1. Mary Ann Troiano, DNP, RN, APN-C Sharon W. Stark, PhD, RN APN-C
Comparing Professional Nurses and Advanced Practice Nurses Perceptions of Confidence and Comfort in Discussing Issues of Sex with Patients
Mary Ann Troiano, DNP, RN, APN-C
Sharon W. Stark, PhD, RN APN-C

2. Patient Sexual Concerns
Seek information about illness and sexual function.
Seek information of illness impact on sexual function.
Seek information of effect of medical treatments on sexual function.
Perceptions of body image, family roles, relationships
& sexual functions. Higgin, Barker & Begley (2006)

3. Sexual Attitudes & Beliefs Survey Magnan & Reynolds (2006)
Study examined nursing (in all specializations) barriers to addressing patients’ sexuality.
Instruments: Sexuality Attitudes and Beliefs Survey
Demographic questionnaire
The theoretical range of the scale is 12 to Higher scores indicate greater barrier.
Convenience sample (N = 302) Midwestern medical center.
Conclusions: Further research to determine accuracy of nurses’ assumption that sexuality concerns are not expected to be addressed.

4. Sexual Attitudes & Beliefs Instrument Magnan(2005)
 Please use the following scale to indicate the degree to which you agree or disagree with each statement:
(1) = Strongly Disagree; (2) = Disagree; (3 )= Slightly Disagree;
(4) = Slightly Agree; (5) = Agree: (6) = Strongly Agree
Circle your response for each item.
Patients expect nurses to ask about their sexual concerns
I make time to discuss sexual concerns with my patients
I am more comfortable talking about sexual issues with
my patients than are most of the nurses I work with
I feel confident in my ability to address patients’ sexual concerns
I am uncomfortable talking about sexual issues

5. Sexual Attitudes & Beliefs Instrument Magnan (2005)
I understand how my patients’ diseases and treatments might
affect their sexuality  
Sexuality should be discussed only if initiated by the patient
Discussing sexuality is essential to patients’ health outcomes
When patients ask me a sexually related question, I advise them to
discuss the matter with their physician
Giving a patient permission to talk about sexual concerns is a
nursing responsibility
Hospitalized patients are too sick to be interested in sexuality
Sexuality is too private an issue to discuss with patients

6. Nursing Barriers to Asking About Sexuality Concerns
Non-proactive in engaging patients’ sexual concerns.
Misperceptions that patients do not expect to address sexuality concerns.
Lack of comfort in addressing sexuality concerns.
Lack of confidence addressing sexuality concerns.
Failure to make time to discuss sexuality concerns.
Higgin, Barker & Begley (2006); Magnan & Reynolds (2006)

7. Nurses Responsibilities Regarding Sexual Issues
Develop understanding of patients’ perceptions of
body image, family roles, relationships, and sexual
functions.
Improve assessment and diagnosis of actual or
potential alterations in sexual function.
Mick, J. (2007)

8. Nurses Responsibilities Regarding Sexual Issues
Increase knowledge and understanding of sexuality
Identify available information and resources.
Apply practice standards.
Develop skill in incorporating questions of sexuality in clinical assessments.
Mick, J. (2007)

9. Comparing Sexual Attitudes Among RNs and NPs
Sexual Attitudes and Beliefs Survey (SABS) administered to 43 baccalaureate nursing students (also registered nurses [RN]) and 40 Nurse Practitioners (NP) during Fall 2008 and Spring 2009.
Focus groups were provided to complement The Sexual Attitudes and Beliefs Survey to identify key concerns of the RNs and NPs.
If participants were unable to attend focus groups, Open-Ended Reflection Questions were ed to those who participated.

10. Registered Nurse Barriers to Discuss Sexuality
SABS scoring = Higher scores indicate greater barrier
Question # 6: Score = Sexuality should be discussed only if initiated by
the patient.
Question # 8: Score = When patients ask a sexually related question, I
advise them to discuss the matter with physician.
Question # 10 : Score = Hospitalized patients are too sick to be interested
in sexuality.

11. Nurse Practitioner Barriers to Discussing Sexuality
SABS scoring = Higher scores indicate greater barrier
Question #1: Score = Patients expect nurses to ask about their sexual
concerns.
Question #4: Score = I feel confident in my ability to address patient’s sexual concerns.
Question # 5: Score = I am uncomfortable talking about sexual issues.

12. Interventions
Two lectures and opportunity for discussion were provided:
Taking a Sexual Health History addressing several key issues such as side effects of medications, chronic illness, cancer and sexually transmitted infections.
Discussing Sexuality with your patients utilizing the PLISSIT and BETTER models.
Focus groups after survey and after lectures.

13. Ex-Plisset Model Taylor & Davis (2006)
Framework to incorporate sexuality into patient discussions.
Interactive/dynamic addresses sexuality concerns of client.
Key elements:
Patient permission-giving as core feature of:
Limited Information
Specific Suggestions
Intensive Therapy
Taylor & Davis (2006)

14. Ex-PLISSIT Model Taylor & Davis (2006)
Highly flexible and holistic in sexual care.
Incorporates reflection and review following interventions.
Expects nurses to give patients permission to discuss sexual health and express concerns.
Involves open dialogue and reflects on interventions.
Seeks patient involvement in reviewing interactions, so that individual needs met.

15. Better Model Mick, Hughes & Cohen (2004)
Assists nurses to include sexuality in patient assessments.
Ensures practice standards are met to provide holistic care.
Bringing up the topic.
Explaining that sex is a part of life to normalize discussion.
Timing of Intervention
Education on sexual side effects of treatment
Recording

16. RN Responses to Focus Groups
“I think first the practitioner has to be comfortable with their own sexuality, their own feelings about sex and intimacy in relationships and discussing that. Because if it is a taboo subject for you personally, you are not going to address it with clients, patients.”
”I am not sure most people would bring it up on their own to a healthcare provider. They think we take care of one thing. They don’t see that as our role (talking about sex).”
“Most of the nurses now are not young. The average age is close to 50 in New Jersey. So these are the people who probably have the hardest time talking about it (sex).”

17. NP Responses to Focus Groups
“I do not have the luxury to stay for 15 to 20 minutes to discuss sexuality.”
“Sexuality assessment question is deferred unlike heart and lungs – No one is going to come back and ask you.”
“I would not bring up sexuality in a dermatology office but in cardiac then it should be part of care.”
“Important for NP to feel comfortable asking about sex but not tell what should be done.”

18. RN Responses to Sexual Health Lecture
”…gave me ‘Permission’ to ask the questions. I have not used the BETTER or PLISSIT model in addressing sexuality with my patients.”
“I have used the BETTER model while talking with one of my friends. It starts out with a friend saying ‘you’re a nurse.’ They always feel they can ask or tell you anything because you are a nurse.”
“…certainly could benefit from more lectures…brought up very Catholic, all girls school…sex was never discussed at home or school…very enlightening and empowering for me.”
“The more I know the easier it becomes to talk about.”

19. NP Responses to Sexual health Lecture
“Bringing it up makes patient know its ok to say.”
“Grew up not talking about sex. Personal barrier ‘cause I did not grow up like that.”
“Advising older women important…they may be closed. If you ask, they may be more open. You initiate it and they say ok.”
“Set up topic by saying I am asking cause it may affect treatment.”
“Be direct – Are you having any issues?”

20. Barriers Identified
The Sexual Attitudes and Beliefs Survey helped identify some barriers to discussion of sexuality and sexual health.
The focus group identified similar results to those cited in nursing literature:
lack of training in answering the patient’s questions.
concerns about sex and sexuality.
perceptions that patients do not expect nurses to address sexuality concerns.
how to address sexuality issues in aging population.

21. Lectures Outcomes
Provided open forum for discussion and situations that RNs and NPs encountered in their home and agency visits.
Some were open to new ideas while others felt that their patient population would not be open to any sexual health questions or information.
After each lecture, several participants asked questions, or discussed their patient situations.

22. REFERENCES
Higgin, A., Barker, P. & Begley, C. (2006). Sexuality: The challenge to espoused holistic care. International Journal of Nursing Practice, 12,
Magnan, M. (2005) Barriers to addressing patient sexuality to nursing practice. MedSurg Nursing,14(5),
Magnan, M. & Reynolds, K. (2006). Barriers to addressing patient sexuality concerns across five areas of specialization. Clinical Nurse Specialist, 20(6),
Mick, J. (2007). Sexuality assessment: 10 strategies for improvement. Clinical Journal of Oncology Nursing 11(5),
Mick, J. , Hughes, M. & Cohen, M. (2004). Using the BETTER model to assess sexuality. Clinical Journal of Oncology Nursing, 8(1),
Taylor, B. & Davis, S. (2006). Using the extended PLISSIT model to address sexual healthcare needs. Nursing Standard, 22(11),