The World Health Organization (WHO) defines sexuality as: “a central aspect of being human throughout life encompasses sex, gender identities and roles, sexual orientation, eroticism, pleasure, intimacy, and reproduction. Sexuality is experienced and expressed in thoughts, fantasies, desires, beliefs, attitudes, values, behaviors, practices, roles, and relationships. While sexuality can include all of these dimensions, not all of them are always experienced or expressed. Sexuality is influenced by the interaction of biological, psychological, social, economic, political, cultural, legal, historical, religious, and spiritual factors”.1 (para5) The WHO regards sexuality as an essential and integrated part of being human, and it is well known that many diseases and treatments have a negative impact on patients’ sexuality and sexual health.1 Studies show that a positive and respectful attitude toward sexuality is important in achieving sexual health.2,3 Nurses view patients holistically, and they often have a central role in patients’ treatment and care.3 Despite this, registered nurses typically do not address sexual issues with their patients.2,4 Consequently, patients do not receive optimized, holistic care that focuses on all aspects of human life.
Some studies have explored why nurses do not address sexuality, and others have focused on the experiences of nurses in the few cases where they have addressed sexuality in their care.2,4-9 When asked, nurses have many and varying considerations and explanations for why they do not address sexuality with their patients. Where they do discuss sexual issues with their patients, nurses often experience embarrassment and discomfort.4-9 Nurses do however acknowledge that sexuality is essential for the patient's quality of life, and that they have a responsibility to address this.7
When nurses do address sexuality, they stress that it is important they know the patient, have met them several times, and share an established relationship.2 The arguments from nurses for not addressing sexuality are convergent, and include a lack of knowledge, a lack of time, and a shortage of private rooms.2,4,6,7 It seems these problems are well known in all parts of the world, irrespective of cultural background, religion or the health care system.
A Swedish survey study of 100 nurses found more than 90% had knowledge about how diseases and treatment affected sexuality.5 About two-thirds claimed they felt comfortable talking about sexual issues with patients and agreed that it was their responsibility to encourage talk about sexuality. However, 80% did not discuss sexual issues with their patients, and 60% did not feel confident discussing these issues. Furthermore, the nurses argued that insufficient time was one of the main reasons for not addressing sexuality with their patients.5
The same research group also conducted a qualitative study with 10 nurses where the aim was to describe how registered nurses reflected on discussing sexuality with patients.6 They found that there “needs to be an understanding among nurses that using their knowledge and talking about sexuality can lead to better quality of life for patients”.6 (p.538) Furthermore, they concluded that “it is imperative that nurses step out of their comfort zone and talk about sexuality”.6 (p.538)
Another study from Sweden included interviews with 10 nurses regarding their conceptions of dialogues about sexuality with cancer patients, and found that the nurses were well aware of the importance of talking with their patients about sexuality.2 However, the nurses commonly did not address sexuality as they considered it the responsibility of the physician. A common belief among the nurses was that patients who had a partner most often managed their sexual problems themselves, and, especially before and during treatment, patients were thought to view sexuality as a low-priority subject. Nurses described a lack of knowledge and skills in how to advise and support the patient's needs regarding sexual issues, and both sexuality and cancer were seen as taboo and sensitive.2 These findings are supported by a study from China that surveyed nurses in an oncology department and found that 58% of the nurses felt uncomfortable talking about sex with patients, and that 87.5% lacked knowledge.4 An Irish survey study found some nurses acted based on what they thought the patients should feel instead of what they knew the patients wanted.7 The nurses argued that the patients would get embarrassed, offended and emotionally distressed if sexuality was discussed, and suggested that patients with a cancer diagnosis did not want to talk about sexual issues as this was the furthest thing from their minds when they had just been diagnosed. Some nurses argued that the patients’ family/significant other would not want them to talk to their relatives about their sexual concerns.7
In a systematic review that encompassed all health care professionals (HCPs), Dyer et al. investigated this issue exclusively in the United Kingdom.8 The authors found the subject of sexuality was not routinely addressed in health care services, even though the HCPs did “believe that it should be”.8 (p.2668) The barriers pointed out by the study participants were lack of time, knowledge and experience, but also lack of confidence, embarrassment and worries about intrusiveness. There were four studies included in this review, and the review authors recognized this limitation. An Australian systematic review from 2016 with a focus exclusively on sexuality in older people supported these findings and also found that a negative attitude towards older people's sexuality was common among HCPs.9
The barriers to discussing sexuality described above might be influenced by the culture in which the nurses lived and undertook their nursing education. The Scandinavian countries (Demark, Norway and Sweden) differ from other countries due to their more liberal views on gender and sexuality,10 and they have a unique respect for fundamental sexual human rights.10 In Denmark, sexuality is recognized in all its diversity both as a valuable part of life and as a basic human right. Since 1956, there has been mandatory sex education in schools in Sweden and in both Denmark and Norway a few years later. In Denmark, same-sex civil partnerships have been permitted since 1989, and all Scandinavian countries have outlawed sexual discrimination.10
We therefore find it of great importance to explore the beliefs, attitudes and experiences of Scandinavian nurses discussing sexuality with those they provide care. Furthermore, we may gain insight into the reasons why some nurses from these countries find it difficult to address sexuality. The recipients of nursing care may be patients, clients or residents, while discussions regarding sexuality may occur in any setting, such as hospitals, outpatient clinics, the community, residential care homes or mental health facilities. The purpose of the review is to identify the beliefs, attitudes and experiences of Scandinavian nurses when discussing sexual issues with their patients, and to provide insights into how sexuality can be addressed in nursing practice.
An initial search of the Cochrane Database of Systematic Reviews and the JBI Database of Systematic Reviews and Implementation Reports indicated that there are currently no systematic reviews specifically dealing with this topic, and there were none in progress at the time of preparing this protocol. Two reviews on associated topics were found, with one including only studies from the United Kingdom and the other exclusively investigating sexuality in older people.8,9 There is a body of knowledge that can be synthesized to inform practice in this area and identify gaps, which would form the basis for further research focusing on why nurses do not address sexuality with their patients. Thus, a systematic review of qualitative studies is proposed to synthesize this body of information.
Types of participants
This review will consider studies on Scandinavian nurses in all health care settings.
Phenomena of interest
This review will consider qualitative studies that explore Scandinavian nurses’ descriptions of their beliefs, attitudes and experiences of discussing sexuality with patients, residents or clients.
The context of the review will include all health care settings where nursing care is provided in any of the Scandinavian countries (Sweden, Norway or Denmark). This may include, but is not limited to, hospitals, community settings, outpatient clinics, residential care homes, or mental health facilities.
Types of studies
This review will consider studies that focus on gathering qualitative data with study designs including, but not limited to, ethnography, phenomenology and grounded theory.
The search strategy aims to find peer-reviewed published studies. A three-step search strategy will be utilized in this review, as follows:
- An initial limited search of PubMed, PsycINFO and CINAHL.
- Searches of all included databases will then be undertaken, using all of the identified keywords and index terms. The initial keywords will be: belief, attitudes, experience, perception, view, intention, sexual issues, sexual problems, sexual disabilities, nursing, nurses, Scandinavia, Denmark, Norway, Sweden.
- Keywords in Danish: opfattelse; erfaringer, sansning, syn, intention, sexologiske temaer, sexologiske problemer, sexologiske dysfunktioner, sygepleje, sygeplejersker, Skandinavien, Danmark, Norge, Sverige.
- Keywords in Norwegian: oppfatning; erfaring, sensorikk, visjon, intensjon, sexological temaer, sexological problemer, sexological dysfunksjoner, sykepleie, sykepleiere, Skandinavia, Danmark, Norge, Sverige.
- Keywords in Swedish: uppfattning, erfarenhet, sinnesintryck; hållning, avsikt, sexuella tema, sexuella problem, sexuella funktionshinder, sjukvård, sjuksköterskor, Skandinavien, Danmark, Norge, Sverige.
- The reference lists of all identified papers will be reviewed to glean potential additional studies.
Studies published in English, Danish, Swedish and Norwegian will be considered for inclusion in this review. Studies published from 1980 onwards will be included because sexuality was increasingly incorporated into nursing education, research, and publications during the 1980s.
Searches will be conducted using the following bibliographic databases:
- Cumulative Index to Nursing and Allied Health Literature (CINAHL)
All studies identified during the database search will be assessed for relevance to the review based on information gathered from the title and abstract by two independent reviewers. A third reviewer will be consulted if a consensus cannot be reached. The full text of the article will be retrieved for all those studies that appear to meet the inclusion criteria, with priority given to peer-reviewed articles. Abstracts, conference proceedings and letters will be excluded.
Assessment of methodological quality
The qualitative papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review, using a standardized critical appraisal instrument from the Joanna Briggs Institute Qualitative Assessment and Review Instrument (JBI-QARI) (Appendix I). If an article does not encompass information according to all ten of the checklist points of the JBI-QARI, the reviewers will discuss the situation in an effort to reach an agreement. Any disagreements that arise between the reviewers will be resolved through discussion, or with the help of a third reviewer.
Qualitative data will be extracted by three reviewers from studies included in the review, using the standardized data extraction tool from JBI-QARI (Appendix II). The data extracted will include specific details about the populations, study methods and any findings of relevance to this review. The findings and illustrations will be assigned a level of credibility according to the JBI-QARI. There will be regular consultation between all three reviewers throughout the data extraction process to ensure the level of finding being extracted is closest to that provided in the included studies. If data is not reported or is missing, no attempts will be made to contact the authors, as some studies may be more than 30 years old.
Qualitative research findings will be pooled using JBI-QARI. This will involve the aggregation or synthesis of findings to generate a set of statements that represent that aggregation. The assembled findings (Level 1 findings) will be rated according to their quality, and then categorized based on the similarity of meaning (Level 2 findings). These categories will then be subjected to a meta-synthesis in order to produce a single comprehensive set of synthesized findings (Level 3 findings) that can be used as a basis for evidence-based practice.
We acknowledge the Danish Centre of Systematic Reviews for their support in this project