European Journal of Cardiovascular Nursing 9 (2010) 24 29 www.elsevier.com/locate/ejcnurse Sexual counselling of cardiac patients: Nurses' perception of practice, responsibility and confidence T. Jaarsma a,, A. Strömberg b, B. Fridlund c, S. De Geest d, J. Mårtensson e, P. Moons f, T.M. Norekval g, K. Smith h, E. Steinke i, D.R. Thompson j on behalf of the UNITE research group a Linköping University, Department of Social and Welfare studies, Division of Health, Activity and Care, Norrköping, Sweden and Department of Cardiology, University Medical Center Groningen, Groningen, the Netherlands b Department of Medicine and Health Sciences, Division of Nursing Science, Linköping University, Linköping, Sweden c School of Health Sciences, Jönköping University, Jönköping, Sweden d Institute of Nursing Science, University of Basel, Basel, Switzerland and Centre for Health Services and Nursing Research, Katholieke Universiteit, Leuven, Belgium e Unit for Research and Development in Primary Care, Jönköping, Sweden f Centre for Health Services and Nursing Research, Katholieke Universiteit, Leuven, Belgium and Division of Congenital and Structural Cardiology, University Hospitals of Leuven, Belgium g Department of Heart Disease, Haukeland University Hospital, Bergen, Norway h School of Nursing and Midwifery, University of Dundee, and Department of Cardiology, Ninewells Hospital, Dundee, UK i School of Nursing, Wichita State University, Wichita KS, USA j Department of Health Sciences/Department of Cardiovascular Sciences University of Leicester, UK Received 1 November 2009; accepted 12 November 2009 Available online 11 December 2009 Abstract Background: Cardiac patients may experience problems with sexual activity as a result of their disease, medications or anxiety and nurses play an important role in sexual counselling. We studied the practice, responsibility and confidence of cardiac nurses in the sexual counselling of these patients. Method: An adapted version of the nurses' survey of sexual counselling of MI patients was administered during a scientific meeting of the Council on Cardiovascular Nursing and Allied Professionals within the European Society of Cardiology. Results: Most of the 157 cardiovascular nurses (87%) who completed the survey felt responsible to discuss sexual concerns with their clients, especially when patients initiated a discussion. However in practice, most respondents rarely addressed sexual issues. The items that nurses reported to counsel patients were closely related to the cardiac disease, symptoms and medications and seldom more sensitive subjects (e.g. foreplay, positions). Nurses estimated that their patients could be upset (67%), embarrassed (72%) or anxious (68%) if they were asked about sexual concerns. One-fifth of the nurses felt they had insufficient knowledge and 40% sometimes hesitated to discuss sexual concerns with clients because they might not know how to answer questions. Additional education on sexuality was significantly related to being more comfortable and active in sexual counselling. Conclusion: Although cardiac nurses feel responsible and not anxious discussing patients' sexual concerns, these issues are not often discussed in daily practice. Nurses might need more knowledge and specific practical training in providing information on sexual concerns and sexual counselling to cardiac patients. 2009 European Society of Cardiology. Published by Elsevier B.V. All rights reserved. Keywords: Nurses attitudes; Sexuality; Sexual counselling Corresponding author. Department of Social and Welfare Studies (ISV), Linköping University, 601 74 Norrköping, Sweden. E-mail address: tiny.jaarsma@liu.se (T. Jaarsma). 1474-5151/$ - see front matter 2009 European Society of Cardiology. Published by Elsevier B.V. All rights reserved. doi:10.1016/j.ejcnurse.2009.11.003
T. Jaarsma et al. / European Journal of Cardiovascular Nursing 9 (2010) 24 29 25 1. Introduction Although several international guidelines [1,2] recommend that health care providers discuss sexual function with their cardiac patients, this seem to pose difficulties and is rarely done in daily practice. Most nurses and other health care providers do not routinely assess sexual problems in cardiac patients [3,4]. Barriers to providing sexual counselling can be related to a lack of available time, knowledge or training, ambivalent attitudes and beliefs about sexuality, a lack of responsibility for it or the perception that the patient would feel uncomfortable or too ill to address sexual issues [3 5]. Patients themselves might also experience barriers which prevent them from initiating discussions, including a perception that individual practitioners do not appear to be experienced enough to understand the patient's problems or feelings of shyness and embarrassment [6]. Although cardiac patients do report sexual concerns and sexual problems [8,9], and previous studies have reported that they have a need for information, patients might be reluctant to discuss these items with their health care provider. Several years ago, Steinke et al. assessed the attitudes of nurses toward sexual counselling in a US health care provider population [10]. To expand on this work and to potentially improve the future education for nurses, the attitudes of nurses visiting a European cardiac nursing congress and a description of their routine practice of sexual counselling in cardiovascular patients was explored. Accordingly, the aim of this study was to describe the responsibility, confidence and practices of cardiac nurses on sexual counselling of cardiac patients and how they estimated the comfort of their clients when discussing sexual concerns. 2. Research questions What is the prevalence and content of sexual counselling to patients of cardiac nurses? How responsible do cardiac nurses feel in addressing sexual concerns with patients? How confident do cardiac nurses feel in addressing sexual concerns with patients? How do cardiac nurses estimate the comfort of patients to discuss sexual concerns? What demographic and educational factors are related to comfort, confidence, practice and estimation of the clients comfort in addressing sexual concerns? 3. Methods 3.1. Study population and data collection Data were collected among the participants of the 9th Annual Spring Meeting on Cardiovascular Nursing organised by the Council on Cardiovascular Nursing and Allied Professionals (CCNAP) of the European Society of Cardiology in Dublin on April 23 24 2009. There were congress delegates from 23 countries, mostly from Europe (89%). Questionnaires were distributed during the congress and delegates were invited to complete the questionnaires during the congress and return them anonymously. 3.2. Measurement and data management The nurses survey of sexual counselling of MI patients [10,11] was used as a basis for the questionnaire. This questionnaire contains 7 subscales. The UNITE study group discussed the inclusion of subscales and suitability for the content of the items administrated at a congress. Issues of length of time to complete the questionnaire and sensitiveness of the topics were discussed. As a result, the subscales values, discussion and staff were not included and 1 question on the need for education was added. The following 4 subscales were included Practice (8 items): this subscale addressed the overall practice of sexual counselling. For example: in the past year, with what percentage of your clients have you assessed sexual health? Four items are scored from 0 to 3 and 4 items from 0 to 5. The subscale score ranges from 0 to 32. For reason of clarity in presenting the data, the scores in percentages of the 6 answer categories were recorded into: never (0%), sometimes (1 20% and 21 40%) and often (41 60%, 61 80%, and 81 100%). Responsibility (5 items): this subscale addressed the perceived responsibility of nurses to provide sexual counselling. For example: nurses have a responsibility to discuss sexual concerns with their clients (strongly agree strongly disagree). All items could be scored from 0 to 4, with a subscale range of 0 20. Confidence (5 items). This subscale reflects the perceived confidence and knowledge for sexual counselling. For example I know enough to answer most questions my clients have related to sexuality (strongly agree strongly disagree). All items could be scored from 0 to 4, with a subscale range of 0 20. Client (4 items). This subscale describes the nurses' estimation of the comfort of the client discussing sexuality and perceived patient response to discussing sexual concerns. All items could be scored from 0 to 4, with a subscale range of 0 16. An additional 10 questions were added concerning content of sexual counselling with cardiac patients, e.g. warning signs to report. [10] Reliability of the subscales using Cronbach's alpha have been reported: practice (0.89), responsibility (0.75), confidence (0.79), and client (0.79). [10] Subscales were calculated reversing 8 items and adding separate items to a total subscale scores.
26 T. Jaarsma et al. / European Journal of Cardiovascular Nursing 9 (2010) 24 29 Table 1 Demographic data of the cardiac nurses (n=157) who completed the questionnaire. Female gender n (%) 139 (89%) Age (mean±sd) 42±8 Marital status Married/living with partner 106 (67%) Never married 38 (24%) Divorced/widowed 13 (9%) Position Staff nurse 51 (33%) Clinical specialist 59 (38%) Non clinical Nurse manager 16 (10%) Educator 6 (4%) Researcher 20 (12%) Other 5 (3%) Country of residence Ireland 35 (22%) United Kingdom (including Scotland) 18 (11%) Norway 17 (11%) Netherlands 16 (10%) Canada 18 (10%) Sweden 14 (9%) Denmark 11 (7%) Other 32 (20%) Years in cardiac nursing 0 5 years 22 (14%) 6 10 years 31 (20%) N10 years 95 (61%) Not working in cardiac nursing 9 (5%) Highest level of education Basic nursing training 26 (17%) Cardiac specialisation 47 (30%) Master 54 (35%) PhD 28 (18%) Education on sexual counselling Yes 27 (17%) No 129 (82%) Missing 1 (1%) Other including Austria (1), Barbados (1), Belgium (3), Finland (4), Germany (1), Greece (3), Italy (5), Lebanon (1), Malaysia (2), Poland (2), Spain (3), Switzerland (2), Turkey (1), and USA (2). 4. Results 4.1. The study population In total, 157 of the 477 registered participants returned the questionnaire (response rate 33%). Demographic data are shown in Table 1. Respondents were mostly female, married, with a mean age of 42 years (±8). Most nurses (71%) worked in a clinical setting, such as a CCU, cardiac rehabilitation program or an outpatient clinic. The other nurses reported to work in research, education or administration. The majority of the respondents (83%) had additional training after their basic nursing training (e.g. cardiac specialisation or academic degree) and 17% reported to have taken any continuing education or workshops on sexuality in nursing practice. A total of 116 (78%) of the nurses were interested in attending a future international workshop on sexual of cardiac patients. Most respondents were from Ireland, the Netherlands, United Kingdom and Scandinavia, which was reflective of the participation of the conference. 4.2. Prevalence and content of sexual counselling Approximately one in 10 nurses frequently assessed clients' sexual health (11%), frequently taught about the effect of cardiac medications on sexual functioning (7%), frequently answered clients' questions about sexuality (10%) and frequently listened to clients' concerns about sexuality (11%). Most respondents reported to address these issues rarely or occasionally or to refer to sexual counselling only sometimes (Fig. 1). The total subscale practice score could theoretically range from 0 to 32, with higher scores indicating better performance of nurses in sexual counselling in daily practice. Obtained scores ranged from 0 to 30, with a mean score of 17 ±6. Ten questions regarding sociodemographic and professional background were asked on age, gender, nursing education, continuing education and position. 3.3. Data analysis Data were entered into SPSS 15.0. Descriptive analyses were used to describe the sample and the responses to the study variables. The results from closed-ended questions were tabulated to illustrate frequency distribution and ranges. Student's t tests were used to compare the normally distributed scores on the subscales of nurses with and without continuing education in sexuality and of nurses with N10 years and those 10 years experience in cardiac nursing. One-way analysis of variance was used to compare the subscale scores of nurses in staff positions, clinical specialists and those not involved in direct patient care. Fig. 1. Practice of sexual counselling (n=157).
T. Jaarsma et al. / European Journal of Cardiovascular Nursing 9 (2010) 24 29 27 Fig. 2. Specific items for sexual counselling (n=157). The items that nurses reported to counsel patients on most frequently related to: when to resume sexual activity; warning signs to report; the use of medications such as nitroglycerine if the patients had pain during sexual activity; and effects of medication on sexual activity. Most subjects reported occasionally or never discussing positions to be used, the use of foreplay, and unfamiliar surroundings/partners (Fig. 2). 4.3. Responsibility In total, 87% of the respondents agreed that nurses have a responsibility to discuss sexual concerns with their clients; 9% disagreed; and 4% were not sure. Thirteen percent of the nurses answered that in most situations it was inappropriate for nurses to discuss sexual concerns with their patients, while 77% did not think it was inappropriate and 10% were not sure. Most nurses thought that discussing sexual concerns was appropriate when the patients initiated the discussion, but less nurses thought that nurses should always initiate this discussion (see Fig. 3). On the subscale responsibility, the theoretical range was 0 20, with higher scores reflecting a higher feeling of responsibility of the nurses to initiate sexual counselling. In our sample we found a mean score of 15±3, with obtained scores ranging from 5 to 20. 4.4. Confidence One-fifth of the nurses (19%) reported that they did not feel knowledgeable about sexuality. The majority (64%) felt somewhat knowledgeable, and 15% felt very knowledgeable. Half of the respondents answered that they knew enough to answer most questions their clients have related to sexuality, but 40% sometimes hesitated discussing sexual concerns with clients because they might not know how to answer questions. Half of the nurses felt comfortable discussing patients' sexual concerns and they were seldom anxious (Fig. 4). On the subscale Confidence, the theoretical range was 0 20, with higher scores reflecting a higher feeling of confidence of the nurses to discuss sexual concerns. In our sample we found a mean score of 12 ±3, with actual scores ranging from 2 to 19, reflecting that nurses were somewhat confident in providing information. Fig. 3. Appropriateness of initiation of discussion of sexual issues (n=157). Fig. 4. Comfort and anxiety in discussing sexuality and sexual concerns (n=157).
28 T. Jaarsma et al. / European Journal of Cardiovascular Nursing 9 (2010) 24 29 4.5. Comfort of patients Half of the nurses (55%) reported that their patients sometimes could be offended if they offered to discuss sexual concerns, and 67% estimated that their patients would be upset, embarrassed (72%) or anxious (68%) if they were asked about sexual concerns. On the subscale Client, the theoretical range was 0 16, with higher scores reflecting that patients would feel more comfortable about discussing their sexual concerns. In our sample we found a mean score of 9±2, with obtained scores ranging from 4 to 16. 4.6. Related factors Nurses with additional continuing education on sexuality had significantly higher scores on the subscales confidence (t=2.0, pb0.05), practice (t=3.0, pb0.005), responsibility (t=3.0, p b0.005) and client (t=2.6, pb0.05) compared to those without such education. No differences were found in subscale scores between nurses who had worked less or more than 10 years in cardiac care. There was a significant difference between the nurses in the 3 different positions: staff nurses; clinical specialist; and those not directly working in clinical practice for the subscales confidence (F =5.5, p =0.05), responsibility (F =6.0, p =0.03) and practice (F=7.5, p=0.01). Post hoc analysis showed that staff nurses scored significantly lower in confidence than nurses not working directly in patient care (p=0.018), and lower in responsibility and practice than the clinical nurse specialists (p b 0.05) and the nurses not working directly in patient care. 5. Discussion This is the first European survey on the practice of sexual counselling of patients by cardiac nurses. The majority of nurses (87%) agreed that nurses have a responsibility to discuss sexual concerns with their clients. However, many nurses do not address these concerns of their patients in daily practice. If information on sexual activity is provided, it mostly concerns areas that are close to practical and rather safe subjects related to the cardiac disease such as warning signs and effects of medication. This limited direct assessment and counselling of cardiac patients by nurses is a concern. Sexual problems are common in cardiac patients, and their lives and that of their partners might be adversely affected [7 9]. Previous studies have shown that cardiac patients do worry about resuming sexual activity and are in need of education and counselling regarding this issue [7,8]. In our data, we found that a majority of nurses also estimated that their patients sometimes would be upset, embarrassed or anxious if they were asked about sexual concerns. Although the sample differed from a previous US sample described by Steinke et al., [10] the results concerning the responsibility experienced by the cardiac nurses in our study is comparable, with subscale scores of 14 in a cardiac rehabilitation sample in the US study compared to 15 in our sample. A recently published national survey from Sweden described that coronary care unit teams do not provide sufficient education to patients after myocardial infarction and that there is a lack of educational strategies and material [12]. Half of the sample reported that they were usually conformable in discussing sexual concerns with their patients and seldom felt anxious. Still, one-third often felt anxious in discussing sexuality and 15% seldom felt comfortable discussing this subject. The majority of nurses reported they felt somewhat knowledgeable, but one in five nurses did not feel knowledgeable at all on sexuality. Similar to the previously published data from nurses in the US, nurses had minimal or no continuing education on sexual counselling following their basic training [10]. Nurses might benefit from specific training courses to assist in developing the knowledge and skills to discuss sexual issues in practice in order to feel at ease discussing matters of sexuality and to apply new skills [13,14]. We found that nurses with additional continuing education on sexuality had significantly higher scores on all the subscales compared to those without such education. Both nurses and patients might benefit from implementing structured assessment forms or questions that can be used to address sexual concerns. (For example: what concerns do you have about resuming sexual activity with your cardiac condition (insert appropriate term, e.g. heart attack, implantable defibrillator, heart failure, etc.)). It might help nurses to discuss the topic of sexual concerns within the context of exercise, in a general discussion on consequences of the disease or the treatment for daily life or to introduce the topic of return to sexual activity as a component of exercise. Also within the context of initiating and uptitrating medication (e.g. beta blocker), changes in sexual response can be introduced or the fear for impotence can be discussed, for example by stating: Some people report sexual problems as a result of taking this medication (beta blocker). Have you experienced that or is it a concern for you? Here again, nurses could benefit from a practical workshop with a case scenario to actually practice the wording and the approach that would suit them and their patients best. There was a difference between nurses directly working in clinical practice and those who were currently engaged in more research or educational settings. This might be explained by the fact that nurses involved in education and research have more theoretical knowledge in the area and more confidence, or by the fact that it seems easier from a distance to counsel patients on sexuality, but in daily practice it is more difficult. A limitation of this study is the generalisablity of the study results. We recognise that this is a highly selective
T. Jaarsma et al. / European Journal of Cardiovascular Nursing 9 (2010) 24 29 29 sample. Firstly, delegates visiting a cardiac care conference might not be representative for the majority of nurses working in daily clinical practice. However in our sample, 71% worked in a clinical setting, such as a CCU, cardiac rehabilitation program or an outpatient clinic. Secondly, participants were invited to participate on a voluntary basis, and as a result not all conference delegates returned the questionnaire. It is reasonable to suggest that especially those nurses who did not feel comfortable to answer questions on this subject or who did not think addressing sexual function is an appropriate subject to address in nursing care, did not complete the questionnaire. Hence, the low response rate was a remarkable secondary finding. In previous projects of the UNITE research group, with a similar procedure of data collection during the annual conference, response rates of 83% [15] and 50% [16] have been achieved. The subjects of these surveys were risk factors of heart disease and family presence during CPR respectively. Although we did not record the reasons for not responding to this survey on sexuality, the low response rate might confirm the sensitivity of this subject. The low response rate also seems to justify the choice of the UNITE group to exclude items from the original questionnaire related to the nurses' own values on sexuality, which could have made the questionnaire even more sensitive for the nurses to complete. 6. Conclusion Although cardiac nurses feel responsible and not anxious discussing patients' sexual concerns, these issues are not often discussed in daily practice. Nurses might need more knowledge and specific practical training in providing information on sexual concerns and sexual counselling of cardiac patients. Acknowledgements We would like to thank all participants for completing the questionnaires. The study was financially supported by the Council on Council on Cardiovascular Nursing and Allied Professionals (CCNAP) of the European Society of Cardiology. References [1] Dickstein K, Cohen-Solal A, Filippatos G, McMurray JJ, Ponikowski P, et al. ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur J Heart Fail 2008;10:933 89. [2] Heart Failure Society of America. HFSA 2006 Comprehensive Heart Failure Practice Guideline. J Card Fail 2006;12:10 38. [3] Steinke EE, Patterson P. Sexual counseling of MI patients by cardiac nurse. J Cardiovasc Nurs 1995;10:81 7. [4] Katz A. Do ask, do tell: why do so many nurses avoid the topic of sexuality? Am J Nurs 2005;105:66 8. [5] Rerkpattanapipat, et al. Sex and the heart: what is the role of the cardiologist? Eur Heart J 2001;22:201 8. [6] Gott M, Hinchliff S. Barriers to seeking treatment for sexual problems in primary care: a qualitative study with older people. Fam Pract 2003;20: 690 5. [7] Steinke EE, Gill-Hopple K, Valdez D, Wooster M. Sexual concerns and educational needs after an implantable cardioverter defibrillator. Heart Lung 2005;34:299 308. [8] Jaarsma T. Sexual problems in heart failure patients. Eur J Cardiovasc Nurs 2002;1:61 7. [9] Jaarsma T, Dracup K, Walden J, Stevenson LW. Sexual function in patients with advanced heart failure. Heart Lung 1996;25:262 70. [10] Steinke EE, Patterson-Midgley P. Sexual counselling of MI patients: nurses' comfort, responsibility, and practice. Dimens Crit Care Nurs 1996;15:216 23. [11] Waterhouse JK. Development and testing of a structural equation model of nursing practice related to sexuality. Doctoral dissertation. University of Delaware. 1996; UMI microform 9718780. [12] Ivarsson B, Fridlund B, Sjöberg T. Information from health care professionals about sexual function and coexistence after myocardial infarction: a national survey. Heart Lung 2009;38:330 5. [13] Steinke EE, Wright DW. The role of sexual satisfaction, age, and cardiac risk factors in the reduction of post-mi anxiety. Eur J Cardiovasc Nurs 2006;5:190 6. [14] Post MWM, Gianotten WL, Heijnen L, et al. Sexological competence of different rehabilitation disciplines and effects of a discipline-specific sexological training. Sex Disabil 2008;26:3 14. [15] Scholte op Reimer WJ, Moons P, De Geest S, Fridlund B, Heikkilä J, Jaarsma T, et al. Cardiovascular risk estimation by professionally active cardiovascular nurses: results from the Basel 2005 Nurses Cohort. Eur J Cardiovasc Nurs 2006;5:258 63. [16] Axelsson ÅB, Fridlund B, Moons P, Mårtensson J, Jaarsma T, Scholte op Reimer W, et al. European cardiovascular nurses attitudes and experiences of having family members present in the resuscitation room. Eur J Cardiovasc Nurs 2010;1.