Nurse Practitioners' Understanding of Sexual

NURSE PRACTITIONERS’ UNDERSTANDING OF SEXUAL HEALTH

INTERVENTIONS

DEIRDRE D. RAIMEY

Submitted in partial fulfillment of the requirements for the degree of Doctor of Nursing

Practice

Committee Chair: Dr. Joyce Fitzpatrick

Frances Payne Bolton School of Nursing

Case Western Reserve University

May 2017

Sexual Health 2

CASE WESTERN RESERVE UNIVERSITY

FRANCES PAYNE BOLTON SCHOOL OF NURSING

We hereby approve the scholarly project of

Deirdre D. Raimey

Committee Chair

Dr. Joyce Fitzpatrick

Committee Member

Dr. Carol Musil

Committee Member

Dr. Jeffrey Jones

Date of Defense

March 24th 2017

*We also certify that written approval has been obtained for any proprietary material contained

therein Sexual Health 3

Sexual Health 4

Abstract Aims. The purpose of this study to examine certified nurse practitioners’ learning needs related to sexual health concerns, to assess frequency of sexual health interventions, and to evaluate the perceived barriers to the application of sexual health interventions in health care.

Design. Descriptive study administered via internet-based questionnaire.

Methods. A convenience sample of 574 certified nurse practitioners (CNP) was obtained from

Ohio Board of Nursing. The Learning Needs for Addressing Patients’ Sexual Health Concerns was used to assess knowledge. The Nursing Interventions on Sexual Health Scale was used to assess the frequency of sexual health interventions used in nursing practice. The perceived barriers to the utilization of sexual health interventions among CNPs were assessed using a checklist based on the literature pertaining to sexual health care in nursing.

Results. “The influence of treatment on sexuality” was the highest learning need.

“Biopsychosocial factors on altered sexual activity” was the lowest learning need. The frequency of nursing intervention in sexual health care among CNPs is average and the behavioral frequency of nursing intervention decreases from the permission level to the specific suggestion level when evaluating care based on the PLISSIT model. Barriers to sexual health care are similar to what is reflected in the literature.

Conclusions. While nurse practitioners have the knowledge to manage sexual health concerns, there is a need for further research. CNPs require comprehensive sexual health education and specialized clinical preparation to manage sexual health concerns.

Sexual Health 5

Certified nurse practitioners (CNP) and other members of the healthcare team typically do not receive adequate training in human sexuality or the evaluation and treatment of sexual concerns in their formal training (Rowniak & Selix, 2016). As a result, CNPs are often uncomfortable assessing and managing sexual issues (Maes & Louis, 2011). Given the changes in health care delivery nationally, CNPs are often the first point of contact for individuals with sexual health concerns or problems. Despite the fact that nurses are the most trusted healthcare providers and are known for providing holistic care, it is well noted that patients of all ages frequently perceive that health care professionals (in general) are uncomfortable managing sexual health concerns during office visits (Office of the Surgeon General; Office of Population

Affairs, 2001).

CNPs have a unique opportunity to create an environment conducive to sexual health assessment by giving patients permission to voice sexual concerns (Gott, Hinchliff, & Galena,

2004). It is expected that clinicians who are sexually literate, comfortable, and competent will be more likely to address patient concerns related to sexuality and, as a result, patients will be more likely to protect their sexual health and improve other areas of health in general (Robinson,

Bockting, Simon, Rosser, Miner, & Coleman, 2002). Present and future CNPs should have the knowledge, skills and comfort to practice in the area of sexual health care without only focusing on the prevention of sexually transmitted infections and the provision contraceptive management

(Rowniak & Selix, 2016). The purpose of this study was to examine CNPs’ learning needs pertaining to sexual health concerns, assess CNPs’ frequency of use of sexual health interventions, and to identify the perceived barriers to the utilization of sexual health interventions among CNPs in the provision of health care in the state of Ohio.

Background Sexual Health 6

This research stemmed from an understanding of the PLISSIT model developed by American psychologist Jack Annon. The PLISSIT model has been used for the past 39 years by health care professionals to address the sexual health concerns of patients in a variety of settings (Taylor &

Davis, 2007). PLISSIT is an acronym that represents the four levels of sexual health intervention. The levels of the PLISSIT model include Permission, Limited Information, Specific

Suggestions, and Intensive Therapy (American Association of Sexuality Educators, Counselors and Therapists, 2014). As the level of intervention increases, greater knowledge, training and skills are required (American Association of Sexuality Educators, Counselors and Therapists,

2014). According to Annon, most people experiencing sexual problems can resolve them if they are 1.) Given Permission to be sexual, to desire sexual activity and to discuss sexuality, 2.)

Receive Limited Information (patient education) about sexual matters, and 3.) Are given Specific

Suggestions (sexual health interventions) to address sexual problems (AASECT, 2014). The

PLISSIT Model assumes that the health professional intervening with the individual patient/client has knowledge of sexual health and related interventions and is able to intervene in practice. The proposed study was the first step in determining the learning needs (level of knowledge), frequency of sexual health interventions and barriers to interventions among nurse practitioners. This baseline information is important in determining future work to prepare nurse practitioners for intervening with individuals with sexual health concerns and removing potential barriers for these providers.

A search of the literature was conducted using the search terms sexual health, sexuality education, learning needs, information needs, knowledge, nurse practitioners, medical providers, skill, sexual health assessment, and sexual dysfunction. The following databases were utilized:

ProQuest Nursing and Allied Science, Academic Search Complete, PubMed, ScienceDirect, and Sexual Health 7

CINAHL PLUS with Full Text. There are very few articles published on the subject of knowledge and skill in the provision of sexual healthcare in the past ten years. The selected articles were chosen because the concepts of each study closely match the concepts of the present study and, for some of the articles selected, the recommendations for further research match the purpose of the present study. This review of the literature represents the most relevant research from in from 2001 to 2016.

Learning Needs

Learning needs assessments can be used to determine the knowledge base and skill of providers; learning needs are defined as the gap between what a provider currently knows about a topic and a higher level of knowledge that is associated with a higher level of professional performance (McKnight, 2013). There is a relationship between knowledge and learning needs.

While there are no scholarly articles that pertain to the learning needs of healthcare professionals in the provision of sexual health care, there are articles in other areas of healthcare that address learning needs in nursing.

One study concluded that the healthcare providers’ learning needs were consistent with the topics that the healthcare providers themselves identified as knowledge deficits

(Giangregorio et al., 2007). This outcome is important to the study because it justifies the rationale for assessing learning needs in sexual health care. Another project revealed that self- disclosure using the competency-based mental health learning needs assessment yields a high accuracy rate of 95% in self-reports of skill based deficits (McKnight, 2013). This outcome is important to the study because it demonstrates the accuracy of self-identified learning needs when determining topics of focus in the development skill based sexual health care education for

CNPs. It has been suggested that future research is needed in the area of learning needs Sexual Health 8 assessment to improve the quality of health care, to advance nursing practice, and to improve the lives of individuals, populations, and the community in general (McKnight, 2013).

Sexual Knowledge

As with all healthcare, knowledge is a critical component to the provision of sexual health care and researchers sought to investigate how this knowledge is developed in educational programs for all members of the health care team. Providers with adequate sexual health care knowledge can have a positive effect on patient outcomes. In a study of medical students, researchers found that 87.5% of medical students in the United States and Canada received only a single lecture on sexual health (Solursh et al., 2003). Of 199 medical students surveyed in

2004, only 35% felt that medical school prepared them well for dealing with sexual health cases regardless of their year of study. (Faulder, Riley, Stone, & Glasier, 2004).

In all of the research reviewed for this project, there is only one article that focused on nurse practitioners and sexual healthcare. Maes and Louis (2011) surveyed 100 nurse practitioners to explore sexual history-taking habits with patients 50 years of age and older. When the nurse practitioners were asked about academic preparation in sexual history taking, 60% of the nurse practitioners indicated that their training included formal courses, 53% learned about sexual health by way of continuing education, 62% obtained their sexual health training via self-study, and almost 14% of nurse practitioners indicated they had no preparation or did not recall having any preparation in sexual history taking at all (Maes & Louis, 2011).

Most of the studies evaluated students’ educational needs in sexual health care

(Saunamaki & Engstrom, 2013) (Sung & Lin, 2013) (Walker & Davis, 2014) (Sung, Huang, &

Lin, 2015) (Carabez, Pellegrini, Mankovitz, Eliason, Ciano, & Scott, 2015), and there was only one study that focused on the education needs of CNPs in sexual health care (Maes & Louis, Sexual Health 9

2011). Therefore, outcomes of the present study will add to the existing literature of CNPs’ knowledge in sexual healthcare.

Sexual Health Interventions

After the World Health Organization’s consultation on sexual health in the 1970s, researchers continued to investigate the provider’s approach to the provision of sexual healthcare. Styles of sexual healthcare could be characterized as being ‘proactive’ or ‘reactive’ according to the health care workers’ perceived responsibility to initiate discussions of sexual concerns with patient (Gott et al., 2004). Health care workers who took a proactive role in sexual health management saw mentioning sexual issues within an appropriate context as part of their clinical role while others saw their role in sexual health management as essentially reactive and to respond to concerns and problems brought to them by a patient (Gott et al., 2004). In a peer- led sexual health education program at the University of Edinburg, medical students most felt more comfortable discussing sexual matters with patients of the same gender as themselves

(Faulder et al., 2004).

Seventy-eight percent of medical doctors attending a workshop on sexual dysfunction in

Greece answered that they routinely ask their patients whether they are experiencing any sexual dysfunction when surveyed on their involvement in sexual health care (Tsimtsiou et al., 2006).

The medical and nursing staff of the Nephrology Department and the nurses of the Cardiology

Ward in Spain rated the importance they give to patient’s sexual health moderately high, but

86% of respondents admitted that they do not give sufficient sexual healthcare; 92% of the subjects never initiate the conversation to address sexual health issues with patients (Ho &

Fernandez, 2006). Five factors were identified to explain the phenomenon: Lack of sex education for healthcare providers, embarrassment, culture, lack of healthcare experience and religion (Ho Sexual Health 10

& Fernandez, 2006).

Final year nursing students in Hong Kong acknowledge the nurse’s role in sexual health care but were hesitant to take an active role in practice because they felt they were not ready were due to inadequate knowledge, feelings of anxiety, worries about colleagues/clients reaction, and poor examples of how to approach sexual health scenarios (Fong, Ha, & Yuen, 2009). In Scotland when it came to discussing sexual health with adolescent or young adult patients in their care, whether or not the nursing students discussed matters of sexual health education with young people relied on placement, comfort, and provider expertise while some nursing students felt that sexual health care is part of the role but only if the nursing unit or health concern pertains to sexual health (Johnston, 2009). The nurse practitioners surveyed also agreed that sexual health care is part of the role but only if the chief complaint is related to sexual health (Maes & Louis,

2011). Maes and Louis (2011) surveyed 100 nurse practitioners and found that only 2% responded that they “always” assess for sexual practices of their patients who are 50 and older.

In a qualitative study on the discussion of sexual health concerns with patients, mental health nurses in Australia described their practice as one where they wait for the consumer to approach them about their sexual concerns, and offer assistance to the consumer when approached (Quinn, Happell, & Brown, 2011). These participants agreed that if a consumer brought the issue up, they would make time to discuss the issue; the mental health nurses commented that they did not tend to raise the issue initially, but rather, at a later stage when they sensed that rapport had been developed, and that such questions would not feel out of place because of their well-developed therapeutic relationship (Quinn et al., 2011).

A qualitative study of 10 oncology nurses from Sweden revealed that cancer patients’ need of talks about and support regarding sexuality were conceived as being low during the Sexual Health 11 whole trajectory of care; the nurses acknowledged that they should talk about sexuality with the patients, but due to their own attitudes, knowledge and skills, as well as conditions in the ward environment they usually did not (Olsson, Berglund, Larsson, & Athlin, 2012). In a study of 142 senior nursing students in Taiwan it was found that 4.2% of senior nursing students usually assessed patterns of sexual function, 62.7% of senior nursing students seldom encourage discussion on sexual problems, 81% of senior nursing students seldom conveyed willingness to listen to patients’ sexual concerns in illness, 78.2% of senior nursing students seldom assessed patients’ ability to function as husband and wife and 81.7% of senior nursing students seldom discussed ways to increase sexual attractiveness (Huang, et al. 2013). In the same study, 85.9% senior nursing students seldom provided information on the physiological effects of sexual activity, 84.5% seldom taught the differences between male and female sexuality, 88% seldom encouraged discussions on changes in body appearance/function with their partner, 89.4% seldom taught patients to plan sexual activity after rest periods, 90.8% seldom used the terms

“erection,” “intercourse,” or “masturbation” in sexual health care (Huang, et al., 2013).

Readily available resources were cited as ways to improve the accuracy of the advice given (Walker & Davis, 2014). The most recent research related to skills in sexual health care suggest that without supporting knowledge and positive attitude, nursing students are not equipped to take an active role and have confidence into nursing practice. (Sung et al., 2015).

An article was published by the faculty of the family nurse practitioner program at the

University of San Francisco School of Nursing and Health Professions regarding a sexual health program developed using a faculty practice model to teach students how to conduct a sexual health history and physical exam, demonstrate cultural competence with patients from sexual minority groups, the diagnosis and treatment of sexually transmitted infections, and Sexual Health 12 contraception management (Rowniak & Selix, 2016).The sexual health training focused on sexual health care and the lesbian/gay/bisexual/transgender population; it was comprised of two components: 1.) Lectures, readings and videos regarding sexual health and the cultural considerations of sexual minority groups, and 2.) A clinical rotation with supervised by an experienced faculty member as a preceptor at a public health clinic that primarily treats sexually transmitted infections in San Francisco (Rowniak & Selix, 2016). While no formal measurements were taken with regard to the content and efficacy of the program, the students found that receiving sexual health education combined with the specialized clinical training was a positive experience that afforded them the opportunity to incorporate the skills of sexual health care management into their own practice (Rowniak & Selix, 2016).

Barriers

Prior research indicates that the biggest barriers to sexual history taking were lack of time

(59%), interruptions (30%), and limited communication skills (29%). Only 3% of nurse practitioners responded, “Sexual histories are not appropriate with patients 50 and older,” while

6% responded “sexual history taking is embarrassing” (Maes & Louis, 2011, p. 220). An identified barrier to taking a sexual history among nurse practitioners was “not being able to cope with issues that can arise with sexual history responses” (21%) (Maes & Louis, 2011, p.

220).

Five patterns emerged as barriers to sexual health counseling among nurses caring for patients in recovery from myocardial infarction: 1.) Inadequate pattern of knowledge, 2.) Pattern of Dissonance, 3.) Pattern of time/Environmental Constraints, 4.) Pattern of Deferral, and 5.)

Pattern of Inadequate Reources (Barnason, Steinke, Mosack, & Wright, 2013). Saunamaki and

Engstrom (2013) found that nurses felt conflicted about what they should do as professionals and Sexual Health 13 what they actually wanted to do which serves as a barrier to nurses providing sexual health care.

This conflict was categorized into three themes: “Out of My Hands” which implies that there are barriers beyond the nurses control that prevent them from being able to discuss sexual health concerns with patients, “Prejudice” which implies that the nurses personal beliefs prevent them from discussing sexual health with patients, and “Discomfort” which implies that nurses are insecure in their ability to provide sexual healthcare (Saunamaki & Engstrom, 2013).

Summary

The evidence supports the use of learning needs assessments as a tool to determine the knowledge base and skill needs of all nurses of all skill levels (McKnight, 2013) as, often times, the nurse’s learning needs are consistent with the topics that nurses themselves identify as knowledge deficits (Giangregorio et al., 2007). Based on the review of the literature, both medical doctors and nurse practitioners are not receiving comprehensive sexuality training in the programs that prepare them for practice. This lack of knowledge translates into the omission of sexual health assessment of patients receiving care (Ho & Fernandez, 2006). A health care worker who does not have knowledge of sexual health may have a more biased perception of providing sexual healthcare, even at the lowest level of intervention (Fong et al., 2009). If a health care worker has sufficient knowledge of sexual health, they are more likely to have a positive attitude towards sexual health and, in turn, are more likely to address sexual health concerns with their patients (Saunamaki & Engstrom, 2013). There is a need for sexual health education combined with specialized clinical training to encourage nurse practitioners to translate their knowledge into practice (Rowniak & Selix, 2016). Future research should ensure that sexuality is recognized as a need for education and training, and is included in both undergraduate and graduate curricula to help nurses appreciate the importance of sexuality and to Sexual Health 14 feel a greater degree of comfort and confidence in supporting the sexuality concerns of patients

(Quinn et al., 2011).

Of the literature reviewed, there were very few studies conducted in the United States. A majority of the studies were conducted with students in medical school and baccalaureate nursing programs. Only one study examined the role of nurse practitioners in sexual health assessment (Maes & Louis, 2011). The proposed study will identify knowledge deficits related to sexual health among CNPs by assessment of learning needs. With the resulting data, a curriculum could be developed to address the identified deficits in knowledge and sexual health intervention skills among CNPs. By examining the frequency that CNPs utilize sexual health interventions, goals can be developed to incorporate sexual health care as a part of the regular standard of care consistent with the PLISSIT Model for guiding interventions in sexual health.

Purpose and Research Questions

The purpose of this study was to examine CNPs’ learning needs related to sexual health concerns, to assess CNPs’ frequency of use of sexual health interventions (specifically permission, limited information, and specific suggestions), and to identify the perceived barriers to the utilization of sexual health interventions among CNPs in the provision of healthcare. In pursuit of the purpose, this study sought to answer the following research questions:

RQ 1: What level of learning needs do CNPs possess with regard to their clients’ sexual health concerns?

RQ 2: How frequently do CNPs apply sexual health interventions?

RQ 3: What are the perceived barriers to the utilization of sexual health interventions among

CNPs in the provision of health care?

Methods Sexual Health 15

The study was a descriptive, quantitative study using a cross-sectional approach. The survey was distributed by way of internet-based questionnaire.

Sample

A convenience sample of CNPs from Ohio was recruited from the Ohio Board of

Nursing. Nurse licensure information is considered public record; as a result, a request was submitted to the public information tracking team for a list of all CNPs licensed in the state of

Ohio. An Excel file was received with contact information for over 13,000 advance practice nurses in the state of Ohio. From this population of advance practice nurses, only CNPs were invited to participate and all other advanced practice nurses were excluded.

Inclusion Criteria

Inclusion criteria for the subjects was CNPs (with no less than one year of experience) who provide direct patient care for no less than 20 hours per week.

Measures

Demographic data collected included: Gender, marital status, age, religion, race, ethnicity, residential zip code, and highest level of education completed. Background data collected included years of nursing experience, years of experience as a CNP, nursing specialty/certifications, previous education in sexual health, occupational zip code, and average hours of direct patient care.

The Learning Needs for Addressing Patients’ Sexual Health Concerns (LNAPSHC) is a

24-item instrument to assess the learning needs of CNPs in the provision of sexual health care

(Tsai, Huang, Liao, Tseng, & Lai, 2013). Each item will be rated by the respondent by using a

Likert-type scale with 4-point response categories scored as “0 = do not need, 1 = mild need, 2 = Sexual Health 16 moderate need, and 3 = strong need” (Tsai, et al., 2013). The LNAPSCH has a Cronbach’s Alpha of 0.97 and re-test reliability by Pearson r was 0.89 (P<0.01) (Tsai, et al., 2013).

The Nursing Intervention in Sexual Health (NISH) is an inventory that consists of 19 statements for assessing the extent and frequency of nursing students’ behaviors toward addressing patients’ sexual health concerns (Huang, Lee, Yen, Li, & Tsai, 2013). The NISH consists of 19-items based on the PLISSIT model and is grouped into three levels: permission, limited information, and specific suggestion. Each level has 5 items, 7 items, and 7 items, respectively (Huang et al., 2013). These 19 items have three response alternatives (from 1 = seldom to 3 = usually). The theoretical range of the scale is 19 to 57 points, and a higher score indicates a higher frequency of the nursing students addressing patients’ sexual health concerns

(Huang et al., 2013). The overall Cronbach’s Alpha for the NISH inventory is .96 (Huang C. Y.,

Tsai, Liao, & Lee, 2012).

For this study, the overall Cronbach’s Alpha for the LNAPSCH is .975 with 24 items.

The three LNAPSCH subscale Cronbach’s Alphas are .928 for ‘Sexuality in Health and Illness’ with 6 items, .965 for ‘Communication on Patient’s Intimate Relationships with 9 items, and

.945 for the ‘Approaches to Sexual Health’ with 9 items. For this study, the overall Cronbach’s

Alpha for the NISH is .949. The three NISH subscale Cronbach’s Alphas are .849 for the

‘Permission’ level with 5 items, .867 for the ‘Limited Information’ level with 7 items, and .906 for the ‘Specific Suggestion’ level with 7 items.

Procedure

The study was approved by the Case Western Reserve University Institutional Review

Board. Links to the Qualtrics survey were emailed to the email address submitted by CNPs to the

Ohio Board of Nursing. Sexual Health 17

Data Analysis

Descriptive statistics were used to describe the background variables, and the total and subscale scores on the instruments. Each of the research questions was addressed with descriptive statistics.

Results

A total of 8,377 emails were sent to CNPs licensed by the Ohio Board of Nursing. Of the

8,377 emails sent, there were 719 surveys started and 574 surveys completed resulting in a 7% response rate. The average age of the respondents was within the age range of 45-54 years (SD =

1.155). There were more female respondents (92.7%) than male respondents (7.1%); one respondent identified as transgender (.2%). The most commonly reported race was Caucasian

(91.1%) and the most commonly reported ethnicity was Non-Hispanic (98.6%). These results are presented in Table 1.

Table 1

Sample Characteristics Frequency Percentage Age 25-34 117 20.4 35-44 130 22.6 45-54 164 28.6 55-64 143 24.9 65 and older 20 3.5 Gender Frequency Percentage Male 41 7.1 Female 532 92.7 Transgender 1 .2 Marital Status Frequency Percentage Single, Never Married 61 10.6 Married 430 74.9 Divorced 64 11.1 Separated 7 1.2 Widowed 12 2.1 Race Frequency Percentage Sexual Health 18

Sample Characteristics Frequency Percentage Caucasian 523 91.1 African American 46 8.0 Asian-Pacific Islander 3 .5 Native American 2 .3 Ethnicity Frequency Percentage Hispanic 8 1.4 Non-Hispanic 566 98.6 Highest Level of Education Frequency Percentage Completed BSN 5 .9 MSN 508 88.5 DNP 54 9.4 PhD 5 .9 Professional Degree (JD, 2 .3 MD)

The most frequently reported religions were various forms of Christianity (76.3%). A majority of the respondents, 74.9% are married. The highest level of education completed is a

Master’s of Science in Nursing (88.5%). In terms of nursing experience, a majority of the CNPs were registered nurses with greater than 20 years of registered nursing experience (42.5%) and have at least one year but less than 5 years of experience as a CNP (38.5%). The most commonly reported specialty by the nurse practitioners that participated in the survey was Family Practice

Nurse Practitioner (46.9%). Fifty-three percent of CNPs in the state of Ohio received sexual health education as part of their formal education to become a nurse practitioner. These results are presented in Table 2

Table 2

Background Data Frequency Percentage Religion Baptist 30 5.2 Buddhist 6 1.0 Catholic 173 30.1 Islam 3 .5 Jehovah’s Witness 1 .2 Judaism 7 1.2 Sexual Health 19

Background Data Frequency Percentage Lutheran 25 4.4 Pentecostal 5 .9 Christian 205 35.7 I do not consider myself to 67 11.7 be religious Non-Denominational 52 9.1 Years of Nursing Frequency Percentage Experience (Excluding Nurse Practitioner Experience) At least one year but less 68 11.8 than 5 years 6-10 years of experience 123 21.4 11-15 years of experience 69 12.0 16-20 years of experience 70 12.2 Greater than 20 years of 244 42.5 experience Years of Nurse Practitioner Frequency Percentage Experience At least one year but less 221 38.5 than 5 6-10 years of experience 148 25.8 11-15 years of experience 78 13.6 16-20 years of experience 74 12.9 Greater than 20 years of 53 9.2 experience Hours of Direct Patient Frequency Percentage Care Per Week At least 20 hours, but no 104 18.1 more than 32 hours per week Greater than 32 hours per 470 81.9 week Certification Specialty Frequency Percentage Acute Care Nurse 57 9.9 Practitioner Adult Nurse Practitioner 95 16.6 Adult-Gerontology Nurse 21 3.7 Practitioner Family Nurse Practitioner 269 46.9 Gerontological Nurse 8 1.4 Practitioner Pediatric Nurse 55 9.6 Practitioner Psychiatric Mental Health 34 5.9 Sexual Health 20

Background Data Frequency Percentage Nurse Practitioner School Nurse Practitioner 2 .3 Women’s Health Nurse 33 5.7 Practitioner Past Education in Sexual Frequency Percentage Health Sexual Health Education 309 53.8 was part of my training to become a nurse practitioner Continuing Educations 85 14.8 programs pertaining to sexual health Self-Study/Independent 39 6.8 Learning On the job 62 10.8 training/experience based learning No formal training in 79 13.8 sexual health care has been received

Learning Needs Assessment

CNPs’ responses to each item of the LNAPSHC are summarized by count and percentage. The five items that showed the greatest learning need in each category (the highest response rates in the moderate to strong learning needs categories) include:

F1: Sexuality in Health and Illness

¡ Illness, chronic disease, and sexuality (48.7%)

¡ The influence of treatment on sexuality (46%)

¡ The sexual response cycle (43.9%)

F2: Communication on Patients’ Intimate Relationships

¡ Role function related to intimacy (42.9%)

¡ Communicate limitations or modifications in sexual activity (42.7%)

¡ Resumption of sexual activity (42.3%) Sexual Health 21

F3: Approaches to Sexual Health Care

¡ Display an accepting, non-judgmental attitude (43.1%)

¡ Obtain a comprehensive sexual health history (41.6%)

¡ Assess patient’s readiness to resume sexual function (39%)

The five items that reflected the lowest learning needs (the lowest response rates in moderate to strong learning needs categories) include:

F1: Sexuality in Health and Illness

¡ Risk and safety in sexual activity and how to respond (60%)

¡ Sexuality throughout the lifespan (59.3%)

F2: communication on Patients’ Intimate Relationships

¡ Body image related to intimacy (72.6%)

¡ Fear and depression related to sexual activity (65.1%)

F3: Approaches to Sexual Health Care

¡ Identify biopsychosocial factors on altered sexual activity (79%)

¡ Refer a patient to another specialist or support group (69.9%)

These results are presented in Table 3.

Table 3

Learning Needs for Addressing Patients’ No Needs Some Moderate Great Sexual Health Concerns Needs Needs Needs F1: Sexuality in health and illness Risk and Safety in sexual activity and how 104 240 165 65 to respond (18.1%) (41.8%) (28.7%) (11.3%) Illness, chronic disease and sexuality 61 234 184 95 (10.6%) (40.8%) (32.1%) (16.6%) The influence of treatment on sexuality 55 255 171 93 (9.6%) (44.4%) (29.8%) (16.2%) Sexuality throughout the lifespan 97 243 158 76 (16.9%) (42.3%) (27.5%) (13.2%) Sexual response cycle 100 222 155 97 Sexual Health 22

Learning Needs for Addressing Patients’ No Needs Some Moderate Great Sexual Health Concerns Needs Needs Needs (17.4%) (38.7%) (27.0%) (16.9%) Human sexuality and health care 78 256 159 81 (13.6%) (44.6%) (27.7%) (14.1%) F2: Communication on patients’ intimate relationships Body image related to intimacy 164 253 113 44 (28.6%) (44.1%) (19.7%) (7.7%) Expression of love and attraction 95 258 165 56 (16.6%) (44.9%) (28.7%) (9.8%)

Admiration for individual characteristics 92 240 166 76 (16.0%) (41.8%) (28.9%) (13.2%) Communicate limitations or modifications 84 245 163 82 in sexual activity (14.6%) (42.7%) (28.4%) (14.3%) Be intimate to engage in pleasurable 124 233 161 56 activity (21.6%) (40.6%) (28.0%) (9.8%) Role function related to intimacy 101 227 190 56 (17.6%) (39.5%) (33.1%) (9.8%) Resumptions of sexual activity 103 228 182 61 (17.9%) (39.7%) (31.7%) (10.6%) Fear and depression related to sexual 135 239 148 52 activity (23.5%) (41.6%) (25.8%) (9.1%) Interdependence between patient and 112 229 156 77 sexual partner (19.5%) (39.9%) (27.2%) (13.4%) F3: Approaches to sexual health care Obtain a comprehensive sexual health 117 218 150 89 history (20.4%) (38.0%) (26.1%) (15.5%) Refer patient to another specialist or 207 194 105 68 support group (36.1%) (33.8%) (18.3%) (11.8%) Provide information to foster adaptation of 167 211 122 74 sexual activity (29.1%) (36.8%) (21.3%) (12.9%) Identify biopsychosocial factors on altered 317 136 64 57 sexual activity (55.2%) (23.7%) (11.1%) (9.9%) Guide a discussion on sexual expression 103 251 148 72 (17.9%) (43.7%) (25.8%) (12.5%) Assess patient’s readiness to resume sexual 118 231 144 81 activity (20.6%) (40.2%) (25.1%) (14.1%) Clarify myths, misinformation and 137 220 141 76 controversy (23.9%) (38.3%) (24.6%) (13.2%) Display an accepting, non-judgmental 93 234 164 83 attitude (16.2%) (40.8%) (28.6%) (14.5%) Have sexual consultations with patients 106 254 151 63 without embarrassment (18.5%) (44.3%) (26.3%) (11.0%)

Sexual Health 23

Nursing Intervention on Sexual Health

The NISH consists of 19-items based on the PLISSIT model and is grouped into three levels: Permission, Limited Information, and Specific Suggestions. PLISSIT is an acronym that stands for Permission, Limited Information, Specific Suggestions and Intensive Therapy (Annon,

1976). The PLISSIT model describes levels of sexual health interventions for health care providers. According to Annon, most people can resolve sexual health problems if they 1.) Are given Permission to be sexual, to desire sexual activity and to discuss sexuality, 2.) Receive

Limited Information about sexual matters, and 3.) Are given Specific Suggestions about ways to address sexual problems. As the level of intervention increases, greater knowledge, training and skills are required (Annon, 1976). The levels of intervention from the PLISSIT model that corresponds with the current scope of practice held by certified nurse practitioners would be

Permission, Limited Information and Specific Suggestions (AASECT, 2014). The next section will discuss the outcomes of the NISH survey among certified nurse practitioners in the state of

Ohio.

Permission. At the Permission level of intervention, the practitioner creates a climate of comfort and permission for clients to discuss sexual concerns, often introducing the topic of sexuality, thereby validating sexuality as a legitimate health issue (AASECT, 2014). The categories with the highest percentages of respondents who seldom conduct sexual health interventions at the Permission Level are as follows:

¡ Discuss ways to increase sexual attractiveness (77.7%)

¡ Assess clients’ ability to function as husband and wife (53.8%)

¡ Assess clients’ patterns of sexual function (49.1%) Sexual Health 24

Limited Information. At the Limited Information level of intervention, the practitioner addresses specific sexual concerns and attempts to correct myths and misinformation (AASECT,

2014). The categories with the highest percentages of respondents who seldom conduct sexual interventions at the Limited Information Level are as follows:

¡ Teach physical difference between male and female sexuality (63.1%)

¡ Teach patient with chronic illness to plan sexual activity (62.0%)

¡ Assess vessels, nerves, and endocrine system related to sexual health (57.7%)

Specific Suggestion. At the Specific Suggestion level of intervention, the practitioner assists the client in formulating ideas about problems of a sexual nature (AASECT, 2014).

Information that guides the plan of care includes taking a sexual history, conducting a physical examination, and ordering the corresponding laboratory tests. Together, the practitioner and the client develop realistic and appropriate goals/solutions by exploring the issues, determining how the issues have evolved over time and by developing a working understanding of the issue at hand (AASECT, 2014). The categories with the highest percentages of respondents who seldom conduct sexual health interventions at the Specific Suggestion Level are as follows:

¡ Encourage patients to participate in social activity to enhance sexual role function

(79.4%)

¡ Discuss sexuality by transcultural considerations (75.3%)

¡ Encourage experimentation with other means of sexual expression (70.6%)

As shown, the highest frequency of nursing interventions in sexual health care are on the level of permission, and then the frequency of sexual health care interventions gradually decreases by each level of intervention thereafter. These results are presented in Table 4.

Table 4 Sexual Health 25

Nursing Interventions on Mean Seldom% Sometimes% Usually% Sexual Health (SD)

Permission Level 1.66 (.55244) 1.) Encourage discussion 1.70 46.0 37.6 16.4 between partners about (.733) sexual problems 2.) Assess clients’ ability 1.56 53.8 36.4 9.8 to function as (.665) wife/husband 4.) Assess clients’ patterns 1.66 49.1 36.2 14.6 of sexual function (.721) 5.) Convey to a patient’s a 2.10 28.9 32.6 38.5 willingness to listen to (.816) their sexual concerns 12.) Discuss ways to 1.27 77.7 17.9 4.4 increase sexual (.532) attractiveness Limited Information 1.65 (.53886) 3.) Use the terms erection, 1.87 38.9 35.7 74.6 intercourse, and (.791) masturbation in Sexual Health Care 6.) Assess vessels, nerves, 1.54 57.7 31.2 11.3 and endocrine system (.690) related to sexual health 7.) Explain the side effects 2.04 28.6 39.0 32.4 of medication on the (.781) sexual response cycle 8.) Provide information 1.60 53.5 33.4 13.1 about physiological effects (.709) of sexual activity 9.) Teach physical 1.49 63.1 25.3 11.7 differences between male (.696) and female sexuality 10.) Encourage discussion 1.56 56.1 31.5 12.4 about changes in body (.703) appearance/function 11.) Teach patients with 1.48 62.0 27.7 10.3 chronic illness to plan (.675) sexual activity Specific Suggestions 1.43 (.52327) 13.) Encourage the client 1.61 54.9 28.7 16.4 Sexual Health 26 to share feelings about (.752) change or loss of a body part 14.) Encourage alternate 1.48 63.9 23.9 12.2 ways to express sexuality (.703) 15.) Encourage 1.38 70.6 20.7 8.7 experimentation with (.641) other means of sexual expression 16.) Discuss alternate 1.43 66.9 23.2 9.9 positions to minimize (.667) discomfort 17.) Discuss sexuality by 1.30 75.3 19.5 5.2 transcultural (.561) considerations 18.) Encourage patients to 1.25 79.4 15.9 4.7 participate in social (.532) activity to enhance sexual role function 19.) Clarify myths and 1.52 59.4 29.1 11.5 taboos of sexuality in (.693) culture

Barriers

The first five items with the highest response rates as it pertains to the barriers that CNPs experience when applying sexual health interventions in clinical practice are as follows: “I don’t have a tool to guide my practice in sexual health assessment” (42.3%), “Time constraints prevent me from discussing sexuality with patients. I don’t have time” (42%), “I don’t have literature to provide my patients about sexual health” (39.5%), I do not have much experience in planning care for patients who identify as lesbian, gay, bisexual, or transgender” (23%), “My patients are too sick to be concerned with sexual performance. Sex is a very low priority” (20.9%). These results are presented in Table 5.

Table 5 Sexual Health 27

Barriers to Practicing Frequency of respondents Percentage of respondents Sexual Health Assessment who agreed that they who agreed that they and Intervention experienced this barrier in experienced this barrier in practice practice I don't have a tool to guide 243 42.3 my practice in sexual health assessment

Time constraints prevent 241 42.0 me from discussing sexuality with patients. I don't have enough time

I do not have literature to 227 39.5 provide my patients about sexual health I do not have much 132 23 experience in planning care for patients who identify as lesbian, gay, bisexual, or transgender

My patients are too sick to 120 20.9 be concerned with sexual performance. Sex is a very low priority

I typically refer patients to 87 15.2 another provider to address sexual health concerns It would be inappropriate to 82 14.3 discuss sexual matters with patients in my current practice

I don't know how to 72 12.5 approach the topic of sexuality with patients. I worry about not being able to use appropriate words to communicate.

I don't feel confident in 69 12 sexual history taking. I wouldn't know how to cope with responses to questions Sexual Health 28

Most of my patients are too 62 10.8 young to discuss sexual matters There is not enough privacy 48 8.4 in my clinical setting to discuss sexual matters

I anticipate that my patients 48 8.4 would refuse to answer questions of a sexual nature

I feel uncomfortable 35 6.1 discussing sexual health with patients. Bringing up sexual health is embarrassing to me

I would not know how to 31 5.4 manage the response of a patient who told me that they were a victim of sexual abuse or assault

Most of my patients are too 20 3.5 old to be interested in sex

The religious affiliation of 16 2.8 my employer makes sexual health care complicated

I am concerned that my 14 2.4 colleagues might opposed to me asking my patients sexual questions

I worry that my patients 12 2.1 might sexually assault me, make inappropriate sexual comments, or misinterpret my inquiry as sexual Sexual Health 29

My personal values and 6 1 beliefs (religious or otherwise) keep me from discussing sexual health with patients

Discussion

According to Dillman, response is a function of contact and cooperation (Dillman,

Smyth, & Christian, 2014). The study had a response rate of 7%, which is much less than the typical 20% response rate that ensures accurate results. There are a variety of reasons why this phenomenon could have occurred. A non-response error implies that the characteristics of respondents differ from those who choose not to respond, especially if only the individuals who have positive attitudes toward sexual health chose to respond to the survey (Dillman et al., 2014).

If the respondents in the survey only have positive attitudes toward sexual health, then those who have negative attitudes about sexual health are underrepresented. There is a real possibility that those who have negative attitudes about sexual health are not represented in the results to the survey as evidenced by the email responses to the invitation to participate. Some nurse practitioners (n = 7) responded to the invitation by email indicating that they have no interaction with patients regarding sexual health, that they were not comfortable answering the questions, and/or asked to have their name removed from the contact list. Despite the fact that there were only 574 responses out of 8,377 invitations, Dillman says that the response rate is only an indirect indicator of survey quality (Dillman et al., 2014). Sexual Health 30

The only mode used to invite respondents to participate in the survey was email.

According to Dillman, 1.) Single mode surveys tend not to be as effective and, by mixing modes, it allows the researcher to take advantage of the strengths and weaknesses of the other modes thereby reducing errors, 2.) Contact by email exclusively produces response rates that are as low as response rates by telephone survey, which have the lowest survey response rate of all modes

(Dillman et al., 2014). Another thing to consider is that the most commonly reported age of the respondents was 45-54 years. Younger respondents tend to communicate with texts and social networking making it harder to reach this group (Dillman et al., 2014).

The outcomes of the study of CNPs in the state of Ohio are similar to the outcomes found in the literature, with minor differences. Evaluating the learning needs of CNPs in sexual health is important for two reasons: 1.) The literature reveals that nurses are reluctant to practice sexual health care because of knowledge deficits (Ho & Fernandez, 2006) (Fong et al., 2009) (Maes &

Louis, 2011) (Olsson et al., 2012), and 2.) Learning needs assessment yields a high accuracy rate of 95% in self-reports of skill based deficits (McKnight, 2013). In comparison to the study conducted by Maes and Louis (2011), the CNPs sampled in both studies received their sexuality education in their formal training to become CNPs.

Competencies for nurse practitioner programs were implemented to help guide curriculum development and establish some consistency in the way that nurse practitioners practice within their respective specialties (Population Focused Competencies Task Force, 2013).

The Population-Focused Nurse Practitioner Competencies Task Force (2013) suggests that nurse practitioners address the genitourinary systems, women’s and men’s reproductive health including, but not limited to, sexual health, prenatal, postpartum, and post-menopausal care.

There is no specification on what it means to provide sexual health (with the exception of the Sexual Health 31 women’s health nurse practitioner competencies), leaving this topic to be interpreted by institutions of higher learning at their own discretion (Population Focused Competencies Task

Force, 2013). This would explain why the findings of this study would yield similar findings to the Maes and Louis study; there is consensus in the ways that nurse practitioners are trained.

The NISH and LNAPSCH were instruments used to assess sexual health interventions and learning needs in sexual health care among student nurses in Taiwan. The NISH is an instrument that uses the PLISSIT model developed by Annon, as an organizing framework

(Huang et al., 2012). The LNAPSCH was based on the outcomes of western-based studies of sexual health care in nursing and the results of semi-structured interviews with 15 senior nursing students in Taiwan about their perceived learning needs in the provision of sexual health care

(Tsai et al., 2013). While the PLISSIT model guided the current study and the development of the instrument, there is a need for continued refinement of both the model and instruments, particularly in relation to the preparation of advanced practice nursing currently.

Of particular interest would be differences in cultural understandings of sexual health among providers studied previously and those who participated in the present study. Prior studies included nurses and student nurses in Taiwan. Traditional Confucianism is the common base of social culture in the mainland of China, Taiwan, and Vietnam (Gao, Zuo, Wang, Lou, Cheng &

Zabin, 2012). The Confucian view of sexuality is that sex is taboo, and that discussions of a sexual nature are forbidden (Gao et al., 2012). The values of Confucianism have become less conservative (Gao et al., 2012) and, as with Western culture, the people of Taiwanese society are encouraged to have a more tolerant and liberal stance when it comes to sexual concerns (Tsai et al., 2013). It is unclear whether or not the respondents understood the questions that were being asked because the CNPs perception of sexual health care is unknown. It is not likely that Sexual Health 32

Taiwanese culture had any impact on the misunderstanding of the questions, but Taiwanese culture may have had an impact on the areas of focus on the LNAPSHC instrument. For instance, discussing sexual attractiveness with patients might be perceived as a boundary violation in

Western culture, unless it pertains to aspects of personal hygiene.

Overall, the CNPs perceived themselves as having ‘some needs’ on the LNAPSHC when it comes sexual health care, which is a positive finding because less than 51% of respondents indicated that they have “moderate to great needs” in any category. The outcomes of the original study reported ‘moderate needs’ needs among the student nurses (Tsai et al., 2012). The disparity in learning needs would be expected because the undergraduate student nurses will not have the same scope of practice upon graduation as the CNPs. Both the CNPs and the undergraduate student nurses had the most learning needs in the category “sexuality in health and illness” and

“communication on patients’ intimate relationships” (Tsai et al., 2012). Despite their learning needs, both the undergraduate student nurses and the CNPs know where to refer someone if the patient has a problem. This is reassuring for patient outcomes, but ideally, CNPs should have the ability to manage most of their patients’ basic sexual health concerns during a routine office visit.

The outcomes of the NISH reveal that less than half of the CNPs surveyed apply nursing interventions in the provision of sexual health care. While less than half of the CNPs are offering some level of sexual health care, the behavioral frequency of the nursing intervention shows a decrease along the PLISSIT model from permission to specific suggestions. It would be expected that the outcomes in this domain would be better given that the respondents indicated that they have the necessary knowledge to provide sexual health interventions. Sexual Health 33

The permission level of the PLISSIT model represents the therapeutic alliance where the patient and the provider discuss sexual health concerns (AASECT, 2014). It is well known that patients do not bring up the topic of sexual health during a routine office visit. The outcomes of the study would indicate that CNPs surveyed are not bringing up the topic of sexual health during the office visit either.

The limited information level of the PLISSIT model is designed to address sexual health problems through education (AASECT, 2014). The NISH outcomes on the limited information level would indicate that a majority of the CNPs surveyed are not providing education about sexual health concerns and are not addressing sexual health concerns in their clinical practice.

This supports the notion that CNPs are hesitant to provide sexual health care even though it is a part of their practice (Gott et al., 2004) (Ho & Fernandez, 2006) (Maes & Louis, 2011), (Quinn et al., 2011).

The specific suggestions level of the PLISSIT Model is where the provider and the patient develop a solution for the sexual health problem (AASECT, 2014). The NISH outcomes on the specific suggestions level indicate a majority of the CNPs seldom offer treatment solutions to sexual health concerns. One of the categories that scored the highest was “seldom discuss sexuality by transcultural considerations” (75.3%). This is surprising because all of the nurse practitioner competencies emphasize the provision of culturally competent care

(Population Focused Competencies Task Force, 2013).

The top five barriers shed light on some of the obstacles that CNPs face in the provision of sexual health care. Most of the barriers that received the highest number of responses are the same barriers that are reflected in study on barriers conducted by Maes & Louis (2011) with

CNPs. The top five responses from the barriers section of the survey fit neatly within four of the Sexual Health 34 five categories developed by Barneson et al., (2013) in the study on barriers encountered by nurses taking care of post-myocardial infarction patients when providing sexual health care. In some instances, the identified barriers may offer some clue regarding the learning needs of CNPs in the provision of sexual health care.

A few of the barriers on the checklist pertain to logistical issues, such as “time constraints” and “lack of privacy.” A majority of the barriers correspond with the learning need category

“Approaches to Sexual Health Care,” specifically, “Obtain a comprehensive sexual health history.” This might explain why the specific suggestion level of intervention has the lowest score on the NISH. The highest identified learning need is “Illness, Chronic Disease, and

Sexuality.” This might explain why the barrier “I don’t have a tool to guide my practice” was the barrier with the highest frequency, “I don’t have literature to provide my patients about sexual health” was the barrier with the third highest frequency, and “I typically refer patients to another provider to address sexual health concerns was the 6th highest barrier. CNPs are trained to use their resources to solve problems and when those resources have been exhausted, the CNP refers the patient to a provider with the level of expertise to solve the problem. The barrier with the 4th highest frequency “I do not have much experience providing care for patients who identify as lesbian, gay, bisexual, or transgender” seems to point to a learning need category of “Approaches to Sexual Health Care.” The 5th highest barrier “My patients are too sick to be concerned with sexual performance” seems to point to all three areas of learning needs and all three levels of sexual health intervention. CNPs need both comprehensive sexuality education and clinical preparation to manage sexual health concerns.

There were several limitations in the study including the use of self-reported data. Also there was a limited response rate and only CNPs from the state of Ohio were surveyed. In addition the Sexual Health 35 instruments used in the study had not been previously used among CNPs or with any nurses in the United States.

Recommendations for future research include program evaluation of sexual health education curriculum offered in nursing programs at the undergraduate and graduate level, qualitative research of the provision sexual health care among advanced practice nurses, and the development of a tool to evaluate the knowledge of comprehensive sexual health care and sexual health interventions in clear terms. In addition, the validity of the instruments used to measure learning needs and sexual health interventions need to be determined for use with advanced practice nurses.

Conclusions

Development of knowledge in sexual health supports positive attitudes and enhances the confidence of CNPs in the provision of sexual health care. While nurse practitioners have the knowledge to manage sexual health, there is a need for further research. CNPs require comprehensive sexual health education and specialized clinical preparation to manage sexual health concerns.

Sexual Health 36

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