Knowledge and Attitudes of Staff Toward Sexuality of Older Adults in Long-Term Care

Aging does not diminish the right to experience and express sexuality. The World Health Organization defines sexuality as “sex, gender identities and roles, sexual orientation, eroticism, pleasure, intimacy, and reproduction.”¹ Sexuality is a core element of humanity, yet there have been periods throughout history of repressing sexual identity, expression, and experiences. In the 1960s, the US underwent a sexual revolution leading to a change in attitudes and increased permissiveness regarding sexuality. Presently, sexuality is typically associated with youth, and older adults are often perceived as asexual beings.²

Older adults continue to desire intimacy and lead active sex lives.^3-5 A study conducted by Lindau and colleagues of 3005 community-dwelling older adults demonstrated that 53% of adults aged 65 to 74 years and 26% of adults aged 75 to 85 years remained sexually active.³ Older adults with health problems may not engage in penetrative sex, but may experience sexuality through other means of intimacy, such as touching, kissing, and cuddling.^3,4 Researchers have also observed older women are less likely than older men to have an intimate partner and be sexually active, in large part due to widowhood.^3,5

Even residents in long-term care settings (LTC) retain desire for sexual expression.^6,7 However, the stigma of sexuality is often heightened within this setting.⁷ Residents’ barriers to expressing sexuality within nursing homes or LTC facilities include physical disability, lack of privacy, and lack of a partner. Additionally, family members and staff may hold negative attitudes toward older adults’ sexual expression. Staff members may perceive LTC facilities as institutions meant to solely provide medical care rather than serve as a home and place of residence.^7,8

Studies have found residential nurses hold more negative and restrictive attitudes toward older adults’ sexuality compared with nonresidential nurses.⁸ Nursing staffs’ restrictive attitudes toward sexuality of LTC residents were found to be secondary to cultural and religious beliefs, their perception of sex as a behavioral problem, and the lack of sexual education during nursing training.^6,7 As such, the aim of this initiative was to increase knowledge and reshape attitudes of nursing staff toward older adults’ sexuality in an LTC facility. Nursing staff have the greatest direct contact with residents, and so we believe they are best suited to cultivate residents’ sexual expression. Furthermore, the education of nursing staff could have the most direct impact on the lives of LTC residents.

Setting
The clinical initiative took place at a Veteran Affairs (VA) medical center, which is a skilled nursing facility for US military veterans with chronic medical and daily functioning care needs.

Intervention
The intervention comprised a 32-minute didactic training developed by the author (OU) and delivered via PowerPoint presentation. The training provided education regarding sexuality and intimacy of older adults. The presentation covered normal age-related changes relevant to sexual activity, common causes of sexual dysfunction, barriers to engaging in sexual activity in a nursing home setting, and information on how beliefs and biases of staff members might impact older LTC residents in this regard. 

Assessment Tool and Data Collection
The Aging Sexual Knowledge and Attitudes Scale (ASKAS) is a 61- item questionnaire developed by White in 1982. The ASKAS was developed for use with older adults and individuals who interact with them, including family members and health care professionals. The knowledge subscale comprises 35 items, to which participants respond true, false, or don’t know. Knowledge scores range from 35 to 105, with lower scores reflecting higher knowledge. The attitudes subscale comprises 26 items, to which participants respond on a 7-point Likert rating scale ranging from 1 (disagree) to 7 (agree). Scores range from 26 to 182, with lower scores reflecting more permissive attitudes.⁹

For this initiative, knowledge scores of 35 to 58 were considered “most knowledgeable,” 59 to 82 were “moderately knowledgeable,” and 83 to 105 were “least knowledgeable.” An attitude score of 61 was considered permissive based on comparative findings in White’s studies.⁹ Values for reliable change were not provided in the original validation study. However, based on the descriptive statistics provided, it was calculated to be 12.65 for the knowledge subscale and 27.69 for the attitudes subscale. 

Demographics

A total of 21 nursing staff members (ie, registered nurses, licensed practical nurses, and nursing assistants) from this VA LTC facility participated in a staff training. Of these participants, 9 had a bachelor’s degree (43%); one had an associate’s degree (5%); 3 had a master’s degree (14%); and 1 had a doctoral degree (5%). Seven participants declined to provide this information (33%). Years of experience in a nursing facility ranged from 2 to 30, with participants reporting an average of 14 years working in an LTC setting (SD = 8.94). Most participants reported that they did not receive education regarding sexuality and intimacy among older adults during their nursing training, nor did they obtain a sexual history from residents as part of history documentation upon admission to the facility (Table 1).
    
Table 1. Staff Responses (N=21) on Nursing Education and Practice Regarding Sexuality in Older AdultsMain Analysis 

The data were analyzed using paired sample t-tests; one compared pre- and postintervention scores on the knowledge subscale of the ASKAS, and the second compared pre- and postintervention scores on the attitudes subscale. Basic descriptive statistics from both administrations of the ASKAS can be found in Table 2. 

Table 2. Pre- and Postintervention Scores on ASKAS Knowledge and Attitudes SubscalesAbbreviation: ASKAS, Aging Sexual Knowledge Attitudes Scale.

Scores on the knowledge subscale decreased following the intervention (t[16] = 5.57; P < .001; d = 1.33), which, given the reverse scoring on this measure, indicates a statistically significant increase in knowledge regarding sexuality in older adults. Scores on the attitudes subscale, however, did not change significantly as a result of the intervention (t[14] = 0.18; P = .85; d = 0.02), indicating that attitudes did not become more or less permissive following the staff training. Total pre- and posttest scores are compared in the Figure. Nursing staff were also asked about the usefulness of this intervention. Overall, nursing staff found the training to benefit their clinical practice, with ratings ranging from 4 to 7 on a 7-point scale, with 7 indicating most beneficial (mean, 5.76; SD ± 1.15). They also recommended that this training be offered in the future, with ratings ranging from 4 to 7 on a 7-point scale, with 7 indicating the highest recommendation (mean, 6.12; SD ± 1.05).

Figure. Total Pre- and Posttest Scores on the ASKAS Knowledge and Attitudes Subscales

ASKAS indicates Aging Sexual Knowledge Attitudes Scale.

The purpose of our initiative was to increase knowledge and improve attitudes of nursing staff toward the sexuality of older adults in a VA medical center LTC facility. Results showed an improvement in knowledge from pretest to posttest, as expected, but no significant change in attitudes. An educational intervention designed to improve knowledge and change of attitudes is not novel. Multiple studies have reported improvement in nursing staff’s knowledge and permissive attitudes through educational training.^10-13 Bauer and colleagues¹⁰ observed an increase of permissive attitudes after a 3-hour workshop. The authors noted the intervention led to greater sensitivity of staff toward the residents’ needs, including the need for sexual expression and intimacy.¹⁰ After a 7-hour educational training, we demonstrated a greater improvement in knowledge compared with attitudes. We surmised a resistance to attitudinal beliefs likely secondary to traditional Chinese culture.¹¹ Our study demonstrated that even the briefest of interventions can improve knowledge.

A key strength of the initiative was the feasibility of this intervention in a real-world LTC setting. A brief 30-minute didactic session, integrated within the nursing staff’s regular meeting schedule, effectively increased knowledge of sexuality and aging. Staff reported that the training addressed a gap in their education and found it useful, underscoring how this approach is feasible for other clinical settings with time constraints, including LTC facilities.

Limitations of this initiative include the sample size, intervention, and follow-up. The training was offered in only two sessions, and a limited number of nursing staff received it due to scheduling limitations and clinical obligations. Additionally, some nursing staff could not complete the training secondary because they had to leave early due to clinical obligations. The intervention was a nonvalidated educational training on older adult sexuality and intimacy. Attitudes were not significantly impacted, although the intervention did not target attitudes as directly as it targeted knowledge. Additionally, baseline scores demonstrated that nursing staff leaned toward permissive attitudes regarding sexuality in older adults. This indicates that, prior to the in-service, staff may have acknowledged the importance of sexual expression in older adulthood but lacked pertinent knowledge on the topic. Lastly, we conducted no follow-up survey or monitoring to determine whether nursing staff maintained knowledge and permissive attitudes. 

Future efforts should consider implementing annual in-service training for nursing staff and incorporating it into new employee orientation training. Follow-up efforts might also investigate the impact of similar training on staff behaviors, such as changes in the number of staff reporting that they obtain a sexual history from LTC residents upon admission. An LTC resident’s medical team must not avoid discussing the topic of sex or defer it to a specialist. The answer is not solely attributing concerns to “you’re aging” or prescribing medication, which may have adverse side effects. Instead, we should become comfortable in evaluating, diagnosing, and treating sexual dysfunction. By identifying patients’ sexual needs and desires, we can teach them about intimacy and explain that sexual satisfaction is not a quick process, but a gradual, progressive process, in which sex does not only have to be penetrative.

This initiative suggests that educating nursing staff improves knowledge regarding sexuality in older adults. Next steps should be to determine how the educational intervention translates into residents’ real-world experience. A survey of LTC residents’ experiences regarding sexual expression would demonstrate a meaningful impact of an educational intervention. LTC and nursing homes facilities should promote a positive culture regarding sexuality and intimacy, as this reflects the views of residents and has the potential to directly impact their quality of life, rather than being viewed solely as an institution of medical and custodial care. Veteran Health Administration policy states “[residents] have a right to consensual sexual activity and [residents] have a right to privacy during those visits.”¹⁴ It is the responsibility of LTC institutions to accommodate and facilitate that right.

Authors: Omici Uwagbai, MD, MPH¹ • Caitlin Tyrrell, PhD² • Sharon Falzgraf, MD³

Affiliations:
¹ Womack Army Medical Center, Fort Bragg, NC
² Spark M. Matsunaga Veteran Affairs Medical Center, Honolulu, HI
³ American Lake Veteran Affairs Medical Center, Tacoma, WA

Disclosures: The authors report no relevant financial relationships. The views expressed herein are those of the author(s) and do not necessarily reflect the official policy of the Department of the Army, Defense Health Agency, Department of Defense, Department of Veteran Affairs or the US Government.

Address correspondence to: 
Omici Uwagbai, MD MPH
1722-C Tagatay
Fort Bragg, NC 28307
Email: ouwagbai@gmail.com