Joumal of Advanced Nursing, 1991,16,1048-1054

Attitudes toward nurses discussing sexual

concems with patients
Julie Waterhouse RN MS
Assistant Profexor

and Margaret Metcalfe RN MS

Assistant Professor, College of Nursing, University of Delaioare, Newark, Delaware, USA

Accepted (or publicahon 25 March I99I

WATERHOUSE J & METCALFE M (1991) Journal of Advanced Nursmg 16,

104&-1054
Attitudes toward nurses discussing sexual concerns with patients
Attitudes toward nurses discussmg sexual concems with chents were examined
m 73 healthy subjects usmg Section A of the Sexual Adjustment Questiormaire
The vanables of age, sex, race, occupation, educational level, mantal status,
importance of sexual activity, fi-equency of discussing sexual relationship with
partner, and number of others with whom sexual concems are discussed were
examined to determme mfluence on subject's attitudes Nmety-two per cent of
subjects thought that nurses should discuss sexual concems with clients
Weighted least squares analysis showed that only two vanables (number of
others with whom sexual concems are discussed and race) were significant
predictors of attitudes

SEXUALITY examination and/or teshcular self-examination to cbents to

Sexuality has been idenhfied as warrantmg nursing assess-
ment and mtervenhon by the Amencan Nurses' Assoa-
ahon (1974), the Nurses Assoaahon of the Amencan
College of Obstetnaans and Gynecologists (1981) and the
Amencan Nurses' Assoaahon and Oncology Nursing
Society (1987) The North Amencan Nursing Diagnosis
Assoaahon mduded 'sexual dysfimction' on its bst of
nursmg diagnoses m 1980, and added 'altered sexuality
pattems' m 1986 (Carpemto 1989) The importance of
nurses addressmg sexuality has also been reflected m the
mcreasmg number of nursmg texts wbdi mdude diapters
on sexuality as an integral part of nursmg care (Bninner &
Suddarth 1988, Ludcmann & Sorensen 1987, Taylor et al
ig^\
Sexuabty is an important aspect of nursing care m a
vanety of settmgs, with dients of aU ages and most medical
diagnoses (Poonnan 1988, Woods 1984) Nurses m numer-
ous cbmcai sethngs should be teadimg breast self-
Correspondenu Juhe Waterho^ Assistant Professor College of Nursing, University ^"°^'^
of Delaware Naoark, Delmeare 19716, USA
"^^^^ ^^« percentage of these cancers diagnosed m the
^^'v stages (Frank-Sh-omberg 1986, Taylor et al 1989)
Nunses workmg with dients who have undergone mastec-
^O'™^'' hysterectomies, colostomies and many other surgi-
cal procedures should be encouragmg discussion of sexual
^ ° " ^ ^ * ^^'''^'^ *° ''^"S *«t^ ^^^ * ^ 8 ^ >" both
^'^^^^ and their parhiers (Hogan 1980, Woods 1984)
Curses m sdiool, matemity and commumty settings
should be providmg mfonnation on birth confrol and
^''"^^ behaviour to adolescent dients to decease the cnh-
^ V ^^^ madence of teenage pregnancy and sexually
transmitted diseases (Bobak et al 1989, Olds et al 1988,
Poonnan 1988) Psydiiafric dients (Young 1987), disabled
cbents (Medhat et al 1990, Rieve 1989), individuals with
'^^^ (Greenberg 1987, MacElveen-Hoehn 1985, Smith
^989), dients with myocardial mfarchons (Baggs & Karch
1^87, McCann 1989, Tardiff 1989), post-sfroke pahents
(Burgener & Logan 1989) and dients with multiple
^^ewiS & T h o m t o n 1 9 8 9 , T h o m t o n & D e w i S
1989) all require nursmg mtervenhon m the area of

1048

sexuabty Perhaps most tmportantly, nurses m many cbm-
cal settings (schools, occupahonal health, matemity, com-
mumty, etc) should be tndudtng spectfic teacbng on safe
sexual prachces to prevent the transmtsston or acqutsthon
of HIV and AIDS (Andnst 1988, Pugbese & Lampinen
1989, Talashek d al 1990)
Although life-threatentng illness may make sexual coun-
sellmg a low pnonty for some patients dunng the acute
phase of illness, the tndividual's sexuality should not be
completely disregarded even at this time Lack of pnvacy,
invasive procedures involving pnvate body parts, limited
visiting hours, medicahon side-effeds and fear of death
can easily cause the cnttcal care pahent to feel 'asexual'
Assessment of and teaching about sexuality are important
aspects of acute care which should be addressed by cnhcal
care nurses whenever possible (Baggs 1986, Baggs & Karch
1987, Campbell 1978, Scalzi 1982, Scalzi & Dracup 1978,
Thelan dal 1990)
LITERATURE REVIEW
In spite of the wide acceptance of sexuahty as a legitimate
focus for nursing, lack of knowledge about sexuahty, con-
servative attitudes toward sexuality, and anxiety when
discussmg sexual concems have been found to be wide-
spread among nurses (Fisher 1985, Payne 1976, Shiunan &
Bohachick 1987, Wilson & Williams 1988)
Shuman & Bohachick (1987) found nurses canng for
patients with myocardial infarctions (MI) to be conserva-
tive m their sexual athtudes, but 82% of these nurses
believed that sexual counsellmg of pahents after MI should
be included m the nurse's role Fifty per cent of these nurses
did not feel knowledgeable or comfortable enough to pro-
vide consistently patients with sexual counsellmg m
post-MI educahon
Webb (1988) studied 50 nurses workmg in gynaecologi-
cal and other practice areas m Great Bntam, and found
defiaenaes m knowledge of sexuality needed to give
advice to pahents These nurses answered only 58 8% of
the knowledge items correctly, and nurses working in
gynaecology did not score significantly better than nurses
working m other areas Webb also found the attitudes of
these nurses to be somewhat conservative and ngtd
Age, rebgion and rebgiosity had no significant effeds on
attitudes m t b s study
Wilson & Wilbams (1988) assessed a large sample of
oncology nurses for attitudes and behaviours related to
mcluding sexu«dity m their prachce Abnost 90% had
offered sexual counselbng to 10 or few pahents m the past
6 months Twenty-five per cent had never offered sexual
counsellmg to their patients, and the majonty were not
Dtsa4sstng sexual concems
makmg referrals for sexual counselbng In spite of tbs, 91%
felt they would be comfortable discussing sexuality if the
cbent initiated the discussion
Krueger et al (1979) surveyed 108 women who under-
went hysterectomy, and found that only 11% tdenhfied the
nurse as the person who suppbed the most valuable infor-
mation regarding sexual adjustment Forty-five of the 108
subjects in this study wrote comments suggesting nurses
tnttiate discussion of sexual concems, because they pre-
ferred to talk to another woman about sexuality, rather
than to a man
Young (1987) interviewed 100 hospitalized surgical
patients regarding sexual concems and discussions with
health care professionals Ninety-two per cent of these
patients indicated they thought discussions on sexuality
with health care professionals were appropnate Only 30%,
however, had been involved in such a discussion durmg
their current illness
Simtlarly, Baggs & Karch (1987) found that only 33% of
women with coronary heart disease received mformahon
about retum to sexual activity Seventy-six per cent of
these women said health professionals should routmely
inittate dtscussions about sexual activity
Sexual counselling
Jentans (1988) reported on sexual coimselbng received by
27 women who underwent surgery cind radiotherapy treat-
ment for endometnal and cervical cancer Fifty-mne per
cent of these patients received no uiformahon from any
health professionals about their sexual funchomng
Radiotherapists provided most of the sexual counselling,
nurses provided no mformahon Eighty-eight per cent of
the subjects indicated they would be most comfortable
with sexual discussions which were imhated by the
physician or nurse
The research reviewed clearly indicates that the majonty
of nurses still do not provide dients with counselbng in the
area of sexuality Addihonally, research mdtcates that
pattents would prefer heetlth care professioneils to imtiate
discusston about sexual concems Why is it that nurses
exped clients to initiate discussion about sexuality, while
cbents want nurses to mhoduce the topic?
One reason may be nurses' perceptions of clients' expec-
tations Schnarch (1981) determmed that sophomore and
semor medical students erroneously perceived pahents as
being much more conservahve sexually than the pahents
reaUy were These athtudes persisted affer the students
took a sex educahon course Schnarch points out that the
likelihood of a physiaan discussmg sexual concems with a
1049
J Wttierhouse and M Metcalfe
Table 1 Respcmses to the
question, 'Do you bebeve that Always Almost always
nurses should diseuss sexual
eoneems with their patients?'
n 13 6 45
% 17 5 52
patient will be influeneed by the phystaan's percephon of
the patient's probable response
In tbe Kautz et al (1990) study, nurses cited the most
common bamer to addressmg clients' sexual coneem as
'disetissmg sextiabty eauses tbe patient anxiety' These
nurses may bave assumed tbat patients did not tbink nurses
should address sexuality, so that doing so would merease
ebents' anxiety
PURPOSE OF THE STUDY
If nurses pereeive that most individuals do no bebeve
sexuality is appropnate for nurses to address, they may be
less likely to offer sexual eotmseUing to dients No studtes
were found wbteb examme athtudes of the general pubbe
toward tbe appropnateness of sexual eotmseUmg by
nurses, nor is there any available researeh on faetors
whieh mfluenee these athtudes This study was undertaken,
therefore, to examme these opinions
The purpose of the study was to explore the athtudes of
healthy individuals toward nurses diseussmg sexual eon-
eems vnth their patients, and to identify faetors whieh may
mfluenee these athtudes Nine mdependent vanables (age,
sex, raee, mantal status, occupation, education, crurrent
lmportanee of sexual achvity, frequency of cbscussmg
sexual relahonship with partner, and number of others with
wbom sexual concems are disc:ussed) were exammed for
tbeir mfluence on athtudes
METHODS
Sample
Tbe sample consisted of 88 subjeds seleeted from cnirrent
and retired employees at a large umversity Cntena for
partiapahon m the study were 25 to 75 years of age,
ability to read and vtmte Enghsh, and goieral good health
(determined by tbe subject)
Two tbousand four hundred tmsbUed/manual, salaried,
and professional err^loyees randcmily selected by com-
puter were contaded by letter to request parhapation m
the testmg of a queshoruuure One hundred of the indi-
viduals who mdicated willmgruss to partiapate were
randomly seleded to be subjects, but only 88 actuaUy
1050
Sometimes Almost never Never
4
2
65 5 27 55
signed the eonsent form and eompleted the questionnaire
Fifteen subjeds were eliminatedfromthe data analysis due
to missmg data Questionnaires were identified by code
number only, and subjects were assured of eomplete
eonfidentiabty regardmg their responses
Ideal subjeet to vanables ratio is generaUy desenbed as
10 1, but others eonsider a 5 1 raho suffiaent (Tabadinick
& Fidel 1983) The 73 9 raho used m this study exceeds this
5 I ratio, but does not achieve a 10 I ratio
Of the 73 subjeets wbo partiapated m the study, 53
were male and 20 were female (73% and 27%, respeehvely)
Ages of the subjeets ranged from 29 to 58 years with a
mean of 42 years Nmety-six pier eent of the subjeets were
Caueasian, 4% were Afnean-Amenean Two thirds (68%)
of the subjects held baehelor's or higher degrees, 16% had
attended some eoUege, 15% had high school diplomas
Most subjeets worked m professional (67%) or eleneal/
teehmeal (30%) oeeupahons, and a large majonty (77%)
were mamed
Instrumentation
Data were eoUeeted using Seehon A of the Sexual Adjust-
ment Questionnaire (SAQ) The questiormaire was devel-
oped by Waterhouse & Metealfe (1986) to assess the
impaet of cancer and its treatment on sexuabty The SAQ is
a 16 page, 108-item tool admmistered m three sections
Most responses are measured on a five-point Likert-type
scale and have been assigned numeneal values for sconng
purposes Sedion A was designed to assess subjects'
eurrent sexual athtudes and funetionmg
Seehon A also contams a queshon which asks, 'Do you
bebeve nurses should cbscuss sexual concems with their
patients?' Responses to this queshon were used to measure
athtudes toward nurses discussing sexual concems
Responses were scored with 'always' equal to one, through
to 'never' equal to five Lower responses, therefore, mdicate
more positive attitudes toward discussing sexual eoneems
Responses to three other queshons on Sechwi A were used
as measures of importance of sexual activity,frequencyof
discussing sexual relahonship with a partner, and number
of others with whom sexual concems are discussed A
back^ound informahon sheet was admimstered with
 Discussing sexual concems

Table 2 Breakdown of responses by independent vanables Sechon A of the SAQ to coUect demograpbc data such as
age, race, sex and educahonal level
Vanable n Mean response Content validity of the SAQ had previously been
favourably evaluated by a panel of six experts m nursmg,
sexuality and stahshcs (Waterhouse & Metcalfe 1986)
Age
Test-retest reliability of the SAQ m two earlier stucbes was
20-30 4 175
measured usmg healthy subjects at 0 672 (Waterhouse &
31-40 34 2 68
41-50 Metcalfe 1986) and 0 933 (Metcalfe 1988) Intemal consist-
20 2 80
51-60 11 2 91 ency using Cronbach's alpha was measured at 0 7 (Metcalfe
61-70 4 2 75 1988)

Sex
Female 20 2 35 Procedures
Male 53 2 83 The SAQ was adrmnistered by mail with a covenng letter
explainmg the purpose of the study and sfressmg the
Race
confidenhality of responses Data were analysed usmg
Black 3 167
SAS
Caucasian 70 2 74

Mantal stahis RESULTS

Single 7 2 71
Mamed 56 2 70 Attitudes
Widowed 5 2 80 Responses of the subjects to the question, 'Do you bebeve
Divorced 4 2 50 that nurses should discuss sexual concems with their
Other 1 3 00
pahents?' are presented m Table 1 Twenty-six per cent felt
Occupation nurses should 'always' or 'almost always' discuss sexual
Unskilled/manual 2 30 concems with their patients Sixty-six per cent responded
Clencal/technical 22 2 59 that nurses should 'somehmes' discuss sexual concems
Professional/management 49 2 73 with patients Only 8% of subjects felt nurses should
'never' or 'almost never' discuss sexual concems with
Educahon pahents
High school 10 240 Mean responses broken down by levels of the mdepen-
Some college 13 2 77 dent vanables are presented m Table 2 Attitudes appear to
College degree 11 2 37 be more posihve (lower means) in younger subjects, m
Postgraduate 39 2 85 women, m Afncan—Americans, in those for whom sexual
activity was extremely or very important, and m those
Importance of sexual achvity
5
who discuss sexual concems with others Attitudes were
Shghtly important 3 40
Important 35 2 83 also more positive m those subjects who discuss their
Very important 23 2 48 sexual relahonship with their partners very often or not
Extremely important 10 2 40 at all, and were more negative m those who sometimes
discuss their sexual relationship with their partners
Discussion of sexual relationship with partner
Never 2 2 00
Almost never 5 2 60 Influence of independent variables
Sometimes 34 3 09 Ordinary least squares regression was used to explore the
Often 26 2 50 influence of the nme independent vanables on subjects'
Very often 6 167 athtudes toward nurses discussing sexual concems with
their dients Dummy vanable coding was used for the
Number of others with whom sexual concems are discussed
mantal status and occupation vanables
No one 45 2 95
One person 26 2 31 Results of fittmg the least squares equahon connechng
Two people 200 athtudes toward nurses cbscussmg sexual concems and the
mne mdependent vanables are given m Table 3 To corred

1051
/ Waterhouse and M Metcalfe

Table 3 Regression of nine

vanables on attitudes toward Standard Standard OLS WLS
nurses discussing sexual Vanable Estimate estimate error f-Value f-Value
concems
Age 000044 000416 001320 0034 0 030
Sex 054903 025119 0 27753 1-978 1914
Race 110984 0 22600 061165 1814 1464
Mantal status
Single - 0 50708 -0-15316 047588 -1066 - I 218
Mamed - 0 37046 - a i 6 0 6 2 0 32445 -1142 -1109
Occupation
Professional -121309 - 0 58459 0 76568 -1584 -1357
Clencal/technical -055938 - 0 26330 0-75251 - 0 743 -0644
Educahon 0 21665 0 24883 015668 1383 1307
Importance of sexual activity - 0 24192 - 0 20170 015588 -1552 1248
Discussion of sexual -0-12232 -010537 014722 -0831 - 0 809
relationship with partner
OLS = ordinary least squares DO - 0 4687 -026201 0 22661 - 2-069 - 2 405
WLS = weighted least squares
D O = Number of others with whom F= 2 271, probability = 0 02, R^'• = 0 2878, adjusted R^ = 0 186
sexual concems are discussed

Table 4 Regression of three

vanables on athtudes toward Standard Standard OLS WLS
nurses discussmg sexual Vanable Estimate estimate error f-Value f-Value
concems
Sex 041330 018909 024671 1 675 1746
Race 106404 0 21669 054412 1 -956 2-416
BoU* values = P ^ 0 0 5
OLS = ordinary least squares DO -048820 - 0 27287 0 20126 - 2 -426 -2-603
WLS = weighted least squares
D O = Number of others with whom f = 5 05 7, probability = 0 003, l^
F = 0180, adjusted R^ = 014
sexual concerns are discussed.

for heteroscedashaty m the data, a weighted least squares
approach was used to calculate correct lvalues Only
'number of others with whom sexual concems are dis-
cussed' (DO) was found to have a sigmficant f-test using
the weighted least squares approach
Reanalysis
The data were reanalysed usmg only the tbee vanables
with the bghest f-test values Results are given m Table 4
Standardized regression coeffiaents for the vanables tn the
reduced model (sex, race and DO) were 0189, 0 216 and
—0273 respechvely f-Tests for race and DO were sig-
nificant at the P^O05 level, the significance level for sex
was 009 Sex was left m thefinalmodel, however, due to
the theorehcal importance of tbs vanable m determmmg
athtudes towards discussmg sexual concems Weighted
least squares was agam used to corred the Mests for
heteroscedastiaty
Thefittedleast squares equahon for the final model was
Athhides = 2 07 -f- 0 I89(Sex) -|-
0 2I6(Race) - 0 273(DO)
Approximately 15% of the vanahon in attitudes towards
nurses discussmg sexual concems can be predicted by sex,
race, and number of others with whom sexual concems are
discussed (adjusted R^ = 0145) Females, Afiican-
Amencans, and those who discuss sexual concems with
one or more others are predided to have more positive
athtudes Companson of the standardized regression
coeffiaents shows that discussing with others has the
largest influence on attitudes, race has the next greatest
influence, and sex has the least influence of the three
vanables
DISCUSSION
Results of this study mdicate that most healthy people feel
that sexual counsellmg by nurses is appropnate at some

1052

times, but several weaknesses m the study limit its intemal
and extemal validity First, attitudes toward discussing
sexual concems were measured usmg responses on only
one item Since longer tests are generally more reliable
(Allen & Yen 1979), measurement usmg one item only may
have severely reduced rebabibty Second, the study sample
was small, heavily male, and much more highly educated
than the general population Results m this study, there-
fore, may not be representative of athtudes in the total
population
Third, the fact that subjects volunteered to participate in
the study mtroduces a senous selection bias Incbviduals
who agree to complete a questionnaire about sexuabty are
likely to have more interest m the subject than individuals
who do not volunteer (Fowler 1988) Thus, the study
results may be biased toward more positive attitudes
Last, the fact that only 15% of the vanance m athtudes was
accounted for indicates that at least one, and probably
several, important vanables were omitted from the study
The above limitations suggest that the results of this
study must be interpreted with caution, they are reported
here due to the paucity of research cunently available on
sexuality m nursing practice The finebngs should be inter-
preted m bght of the bmitahons, but may be useful as a
stimulus for discussion and further research
Positive attitudes
A large majonty of the subjects m this study felt that
discussion of sexual concems by nurses was appropnate at
least some of the time Females showed more positive
attitudes toward nurses discussing sexual concems than
did males This cbfference may be explamed by the per-
vasive image of the nurse as female and the physician as
male Female subjects may have expressed more positive
attitudes toward discussmg sexual concems with a health
professional of the same sex The Krueger et al (1979)
findmgs support this explanahon
More posihve athtudes m Afncan-Amencan subjects
could be due to cultural differences, but since only three
subjects were Afncan-Amencan, the differences may not
be authentic More posihve athtudes in those who discuss
sexual concems with others may be due to previous posi-
hve expenences and higher comfort levels in discussing
sexual concems
The fad that the vanables of age, mantal status and
educational level had no significant influence is of mterest
since Young (1987) found that women who were younger,
mamed and better educated were more likely to receive
sexual counselbng from physicians
Dtsctisstng sexttal concems
Sexuality is as important as other aspects of human
health and should be mcorporated into nursmg assess-
ments and other aspects of nursing care Pnvacy for the
pahent and partner should be allowed as much as possible
Nurses worhng with cbents with medical diagnoses such
as MI, chronic obstruchve pulmonary disease, cerebral
vascular accident, cancer and AIDS should be encouragmg
cbscussion of sexual concems related to bvmg with these
diseases in both dients and their partners
Most importantly, nurses should lmtiate commumcation
about sexuabty Cbents should be asked how their llbiess
has affected the way they see themselves as a man or
woman, and should be asked if they have any concems
about how their disease or treatment will influence their
sexuality
CONCLUSION
The results of this study, although provisional, suggest
that clients can be expected to have positive attitudes
toward nurses cbscussmg sexual concems Further research
on a larger, more diversified sample is needeci but until
such an investigation is done, nurses should assume that
their dients consider discussion of sexual concems appro-
pnate, and stnve to address sexuality with a large portion
of their clients
Since clients' attitudes do not appear to be influenced by
age, mantal status or education, nurses should be careful
not to limit discussion of sexual concems to certam
categones of cbents Discussion of sexual concems
initiated by the nurse is valuable for all patients and it is
time nurses stopped assuming that cbents do not wish to
discuss sexuality
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