefs about the disclosure of WSH (3 items). After removing 15 items, the final scale consisted of 18 items (Table 4).
Table 3
General results of factor analysis with different methods
Number | Method | Rotation | Variance | KMO | Bartlett test | Number of dimensions | Items | The number of items in each dimension | Variance of each dimension | |
|---|---|---|---|---|---|---|---|---|---|---|
Without deleting item number 32 | 1 | Principal Axis Factoring | Varimax | 46.800 | 0.814 | χ2 = 1627.63 Df = 91 P < 0.0001 | 3 | 14 | 6 | 20.54 |
5 | 15.09 | |||||||||
3 | 11.24 | |||||||||
2 | Maximum Likelihood | Varimax | 47.946 | 0.756 | χ2 = 1302.89 Df = 66 P < 0.0001 | 3 | 12 | 4 | 18.21 | |
5 | 16.59 | |||||||||
3 | 13.13 | |||||||||
4 | 18.21 | |||||||||
3 | Principal Component Analysis | Varimax | 49.48 | 0.780 | χ2 = 1494.94 Df = 120 P < 0.0001 | 3 | 16 | 6 | 20.43 | |
5 | 16.02 | |||||||||
5 | 13.02 | |||||||||
After deleting item number 32 | 1 | Principal Axis Factoring | Varimax | 47.68 | 0.790 | χ2 = 1443.953 Df = 105 P < 0.0001 | 4 | 15 | 5 | 16.11 |
5 | 13.51 | |||||||||
3 | 10.29 | |||||||||
2 | 7.76 | |||||||||
2 | Maximum Likelihood | Varimax | 44.92 | 0.758 | χ2 = 1376.087 Df = 120 P < 0.0001 | 4 | 16 | 7 | 15.21 | |
4 | 12.00 | |||||||||
3 | 9.72 | |||||||||
2 | 7.98 | |||||||||
3 | Maximum Likelihood | Varimax | 53.487 | 0.786 | χ2 = 1604.676 Df = 153 P < 0.0001 | 4 | 18 | 6 | 16.38 | |
5 | 15.41 | |||||||||
4 | 11.06 | |||||||||
3 | 10.62 |
Table 4
Factors extracted from exploratory factor analysis using principal component analysis (PCA) method and Promax rotation
Items | Factor Loading | Communalities | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|
Component 1 | Component 2 | Component 3 | Component 4 | Extraction | initial | |||||
1. The fear of embarrassment reduces the motivation to disclose WSH. | 0.476 | 0.499 | 1 | |||||||
2. Disclosing WSH leads victims to be stigmatized and marginalized. | 0.720 | 0.630 | 1 | |||||||
3. WSH disclosure can damage victims’ reputation and self-esteem. | 0.807 | 0.609 | 1 | |||||||
4. Disclosing WSH undermines professional integrity and reputation. | 0.791 | 0.690 | 1 | |||||||
5. The threat of family blame and punishment discourages WSH disclosure. | 0.586 | 0.422 | 1 | |||||||
6. Disclosing WSH can lead to spousal distrust and relationship breakdown. | 0.721 | 0.582 | 1 | |||||||
7. If harassers hold a higher job position, disclosing and proving WSH becomes difficult. | 0.582 | 0.404 | 1 | |||||||
8. The fear of losing a job reduces the motivation to disclose WSH. | 0.648 | 0.486 | 1 | |||||||
9. Harassers can be exonerated if they have connections. | 0.793 | 0.547 | 1 | |||||||
10. Some authorities exonerate harassers based solely on their outward behavior, appearance, and reasonable attire. | 0.702 | 0.498 | 1 | |||||||
11. Some authorities neglect WSH complaints to avoid challenges and trouble. | 0.668 | 0.497 | 1 | |||||||
12. Victimized women are blamed due to their unconventional clothing and makeup. | 0.482 | 0.447 | 1 | |||||||
13. It is better to remain silent about WSH because victims may be blamed. | 0.595 | 0.534 | 1 | |||||||
14. Walking away from harassers puts an end to WSH and there is no need to disclose. | 0.812 | 0.667 | 1 | |||||||
15. To avoid continued WSH, it is better to change hospitals, departments, or shifts instead of disclosing it. | 0.702 | 0.564 | 1 | |||||||
16. People who witness WSH have a moral obligation to report it. | 0.803 | 0.645 | 1 | |||||||
17. Reporting WSH is an effective way to combat the issue. | 0.817 | 0.655 | 1 | |||||||
18. Disclosing WSH provides a sense of relief and tranquility for victims. | 0.548 | 0.492 | 1 | |||||||
Eigen Value | 4.198 | 2.698 | 1.53 | 1.34 | ||||||
Variance of each Dimension | 23.32 | 14.99 | 8.51 | 7.44 | ||||||
Cumulative variance | 54.273 | |||||||||
Convergent validity
All 330 participants who completed the NAWSHD-S also completed the Nurses Sexual Harassment Scale (NSHS). A Spearman correlation coefficient of 0.684 was found between the total scores of these two scales, indicating a strong correlation and confirming convergent validity. The correlation of the subscales of the current scale with NSHS is shown in Table 5.
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Table 5
Correlation between the components and the total scale of NAWSHD-S with NSHS (N = 330)
NAWSHD-S | NSHS | |
|---|---|---|
P value | R | |
Component 1 | < 0.0001 | 0.542 |
Component 2 | < 0.0001 | 0.388 |
Component 3 | < 0.0001 | 0.391 |
Component 4 | < 0.0001 | 0.244 |
Total | < 0.0001 | 0.684 |
Reliability
The reliability coefficients, Cronbach’s alpha, and McDonald’s omega were calculated for the 18-item scale and its four subscales. Cronbach’s alpha values ranged from 0.720 to 0.805, indicating good internal consistency. The omega coefficient for the 18-item scale was 0.770. McDonald’s Omega, a more robust measure of reliability, yielded similar results, ranging from 0.714 to 0.817. To assess test-retest reliability, 30 nurses completed the scale twice, two weeks apart. Intraclass Correlation Coefficients (ICCs) were calculated for all components and the overall scale (Table 6).
Table 6
The Cronbach’s alpha, McDonald’s Omega, SEM, MIC, MDC, Intra-class correlation coefficients of subscales, and the total scale of NAWSHD-S
Component | Cronbach’s alpha | McDonald’s omega | ICC | Confidence Interval | SEM | MIC | MDC (95% CI) |
|---|---|---|---|---|---|---|---|
Component 1 | 0.805 | 0.817 | 0.847 | 0.738–0.907 | 0.82 | 2.11 | 2.27 |
Component 2 | 0.721 | 0.723 | 0.787 | 0.636–0.874 | 0.88 | 1.59 | 2.43 |
Component 3 | 0.710 | 0.714 | 0.776 | 0.624–0.852 | 0.92 | 1.59 | 2.55 |
Component 4 | 0.720 | 0.740 | 0.798 | 0.683–0.896 | 0.62 | 1.12 | 1.71 |
Total | 0.774 | 0.770 | 0.802 | 0.701–0.887 | 1.87 | 4.15 | 5.18 |
Optimize scale length and interpretability
As shown in the exploratory factor analysis table, after conducting the EFA and removing problematic items, finally 18 items remained, which formed the four components of the scale. These four components included: concerns about personality consequences (6 items), concerns about processes and organizational outcomes (5 items), tendency toward alternative strategies (4 items), and ethical beliefs about the disclosure of WSH (3 items). Respondents rate each item on a 5-point Likert scale including strongly agree (1), agree (2), no opinion (3), disagree (4), and strongly disagree (5). In the final scale, three items were reverse-scored, all three of which were in the fourth component (16, 17, and 18). The total score ranges from 18 to 90, with higher scores indicating a more positive attitude toward the disclosure of WSH. The scale demonstrated good practicality, with a low percentage of unanswered questions and a reasonable average response time of 5–15 min. Also, for quantitative interpretability, the values obtained for MIC and MDC for both the total scale and its subscales are shown in Table 6.
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Discussion
This study aimed to develop a scale measuring nurses’ attitude toward disclosing WSH. The resulting 18-item scale comprises four components, including concerns about personality consequences (6 items), concerns about processes and organizational outcomes (5 items), tendency toward alternative strategies (4 items), and ethical beliefs about the disclosure of WSH (3 items). These four components explained 54.27% of the total variance. This variance is acceptable for taboo topics like sexual harassment. Like the present study, in the Cesario study in America, the total variance of the scale was 54.38% [40]. Our results showed that this scale had acceptable validity and reliability. Several studies have also focused on similar scale development and psychometric properties, as summarized in Table 7. The SHRAS developed by Cesario et al. (2018) also consists of 18 items and three components: reporting risks, ethical obligation to report, and reporting application. Both scales employed Principal Component Analysis (PCA) with Promax rotation for factor extraction. While both studies assessed reliability using Cronbach’s alpha, our study additionally employed McDonald’s omega, SEM, and test-retest reliability for a more comprehensive evaluation. We also calculated values for quantitative interpretability, i.e. MDC and MIC, while this was not done in the Cesario scale. The key point is that the SHRAS mainly deals with individuals’ attitudes toward the moral duty to report sexual harassment, whereas in the present study, other aspects of individuals’ attitudes toward the disclosure of sexual harassment were discovered. Some items of the “reporting risks” component, similar to the items of the present instrument, address the consequences and risks of reporting sexual harassment. However, it is not clear in what aspects these risks threaten the individual. In contrast, the present scale specifies this issue in the form of two components: “concern about personal consequences” and “concern about process and organizational consequences.” Additionally, in the third component of the present scale, the items examine the “tendency to seek alternative solutions to disclosing WSH,” which is not present in any of the items of the SHRAS instrument.
Table 7
Comparison of sexual harassment instruments in different studies (based on the newest to oldest
Number | Author/year/country | Scale Name/ Abbreviation | Population and sample size | Number of Items | Number of subscales/ components | Likert spectrum | Validity | Reliability |
|---|---|---|---|---|---|---|---|---|
1 | Gautam and Tewari (2021) India | Knowledge, Attitude, and Practices (KAP) about Sexual Harassment at Workplace | 512 people employed in different organizations-public and private undertakings | 6 items for attitude | 1 | 5 | Rasch model | Real RMSE1=0.98 |
2 | Siyez et al. (2021) Turkey | Attitudes of the Turkish University Students and Staff Toward Sexual Harassment and Assault (ATSHAS) | 150 participants for EFA and 354 for CFA | 9 | 1 | 5 | EFA CFA | Cronbach’s alpha = 0.76 |
3 | Pedneault (2021) Canada | Attitude toward Sexual Aggression against Women (ASAW) scale | 648 men | 13 | 1 | 4 | EFA Discriminant validity | Cronbach’s alpha = 0.92 |
4 | Cesario et al. (2018) USA | Sexual Harassment Reporting Attitudes Scale (SHRAS) | 586 online panelists who reported any current or former employment | 18 | 3subscales include risks, moral duty, and utility | 5 | discriminant validity and EFA | Cronbach’s alpha = 0.87 |
5 | Ruiz et al. (2016) Puerto Rico | Attitudes and Knowledge of Health Professionals toward Sexual Assault in Adult Women (AKSSAW) | 135 participants selected by convenience. including 45 clinical psychologists, 45 social workers, and 45 nurses | 29 | 2components include perception of women and approval for myths | 5 | EFA | Cronbach’s alpha = 0.81 |
Additionally, we used convergent validity, while Cesario used discriminant validity. Both scales use a 5-point Likert scale for scoring, but the scoring direction differs. In our study, strongly agree is assigned a score of 1, while on Cesario’s scale, it is scored as 5. In addition, our scale includes three reverse-scored items, whereas the Cesario scale does not have any reverse-scored items.
The second scale is the Attitude and Knowledge Scale of Adult Women Regarding Sexual Harassment and Assault (AKSSAW), developed by Ruiz et al. (2016) in Puerto Rico. The scale consists of 29 items, with 18 items measuring attitudes and 11 items measuring knowledge.
Notably, among the 18 items related to the attitude section, three directly address the disclosure of sexual assault (Item 1: A woman who has been sexually assaulted is better off not disclosing the abuse, Item 4: Women who do not report sexual assault must have enjoyed it, and Item 17: I think a woman who remains silent about sexual assault does so because she likes me). This scale addresses sexual assault, while there is a distinction between sexual harassment and sexual assault. Additionally, this scale’s focus on women overlooks the male population, despite gender influencing attitudes and responses to sexual harassment. This scale has not been psychometrically evaluated in Iran or other countries, raising questions about its validity and reliability in diverse populations. The content validity assessment involved nine experts, whereas our study engaged 14 experts. For construct validity, exploratory factor analysis identified two components that explain 60.54% of the total variance, which is higher than that of the current study. However, the sample size for their exploratory factor analysis (135 individuals) is smaller than ours. Both scales have acceptable reliability, with the attitude section of this scale having a Cronbach’s alpha of 0.81, which is relatively higher than our scale.
Another potential scale considered for comparison is the Knowledge, Attitude, and Practice (KAP) scale for workplace sexual harassment, designed by Gautam & Tewari (2021) in India. This scale consists of four sections: demographic information, knowledge, attitude, and practice. The attitude section, relevant to this study, consists of six 5-point Likert scale items (ranging from strongly disagree to strongly agree). This section, with a reported Rasch model RMSE Real of 0.98, assesses attitudes toward reporting sexual harassment. It includes items on personal responsibility, perceived futility, and potential consequences of reporting. Five out of these six items overlap with the Cesario et al. scale (2018). Two items, reporting sexual harassment leads to its cessation in the workplace and anyone who experiences sexual harassment should report it, which aligns with ethical beliefs about the disclosure of WSH, similar to the current study. The design of this tool is based on the item-response theory, contrasting with the classical test theory principles underpinning the current tool. Additionally, its development involved a larger sample size of 512 participants compared to the current study.
Table 7 presents the studies by Pedneault (2021) and Siyez et al. (2021). While these studies address attitudes toward sexual harassment or similar concepts, they do not delve into the specific issue of reporting sexual harassment. When comparing the current scale to existing scales, it is evident that most of these scales prioritize attitudes toward WSH, with less emphasis on reporting. However, scales that address attitudes toward disclosing NAWSHD-S incorporate ethical obligations and the consequences of disclosure. Our scale extends this by addressing additional dimensions such as personal consequences and alternative strategies.
To develop a culturally relevant scale for WSH, it is essential to explore this concept within the cultural frameworks. Qualitative data collection methods allow nurses to articulate their experiences in their own words. To develop a culturally relevant scale for WSH, it is essential to explore this concept within cultural frameworks. Qualitative data collection methods allow nurses to articulate their experiences in their own words. Despite conducting individual interviews to ensure confidentiality and trust, the patriarchal culture and the taboo surrounding sexual harassment in the religious context of Iran have influenced the formation of the existing scale items. The social context of Iran is deeply rooted in patriarchal ideologies that perceive the female body as the property and honor of male family members [46]. On the other hand, the cultural sensitivity surrounding sexual harassment in Iran may have limited participants’ disclosures. Iran’s socio-cultural context reveals how gender norms and religious values shape nurses’ attitudes toward WSH disclosure. Societal expectations often discourage women from speaking out, as such actions may conflict with cultural norms. Additionally, religious beliefs can further inhibit disclosure, leading nurses to perceive it as inappropriate [47‐49]. A meta-synthesis showed that countries like Iran, Sri Lanka, Brazil, India, and Egypt have the highest stigma regarding the issue of sexual harassment of women. It seems that the common denominator in these countries is the importance of individual reputation and strict adherence to modesty and honor [50]. In contrast to Western countries, where there is greater openness to discussing sexual harassment, cultural barriers in Iran significantly hinder victims’ willingness to report WSH incidents [1, 16].
Furthermore, another factor that may have influenced the items on the current scale can be examined through the lens of the Theory of Planned Behavior (TPB). This theory posits that an individual’s intention to engage in a behavior is influenced by their attitudes, subjective norms, and perceived behavioral control [51]. In the context of disclosing sexual harassment, nurses’ attitudes are shaped by their beliefs about the consequences of reporting, while subjective norms reflect the perceived social pressure from colleagues and the organizational culture. Additionally, perceived behavioral control pertains to nurses’ feelings of empowerment or constraint based on available resources. Together, these factors elucidate how cultural norms and support systems impact nurses’ willingness to disclose incidents of sexual harassment.
Additionally, as this study focused on nurses in southeastern Iran, the generalizability of the findings to the entire Iranian nursing population is limited. Therefore, future studies should consider the various cultural and ethnic differences present in Iran. Furthermore, the predominance of female participants in both the qualitative and quantitative phases might limit the generalizability of results to male nurses. Future studies should address this gender imbalance.
In addition, while this study provides valuable insights, it is important to acknowledge the inability to infer causality, and we recommend conducting longitudinal studies to monitor changes in attitudes following interventions. Another issue to note is that confirmatory factor analysis was not conducted in this study due to the limited time available for completing the doctoral thesis, and we plan to perform this analysis in future research.
Conclusion
Disclosure of WHS is influenced by individual attitudes, which are shaped by the sociocultural and economic contexts. As attitudes towards the disclosure of WHS vary across cultures, it is advisable to use culturally congruent scales for measurement. The results of this study indicated that the NAWSHD-S is a valid and reliable scale for assessing attitudes toward WSH disclosure, particularly among nurses and other healthcare professionals. Given the sensitivity of WSH within Iranian culture, assessing nurses’ attitudes toward the disclosure of WSH can assist relevant authorities in designing and planning effective prevention strategies.
Acknowledgements
We would like to thank the nurses who participated in the study. The present study is part of a nursing Ph.D. thesis aimed at developing and validating the NAWSHD-S. We sincerely thank all the officials of Kerman hospitals and all the participants who contributed to this study.
Declarations
Ethical approval
This study was conducted as part of a dissertation and approved by the Ethics Committee of Kerman University of Medical Sciences (the code of ethics: IR.KMU.REC.1402.138).
Informed consent
Written informed consent was obtained from all participants, who were fully informed about the study’s purpose and assured of confidentiality. The timing and locations of all interviews were scheduled according to the participants’ preferences. All procedures were conducted in compliance with applicable guidelines and regulations.
Consent for publication
None.
Competing interests
The authors declare no competing interests.
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