Staff beliefs about sexuality in aged residential care.
Abstract: Expression of sexuality is a lifelong need and a basic human right, yet little is known about how staff in aged care facilities approach and manage the sexuality needs of residents. Fifty-two staff members from the rest home component of aged care facilities in one District Health Board completed a survey anonymously. Findings indicated that while the majority believe residents have sexual needs that should be acknowledged and supported, expression of sexuality often created discomfort and the need was not regularly assessed, or managed by a team approach. Lack of privacy, negative staff and family attitudes plus the difficulty of managing risk make responding to sexuality a complex issue. The combination of individual and institutional barriers suggest that thoughtful and creative team strategies are required to address the sexuality related needs of the older person in residential care.

Key Words: Sexuality, residential care, aged, attitude of health personnel.
Article Type: Report
Subject: Medical personnel (Surveys)
Medical personnel (Beliefs, opinions and attitudes)
Sex (Psychology) (Research)
Authors: Gilmer, Mary Jane
Meyer, Alannah
Davidson, Jocelyn
Koziol-McLain, Jane
Pub Date: 11/01/2010
Publication: Name: Nursing Praxis in New Zealand Publisher: Nursing Praxis in New Zealand Audience: Academic Format: Magazine/Journal Subject: Health care industry Copyright: COPYRIGHT 2010 Nursing Praxis in New Zealand ISSN: 0112-7438
Issue: Date: Nov, 2010 Source Volume: 26 Source Issue: 3
Topic: Event Code: 310 Science & research
Product: Product Code: 8010000 Medical Personnel NAICS Code: 62 Health Care and Social Assistance
Geographic: Geographic Scope: New Zealand Geographic Code: 8NEWZ New Zealand
Accession Number: 291701802
Full Text: Introduction

Over twenty-five thousand people aged 65 years or older reside in non-private residential care facilities in New Zealand (Statistics New Zealand, 2007). The people who provide care in these facilities include registered nurses, enrolled nurses, healthcare assistants, managers and other allied health workers (Kiata, Kerse, & Dixon, 2005). These care workers are often confronted with the challenge of addressing the sexuality needs of individual residents while at the same time protecting the safety and rights of all residents.

Sexuality has a range of definitions (Robertson, 2003). Kaiser (2003) describes sexuality as "a complex interplay of needs for intimacy, affection, connection, self-pleasure, self-image, and the individual's context related to gender, ethnicity and community" (p. 463). Sexuality remains a fundamental part of life that does not necessarily abate with age (Lenahan & Ellwood, 2004). The expression of sexuality among elders is normative (Bauer, McAuliffe, & Nay, 2007; Meyer & Roseamelia, 2007; Salzman, 2006). It benefits self-image, social relationships and mental health (Hajjar & Kamel, 2003). While sexuality may shift from genital sex to other forms of intimacy, sexual energy persists even in the frail residential care resident (Ginsberg, 2006). Aged care residents face multiple barriers to achieving normative sexuality. A perception of being unattractive, hesitancy to broach the subject of sexuality, lack of a partner, mental and physical illness and medication side effects have all been identified as impeding sexuality (Ginsberg; Hajjar & Kamel; Jones & Barton, 2004).

Supporting residents to overcome impediments to acknowledging sexuality may require problem-solving in complex situations for which staff and families are poorly prepared. Elder residents' interests in sexual expression are generally viewed by families and staff as 'a problem' (Rheaume & Mitty, 2008). Staff may And sexual behaviours easier and safer to ignore, and perhaps even pathologise (Archibald, 2002). Research suggests that ethical dilemmas, misinformation about ageing, and the lack of provider education and assessment tools are barriers in supporting sexual health in older adults (McAuliffe, Bauer, & Nay, 2007; Tsai, 2004; Walker, Osgood, Richardson, & Ephross, 1998).

Ethical Dilemmas.

International standards state that older adults have many rights including the right to fundamental freedoms (United Nations, 2002). Aged care residents have the right to freedom, self-fulfilment and dignity, including the right to sexual well-being (Age Concern New Zealand, 2007; Alliance for Ageing Research, 2003; Levy, Slade, Kunkel, & Kasl, 2002; Roach, 2004). Consumers of Health and Disability services within New Zealand are assured that their values, culture, beliefs, and personal privacy will be respected and that those involved in their care will 'work together for you' (Health and Disability Commissioner Act of 1994). Nursing competencies include promoting environments that maximise client safety, independence, quality of life and health (Nursing Council of New Zealand, 2007). The aged care residential setting plays a central role in residents realising their individual sexual goals (Hajjar & Kamel, 2003). Therefore, residential institutions and staff have a duty to take reasonable action to support residents' sexuality. This duty, however, may be at odds with protecting themselves and other residents. For example, if the sexual needs of residents are ignored or not assessed and this results in client distress, care providers may be reviewed for unintentional neglect (Glasgow & Fanslow, 2007; Srinivasan & Weinberg, 2006). On the other hand, an institution and its staff could become party to ethical or legal review if a resident was not protected against coercive sexual overtures by another resident (Loue, 2005). The dilemma becomes more pronounced with residents who have dementia, where the consent process for sexual activities becomes blurred and challenging (Lenahan & Ellwood, 2004).

Misinformation about Ageing.

Rodgers and Neville (2007) identified ageism as a significant factor posing a threat to the personal autonomy of the older adult living in a residential setting. Ageism can be accompanied by a tendency to patronise residents as if they were children (Frankowski & Clark, 2009). Ageism and misinformation about ageing and sexuality is evident in the everyday life of residential care institutions, perpetuated by institutions, staff and families alike (Roach, 2004).

Life in residential facilities, by design, is very public. Residential facilities have communal spaces and residents' rooms may not have door locks (Bauer, 1999a). There are few places where residents can be alone. Staff prefer easy, unhindered access to residents while completing their care giving duties (Bauer, 1999b). Studying New Zealand residential care, Bland (2007) discusses how routines and rituals override the possibility of individualized care. Many are "driven more by a desire for organizational efficiency than the comfort of residents" (Bland, 2003, p. 187). These barriers collectively work against acknowledging sexuality needs of individuals in residential care.

If sexuality is not appreciated as a legitimate need among older adults living in a residential setting, then it follows that sexuality assessments and guidelines would not be necessary (Frankowski & Clark, 2009). The taking of an adequate sexual history in order to enable appropriate treatment, education, and sexual health information is likely influenced by staff characteristics (Jones & Barton, 2004; McAuliffe et al., 2007). Interviewing aged care residential staff in Australia and Sweden, Roach (2004) describes staff avoidance of sexuality issues as 'standing guard' against personal discomfort. Staff characteristics related to motivation, education and generation are known to impact health care provision (Archibald, 2002; Wieck, 2007). The younger and higher educated caregiver is likely to have a more permissive attitude towards sexuality (Luadzers, 1995). A health care provider who does not feel supported in her environment may not feel confident to complete a sexual assessment. In some instances, managers have made female staff feel responsible for the sexual expression of male residents; one manger was reported as saying "well maybe you're just too friendly, giving off signals to him" (Archibald, 2002, p. 306). Greene and Burke (2007) suggest that the peak developmental experience requires individuals to move to a cause 'outside of their skin', facilitating opportunities for others to develop to their highest potential. Providing meaningful work for a diverse group of staff in a complex environment requires a culture of workers who feel safe and are free to solve complex problems in creative ways (Kerfoot & Wantz, 2005).

Lack of Provider Education.

For health care providers education about sexuality is vastly inadequate (Wallace, 2008), with many nurses feeling ill-equipped to take a sexual history (Calamidas, 1997; Tsai, 2004). The lack of education (and research) regarding the sexual activity of older adults leaves health care providers unaware of what residents want and need to satisfy their sexual interests (Rheaume & Mitty, 2008). Two New Zealand nurse educators report that sexuality assessments are often left blank or assigned "Not Applicable" in aged care facilities (J. Davidson & A. Meyer, personal communication, December 6, 2007). Despite Standards New Zealand (2001) having the requirement that organisations providing care for older adults demonstrate firstly individualised assessments and secondly actions taken as a result of the assessments, the sexual needs of the older adult are often overlooked (Frankowski & Clark, 2009; Roach, 2004). While international literature suggests reasons why sexuality assessments may not be done, the present researchers felt it important to hear from a sample of New Zealand staff. The aim of the current research was to identify factors influencing aged care residential staff assessment and management of residents' sexuality.

Method

In this descriptive pilot study staff from the rest home component of aged care residential facilities within one New Zealand District Health Board (DHB) were surveyed anonymously. The research proposal was peer-reviewed and ethical approval granted by the Eastern Institute of Technology Review Board, Central Ethics Committee, and the Maori Health Service Manager, Hawke's Bay. A cover letter to potential participants described the study and explained that return of a completed survey indicated consent.

Procedure.

Twenty-one residential aged care facilities were identified within Hawke's Bay DHB. Researchers contacted the nurse managers from the identified facilities and permission was granted to distribute surveys. Eligibility criteria included currently employed individuals providing direct patient care in the rest home component of the aged care facility. Seven hundred anonymous surveys were provided to managers to distribute to eligible staff members. Completed surveys were returned using the stamped addressed envelope provided. All nurse mangers received a follow up phone call to ensure they had received the survey forms, and to answer any queries and promote participation in the research.

Survey.

The survey was developed by the authors based on the literature review (such as from Fairchild, Carrino & Ramirez, 1996). Experts including caregivers, registered nurses, managers, educators, and a geriatrician pilot tested the survey and corrections were made to improve validity and item clarity. The final 18-item survey included both closed-ended (requiring a 'Yes/No' response) as well as open-ended questions. The survey addressed seven employee characteristics (such as age, role, length of time working in aged care and aged care and sexuality training), workplace milieu (3 items), employee beliefs about sexuality (6 items), difficult work place situations regarding sexuality (1 item) and interest in further education (1 item). Employees were asked to describe their understanding of sexuality and how it is expressed by residents. The survey included seven closed-ended favourable sexuality stance items (see Table 1). The internal reliability for these questions was .915 (alpha coefficient). The survey is available from the corresponding author.

Numeric data were entered and analysed using SPSS Statistics (version 17.0, 2008). Analysis was limited to descriptive statistics because the sample was not randomly selected and the study purpose was exploratory. Open-ended question responses were analysed firstly by the researchers independently and secondly as a group. Researchers used content analysis to identify factors named by participants in responding to the open-ended questions. As a pilot study, the study design and analysis focused on naming factors rather than providing a deep description of staff perceptions. Emphasis was placed on respondents' comments rather than the number of times an issue was noted.

Results

Respondent Characteristics.

Fifty-two surveys were returned. While the exact number of employees who received the invitation to participate was unknown, we estimate that 7% of employees responded to the invitation to complete a survey about sexuality in aged care residential facilities. The majority of respondents were female (n=50; 96%), over 40 (n=33; 63.5%; range=20-71 years) and had worked in aged care residential facilities for at least four years (n=37; 71%; range 1-30 years). The majority identified as European (n=39; 75%), followed by Maori (n=8; 15.4%) and other (n=5; 9.6%). Most were caregivers (n=25; 48%), followed by registered nurses (RN; n=13; 25%), enrolled nurses (n=6; 11.5%), managers (n=4; 7.7%) and therapists (n=4; 7.7%). Forty-two participants (81%) reported having had training or education in aged care and 24 (46%) in aged care and sexuality.

Workplace Milieu.

The majority of respondents reported that their workplace had a policy or procedure relating to sexuality (65%) and that their facility provided privacy for consenting couples to engage in sexual behaviour (56%). Among the 13 RN participants, 11 reported including sexuality in their nursing assessment. Some caregivers, however, provided comments identifying the invisibility of sexuality in their workplace. For example, "this is the first time this subject has been bought to my attention" and "the issue has never been addressed to my knowledge" and "it is just not thought about, is not included on life style plan, I don't include it on an assessment". Others wrote of discomfort in addressing the issue, "I would feel uncomfortable approaching the subject". In some cases, an anti-sexuality stance was described: "in the past have been told not to support sexual relationships to the point of being told to ensure the door was left open" and "I have seen in the past where this behaviour has been denied by senior staff"

Sexuality Beliefs.

The overwhelming majority of respondents believed residents have sexual needs (90%); that resident consensual sexual activity and intimacy should be supported by aged care facilities (85%); and that sexuality is a lifelong need (81%). Respondents commented: "If consensual then there should be some support as we should not discriminate just because of age" and "Just because you're old doesn't mean things have to change" and "especially for couples who have been together prior to admission" and "it is an individual's adult human rights issue". Supportive sexuality beliefs, however, were not universal. One respondent wrote, "[I] do not believe that this generation still has [sexuality] need" and another, "the desire for sexual activity in elderly appears minimal".

When asked to describe their understanding of the term sexuality, respondents typically related sexuality to gender expression. Comments included: "the way a person dresses, make-up, jewellery, the way they present themselves", "how a person expresses/gains sexual satisfaction", "sexual intimacy", and "the expression of gender interpersonal interaction, personal function in a way which is comfortable for each individual".

When asked to provide their observations regarding resident sexuality, respondents included both normative and inappropriate actions. Normative actions (behaviours) included "grooming, dressing, manners", "[going to]hairdresser", "hand holding, kissing", "hugging", "masturbation", "courting procedures", "flirting" and "married couple activities". Behaviours that were perceived by respondents [and not necessarily the authors] as inappropriate expressions of sexuality included the following: "improper touching of staff by a male resident", "erections in response to nursing care", "pornographic magazines", "proposition for sex from male resident" and "sexual jokes".

Difficult Situations.

Respondents reported numerous barriers to addressing sexuality in the aged care residential setting. These barriers included lack of privacy; staff, resident and family attitudes; and a desire to protect individuals and the overall residential environment. Some respondents pointed out the difficulty in addressing sexuality in the context of co-morbidities, diminished cognitive and physical abilities and poly-pharmacy (e.g. "medications suppressing desire").

Privacy.

Many respondents talked about the difficulty in providing privacy to support residents' sexuality. This was sometimes related to environmental barriers. Comments about privacy included: "doors that don't lock", "people in and out of resident's rooms all the time", "very few new complexes built now with double rooms to accommodate couples", "there is no such place/room in our facility where consensual sexual activity could take place" and "we could do this better with 'do not disturb' signs".

Attitudes of others.

Attitudes and beliefs around sexuality of other staff, residents and families prevented some respondents from supporting sexuality in the aged care setting. Comments included: "[difficult] when families don't approve", "staff may be embarrassed to find situations", "it is also up to how other residents perceive and are comfortable with the situation", "not easy to talk about" and "some staff are unsure and unable to discuss [sexuality] due to embarrassment and lacking confidence in managing sexuality issues".

Avoiding Risk.

Some respondents were concerned about the safety of residents as well as the effect of open expression of sexuality on other residents: "think residents believe they would not be approved or would be looked down on", "just reminding them what is appropriate in public", "if it threatens the well-being of other residents", and "concerned that the activity is in appropriate private space; some residents had their sexual life in the lounge".

Discussion

The majority of staff participating in this pilot study reported the belief that aged care residents have sexual needs, which should be supported. The majority of nurses reported including sexuality in their assessments. These findings, however, were not ubiquitous and not necessarily representative of the care provided. For example, the majority of staff felt it was not their role to be part of the sexuality assessment plan and in some cases respondents reported being encouraged to take an anti-sexuality stance. Barriers to addressing sexuality in aged care identified in our study--lack of privacy and staff discomfort in facilitating resident sexuality--are consistent with those cited in the literature.

Understanding what was not mentioned might provide insight into why the barriers of managing sexuality overwhelm the beliefs of the majority of respondents that sexuality is important. There was no mention about sexually transmitted infections or injuries, staff abuse of clients (Glasgow & Fanslow, 2007) or homosexual expressions of sexuality. While there was a large amount of discussion about environmental barriers to privacy, and some discussion about personal barriers, nothing was mentioned (nor did we ask) about instrumental support for sexual activity (e.g., condoms, lubricant, medication adjustments). We also did not specifically ask how sexuality assessment information is acted on, how care plans are developed and evaluated. There was no discussion of any particular sexuality assessment instruments. Sexual expression seems to be supported in a more reactive rather than proactive, facilitative manner.

In the wider picture, sexuality is a human need and critical to all nursing assessments. It is important to understand and identify the sexuality needs of the older adult, and have the confidence to ask the right questions to successfully complete a nursing assessment and subsequent care plan. This study highlights the value of a multi-disciplinary approach to addressing sexuality within human rights, health and ethical decision-making frameworks (Everett, 2008). Evidence tells us that residents will not necessarily initiate discussions around sexuality (Kaiser, 1996). Thus, creating a proactive, safe and confidential environment for discussions among staff and residents alike will be necessary to move sexuality into the normative domain.

It is important to consider the limitations of this study. Firstly, we do not know how many staff actually received the survey from their managers. Regardless, the low response indicates that without significant prompting, staff members were reluctant to respond to a survey about sexuality. A low response rate is consistent with a social taboo in addressing sexuality needs of the older adult and suggests a need to raise awareness about the topic. Secondly, we cannot presume, and indeed consider it unlikely, that those who elected to respond to the survey are representative of staff in the Hawke's Bay region, let alone nationally. We know for example that three quarters of our respondents were New Zealand European, while the New Zealand aged care workforce is generally more diverse. Our results, therefore, need to be considered as exploratory only.

We hope this pilot study will stimulate further discussion, education, and policy development about the sexuality needs of aged care residents. Further research is needed to investigate how sexuality assessment information is acted on and how care plans are developed and evaluated. To overcome societal, staff and institutional barriers, thoughtful and creative team strategies are needed to address sexuality needs among residents in the complex environment of aged care facilities.

Editorial Note

The Editorial Board acknowledges there are limitations and flaws of this research, and made a decision to publish this article on the following basis: (a) this research provides valuable insights into how sexuality needs of residents in elder care facilities are generally not attended to, and (b) due to the lack of literature in this area. The Editorial Board invites reader contributions in response to this article for publication in the Our Stories section of Nursing Praxis.

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Mary Jane Gilmer, MN, NP Primary Health Care, Senior Lecturer, Auckland University of Technology

Alannah Meyer, MN, RN, Senior Lecturer, Eastern Institute of Technology, Hawkes Bay

Jocelyn Davidson, RN, BHSc, Dip Gerontology, Lecturer, Eastern Institute of Technology, Hawkes Bay

Jane Koziol-McLain, PhD, RN, Professor of Nursing, Auckland University of Technology
Table 1.
Residential Aged Care Staff Favourable Sexuality Stance (N=52)

Favourable Sexuality               Yes        No      Don't    Missing
Stance Items                      n (%)     n (%)      Know     Data
                                                      n (%)     n (%)

Workplace milieu

* Policies or procedures         34 (65%)   4 (8%)   12 (23%)  2 (4%)
relating to sexuality

* Privacy provided for           29 (56%)  17 (33%)  5 (10%)   1 (2%)
consenting couples to
engage in sexual behaviour

* Sexuality included in nursing  13 (68%)  4 (21%)   2 (11%)     --
assessment (among registered
and enrolled nurses, n=19)

Staff beliefs

* Residents have sexual needs    47 (90%)     --      4 (8%)   1 (2%)

* Sexuality is a lifelong need   42 (81%)   4 (8%)   5 (10%)   1 (2%)

* Aged care facilities ought     44 (85%)   2 (4%)    3 (6%)   3 (6%)
to support consensual sexual
activity of residents

Education

* Interest in receiving          36 (69%)  13 (25%)     --     3 (6%)
sexuality related to aged
care training
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