NURSE PRACTITIONERS’ UNDERSTANDING OF SEXUAL HEALTH INTERVENTIONS By 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 Copyright© (2017) by Deirdre D. Raimey, MSN 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