Nursing practice in sexual dimension of patients: Literature review

Abstract

Background

Sexuality is human rights, a fundamental part of healthy life which is defined as the absence of illness, social, emotional, mental and physical welfare in relation to the sexuality and has become the consideration of health service aspect. Sexual health is one of the parts of the patient's holistic needs in which the nurse has the responsibility and nursing practice through sexual education. Sexual dimension is not an easy to discuss since culturally it is not easy to express. So, it has become a topic which needs to be explored.

Purpose

To identify the description of nursing practice in the patient's sexual health dimension and various factors which obstruct the implementation of sexual discussion.

Methods

The research was conducted using databases such as PubMed, MEDLINE, ProQuest and Google Scholar. The articles were published within the period of 2000–2018. The synthesis was done based on twenty articles with the main variables namely attitude, belief, nursing practice and obstacles in sexual discussion which comply the checklist of Joanna Briggs Institute (JBI) Critical Appraisal Checklist.

Results

There were five main topics which elaborated nursing practice when discussing sexual topic with the patient, namely the attitude in discussing sexuality topic, the level of comfort and self confidence in the discussion, initiation in discussing sexuality, spending time in discussing sexuality and the obstacle in conducting sexual discussion.

Conclusion

Lack of knowledge and the lack of continuity of education through training was one of the factors that obstructed sexual discussion with the patient.

Introduction

Sexuality is a human right and a fundamental part of a healthy life which is the central aspect that consists of sex, identity and gender role, sexual orientation, erotism, intimacy and reproduction. Every individual has the right of care and sexual health information in order to make personal decision toward individual's sexual life.¹ Sexuality has become one of the important aspects in providing health care since 1970.^2,3 Holistic treatment requires that a concept of seeing the patient should be done by assessing the patient comprehensively with the dimension of biology, psychology, social as well as spiritual. As a nurse one should apply its role and function by considering individual needs of each patient through the responsibility of nursing practice by providing educational information.⁴ This has been identified as a component of holistic nursing care by considering sexuality as well as conducting studies of sexuality aspect, specifying a diagnosis of sexuality problem, delivering intervention and evaluation of the results.^5,6 A nurse should remember that the patient is a sexual being in every age and each level of life he is gaining experience which impact their sexual aspect.⁷ Therapeutic relation between a nurse and a patient will directly open the chance to have a sexual discussion and the nurse could specify the patient's relevant sexual problem. But most of the nurses believe that sexuality is a very personal issue to be discussed with the patient and the nurses tend to believe that the patient being taken care in the hospital is not really interested in discussing issue related to sexuality with the nurses.⁸

Sexuality topics are quite controversial and when it is being discussed in context of health service in general or for the mental health will potentially cause different view or perspective related to the sexuality discussion. It is also emphasized that individual experiencing mental health issue related to sexual issues have been covered by misunderstanding, myth, and negativity.⁹ The aim of this study is to identify the depiction of nursing practice in the patient's sexual health dimension and various factors which obstruct the implementation of nursing practice.

Methods

Search strategy

The preliminary search was conducted using three databases, namely PubMed, MEDLINE ProQuest and Google Scholar. The keyword used is MESH (Medical Subject Heading) (“nurses” OR “nurse” OR “nurses’ belief” OR “nurses’ attitudes” OR “nurses’ barriers” OR “nurses’ perceptions” OR “sexuality” OR “sexual health” OR “sexual problem” OR “sexual activity”) AND (“patients” OR “adolescent patients”) and the study search was done during the period of 2000–2018.

Inclusion criteria

The eligibility criteria set in the inclusion criteria is that the article must be related to the behavior, belief and barrier felt by the nurses in discussing sexual issue with the patient.

Search outcome

In the first phase 5057 article titles were chosen and 68 duplications were deleted. In the next phase title and abstract selection was done so that 162 articles which were in line with the main variables such as behavior, belief, nursing practice in sexual discussion with the patient. In the next process each article were read the to eliminate articles that were not in line with the inclusion criteria, As a result finally 20 articles passed the quality appraisal phase.¹⁰

Quality appraisal

The reviewer fully read the selected 20 articles and its relevant assessment was conducted using Joanna Briggs Institute (JBI) Critical Appraisal Checklist (Cross sectional, RCT, Qualitative and Quasi Experimental). The consideration was done for the input and elimination of articles to the synthesis phase using inclusion criteria based on research subject, research sample, validity and reliability of the measurement tool, confounding factor and statistical analysis used in such research (Table 1).

Table 1.

Summary and characteristics of the study.

No	Author(s), year of publication, country	Design & method	Main variables	Sample size
1	(Benoot et al., 2018) Flanders, Belgia	Qualitative: Exploratory Interview	Nurses’ attitude and practices	21 nurses palliative
2	(Leonardi-Warren et al., 2016) UK	Descriptive, Cross Sectional Questionnaire survey & interview	Nurses’ attitude, belief & barriers	77 nurses
3	(Bal and Sahiner, 2015), Turkish	Descriptive Cross-Sectional Questionnaire survey SABS	Nurses’ attitude, belief & barriers	155 nursing students
4	(Jonsdottir et al., 2016), Iceland	Qualitative Experimental Pre-posttest time senses	Nurses’ attitude, belief and barriers	238 Oncology nurses
5	(Quinn et al., 2011) Australia	Qualitative Exploratory Interview	Nurses’ practices	14 mental health nurses
6	(Arikan et al., 2015) Turkish	Descriptive Cross-Sectional Questionnaire survey SABS	Nurses’ attitude, belief and barriers	162 nurses
7	(Oskay et al., 2014) Turkish	Descriptive, Questionnaire survey	Nurses’ attitude, belief and barriers	87 Oncology nurses
8	(Huang et al., 2013) China	Descriptive, Questionnaire survey	Nurses’ attitude, belief and barriers	128 cancer nurses
9	(Moore et al., 2013) Ireland	Descriptive, Questionnaire survey	Nurses’ attitude, belief and barriers	200 Oncology nurses
10	(Hoekstra et al., 2012). Netherlands	Descriptive, Questionnaire	Nurses’ attitude, belief and barriers	122 cardiac nurses
11	(Zeng et al., 2011), China	Descriptive, Questionnaire: Sexual Attitude Belief Scale/SABS	Nurses’ attitude, belief and barriers	202 gynecology nurses
12	(Yung Chun Zeng, 2011), China	Descriptive, Questionnaire: Sexual Attitude Belief Scale/SABS	Nurses’ attitude, belief and barriers	199 Oncology nurses
13	(Julien et al., 2010), America	Descriptive, Questionnaire: Sexual Attitude Belief Scale/SABS	Nurses’ attitude, belief and barriers	576 perioperative nurses
14	(Saunamaki et al., 2010) Sweden	Descriptive, Questionnaire; Sexual Attitide Belief Scale/SABS	Nurses’ attitude, belief and barriers	100 medical/surgical nurses
15	(Mahmoud et al., 2015) Cairo	Descriptive, Questionnaire: Survey	Nurses’ attitude, belief and barriers	200 Oncology nurses
16	(Magnan et al., 2005), America	Descriptive, Questionnaire: Sexual Attitude Belief Scale/SABS	Nurses’ attitude, belief and barriers	148 Oncology nurses
17	(Magnan & Norris, 2006), US	Descriptive, Questionnaire: Survey	Nurses’ attitude, belief and barriers	87 pediatric nurses
18	(Higgins et al., 2008), Ireland	Qualitative Exploratory; Grounded Theory, Interview	Nurses’ response	27 mental health nurses
19	(Wang et al., 2018), China	Descriptive, Questionnaire; Sexual Attitude Belief Scale/SABS	Nurses’ attitude, belief and barriers	268 cardiac nurses
20	(Afiyati, 2017), Indonesia	Descriptive, Questionnaire; Sexual Attitude Belief Scale/SABS	Nurses’ attitude, belief and barriers	135 Oncology nurses

Results

Quantitative Main Findings: (depicted in Figs. 1–4).

Figure 1.

Attitude: Nurses’ sense of responsibility to discuss sexual health.

Figure 2.

Comfort: Nurses’ level of comfort to discuss sexual health.

Figure 3.

Sexuality discussion initiated by patient.

Figure 4.

Nurse felt the lack of time to discuss sexual health.

Table 2: Qualitative Main Findings.

Table 2.

Qualitative main findings.

Qualitative main findings
Attitude	The participant had the view that sexuality discussion was inappropriate due to the conversation on sexual issue between the nurse and the patient was a sensitive thing and it would hurt the patient so the nurse tended to avoid that	The understanding of most of the participant was that sexuality was an important thing and need to be discussed together	The nurse said that sexual topic must be prioritized in the service so that the nurse could breal barriers and active in explore
Comfort	The participant expressed the feeling of uncomfortable	The sexual discussion topic placed the participants outside the comfort zone of their ability and most of the participants avoided such topic	The nurse said that he/she was not comfortable discussing sexuality
Initiation	The participant would ignore the topic or prevent and had no intention to initiate the discussion of sexual issue and would refer the patient to psychiatrist	The participant showed that he/she never initiated a conversation about the patient's sexuality	The participant stated the he/she actively initiated a conversation discussing sexuality or also waited for the patient and spouse
Time	The participant said that there was lack of time to discuss sexuality	The nurses focused on the treatment more so that the time to discuss sexuality was limited	The participant explained that he/she had not much time to discuss sexual topics

The obstacle factors (internal and external) in sexual discussion.

Most of the articles which were from Asia, Australia and Europe explained the nurse's internal obstacles toward the discussion of sexual issue with the patient were related to the nurse's personal matter such as age, sex, nurse's educational background, working tenure, feeling of fear and the opinion on sexual issue, knowledge, marital status, and confidence. There were also external obstacles faced by the nurse toward discussion of sexual health issues of the patient, namely the lack of training related to sexual education and counseling, nurse's work load, language, culture toward the view of sexual concept, the lack of professional health care support, the lack of communication skill, the lack of safe discussion place to maintain confidentiality, limited resources and the lack of information on the sexuality concept and sexual health issues.

Discussion

The attitude in discussing sexuality topic

Generally, the nurse had the positive attitude with adequate sexual understanding of the patient during the sexuality discussion. There were sixteen several studies showing the positive attitude in discussing sexuality topics which was expressed through the nurse's responsibility in providing education or sexual counseling and giving permission to the patient and the family to discuss about sexual issue. However, there were three studies reporting that a small number of nurses had negative attitude and showed ignorance toward the patient's sexuality needs, they were less admitted toward the sexual rights in health care. So, the responsibility lies on him by distributing information willingly and they must be open when the patient asked about sexual health issues faced by them. They must give sexual education or counseling to fulfill the needs of information related to sexuality.^3,5,11–18 It was also added from the research results that responsibility would increase if the nurse had high awareness related to the nurse's role in fulfilling the needs of sexual health information.^3,19

The level of comfort and self confidence in discussing sexuality

The discussion about sexuality was difficult for the nurse due to the faith, belief as well as nurse’ personal view on sexuality, sexual education, the comfort of sexual identity as well as sexual issue was still being perceived as a taboo.^13,20–23 This was strengthen with the research results which explained that personal comfort became the predictor which was closely related in overcoming the patient's sexual issue.^16,19,24

The nurses were shameful of sexual discussion, the fear if the sexual topic may put the patient in shame, the ignorance of nurse's response, the feeling of incompetence in general and not enough confident of the emerging attitude.^25,26 Comfort was the important issue in improving nurse's confidence to discuss sexuality sensitive issues.

Initiation of discussion on sexuality

It was found that sexual issue could be discussed only if it was initiated by the patient and then the nurse would start it. The nurse would not commence the discussion before the patient. The nurse believed that sexuality was too personal to be discussed with the patient. The nurse tended to suggest the patient to discuss it with the doctor or other medical practitioner. Meanwhile this study also revealed that some nurses had the initiative, readiness and was not shameful to discuss the topic of sexual health issue with the patient. But if the patient was interested in and expressed it, then the patient will be invited to the conversation by the nurse.^7,28 Nevertheless, most of the nurses indicated that the patients tended to wait for the nurse to initiate the discussion and sometimes ignored the sexuality issue entirely.^9,27

Spending time in discussing sexuality

The research results showed that even though nurses were aware that sexuality was so relevant with the patient care but in practice the nurse did not have time to discuss this. The nurses only focused on the disease treatment and patient's physical issue along with the factors such as unwillingness of the patient to talk about sexual issue with the lack of knowledge, general view and the nurse's attitude toward sexual issue caused lack of sexuality discussion.^2,5,7,18 Most of the research results revealed that the nurse had the responsibility to talk about sexuality, but in practice the nurse did not take out time for this though she believed that it was the part of her responsibility.^29,30 Only a small part of the study that reported that the nurses were willing to spend her time to discuss sexual health issue with the patient.

The obstacle factor in conducting sexual discussion

The patient consisted of two components, namely internal which was closely related to the relation with the environment, facility and the nurse ability. The main obstacles here was the nurse failure in discussing sexual issue with the patient lied on the internal factors. The attitude and belief that the patient in general did not have much sexual issue and to manage the patient's sexual issue was a taboo, they were considered too personal and a sensitive. So it emerged from the nurse's thought of fear, shame, lack of comfort, insecurity, lack of confidence, and the concept not being in line with the culture and social value.^{5,9,11,15,18,27,31,32} These could be gained by the nurse with growth of self-development and continuing education program either in the form of training or workshop related to the sexuality issue in patient's dimension.^{6,7,14,17,20,31,32}

The results of the present study showed that the nurse was aware of sexuality discussion in nursing practice in the form of responsibility as well as the belief of the importance of having a discussion on sexuality with the patient. However, the nurse felt uncomfortable and was unsure with her own ability in discussing sexuality with the patient. As a result, the nurse tended to refer sexuality topic to the doctor or other medical personnel. The nurse sometimes had no spare time to discuss sexuality with the patient. They perceived this as taboo, too personal and sensitive so that sometimes it became unimportant even though it was related to the disease and the patient's medication. Nurses age, sex, educational background, working tenure, fear, self-confidence and knowledge obstructed in this practice. The external factors which obstructed the sexuality discussion between the nurse and the patient were the lack of training on sexual education, counseling ability, lack of communication skill, nurse workload as well as limited resources, the culture view and social value on sexuality in health care, the lack of safe discussion place which ensured the patient's confidentiality.

This review can help the nurse to have understanding about the nursing practice in giving the health care in the patient's sexuality aspect. This will not only increase nurses’ awareness, knowledge, attitude it will also help to change her belief and faith as perceived by the nurses on the patient's sexual health. Sometimes such faith, values as well as the culture, obstruct the nurse to do nursing care holistically. Sexual education and communication skill are needed by the nurse so that they could improve their knowledge, attitude and self-confidence which will be implemented through discussion and counseling about the patient's sexuality issue.

Conflict of interests

The authors declare no conflict of interest.