Received: 7 August 2018 | Revised: 17 March 2019 | Accepted: 14 April 2019

DOI: 10.1111/jocn.14900

REVIEW

Discussing sexuality in health care: A systematic review

Reginald Fennell NR‐Paramedic/FF, RN, CEN, PhD, MCHES, F‐ACHA, Professor Emeritus ‐
Public Health, Registered Nurse/Paramedic, Family Nurse Practitioner (FNP) Student |
Blair Grant BSN, RN, Clinical Manager

School of Nursing and Health

Sciences, Simmons University, Boston, Abstract
Massachusetts Aims and objectives: Using the PRISMA guidelines, a systematic literature review
Correspondence was conducted to explore current and relevant evidence regarding factors that influ‐
Reginald Fennell, Department of Kinesiology ence nurses’ provision of sexual healthcare education to patients.
and Health (KNH), 106 Phillips Hall, Miami
University, Oxford, OH 45056. Background: The World Health Organization and Healthy People 2020 emphasise
Email: fennelr@[Link] the importance of sexual health care. Although the nursing profession has the abil‐
Present Address ity to develop a competent level of sexuality education, sexual health care is often
Reginald Fennell, Department of Kinesiology ignored in nursing care and education. Many nurses are failing to engage in meaning‐
and Health (KNH), Miami University, Oxford,
Ohio ful conversations about sexual health with patients, and this could lead to negative
Blair Grant, Ekahi Health System, Honolulu, health events. However, patients would like reliable and nonjudgmental access to
Hawaii
education about sexual health.
Design: Electronic databases were searched for articles published between 2012–
2017. Studies of nurses providing sexual health education in healthcare settings were
included. The Melnyk and Fineout‐Overholt (2015, Evidence‐based practice in nurs‐
ing & healthcare, Philadelphia, PA: Walters Kluwer) quality assessment framework
was used. The researchers independently reviewed 532 studies and agreed upon ten
to include in this review.
Results: Findings from this systematic review suggest that nurses’ provision of sexual
health education to patients is influenced by four factors: (a) a lack of knowledge
about sexual health, (b) nurses’ attitudes and beliefs that sexual health care is private
and not a priority, (c) nurses’ comfort discussing sexual health, and (d) perceived bar‐
riers related to time, responsibility and organisational support.
Conclusion: The ten articles reviewed were all Level VI descriptive and qualitative
studies, as defined by Melnyk and Fineout‐Overholt (2015). It is evident that sexual
healthcare information is not being widely addressed. To reduce stigma, the positive
aspects of sexual health care must be promoted on multiple levels.
Relevance to clinical practice: Leaders in professional and community‐based organi‐
zations should be on the forefront of making recommendations for nurses and prac‐
titioners, so they could improve their ability to provide sexual healthcare information
to their patients.

KEYWORDS
health promotion, nursing education, patient teaching, sexual health, sexuality, teacher

J Clin Nurs. 2019;28:3065–3076. [Link]/journal/jocn

© 2019 John Wiley & Sons Ltd | 3065
3066 | FENNELL and GRANT

1 | I NTRO D U C TI O N
What does this paper contribute to the wider global
The 2017 (WHO) defines several terms related to sexual and repro‐
clinical community?
ductive health. The terms defined by the WHO include the following:
• Nurses have a key role in teaching patients about sexual
sex, sexual health, sexuality and sexual rights. A focus of this research
health care.
is sexual health that is defined by the WHO as:
• Knowledge, attitudes and beliefs, comfort, and per‐
ceived barriers need to address nurses' and clinicians'
…a state of physical, emotional, mental and social
comfort level discussing sexual health care with patients.
well‐being in relation to sexuality; it is not merely the
• Professional societies, as key stakeholders in leadership
absence of disease, dysfunction or infirmity. Sexual
roles, should publish guidelines and white papers on ex‐
health requires a positive and respectful approach to
pectations for nursing programmes as well as practicing
sexuality and sexual relationships, as well as the pos‐
nurses and clinicians.
sibility of having pleasurable and safe sexual experi‐
ences, free of coercion, discrimination and violence.
For sexual health to be attained and maintained, the
sexual rights of all persons must be respected, pro‐ discussing sexuality with their patients could also result in cost sav‐
tected and fulfilled.  (WHO, 2017) ings from treating infections and other related illnesses.
Patients would like access to reliable and nonjudgmental care
Published research studies have reported many nurses are not and education about sexual health; however, many nurses do not
comfortable speaking with their patients about topics related to sexual feel they have sufficient education, experience or confidence to
health. Reynolds and Magnan (2005) stated “sexual healthcare is often properly speak with their patients (Martel, Crawford, & Riden,
ignored in nursing care and education” and “(few) studies have exam‐ 2017). Schub and Lawrence (2018), for example, explain that some
ined the development of sexual healthcare and related interventions nurses are often uncomfortable screening for STIs. As an example,
from the perspectives of clinical nurses, particularly with respect to the HIV/AIDS can increase the risk of age‐associated diseases, including
effects of sexual healthcare training programmes on clinical nurses’ chronic inflammation in the body. Associated with chronic inflamma‐
knowledge, attitudes, and self‐efficacy” (p. 2990). tion are many health conditions such as lymphoma, type 2 diabetes
and cardiovascular disease ([Link], 2017). Therefore, this research
problem is salient for myriad reasons.
2 | AIMS Arikan, Meydanlioglu, Ozcan, and Ozer (2015) have described in
research the effect of negative health events on patients due to the
The Centers for Disease Control and Prevention (CDC) provides in‐ failure of nurses discussing sexual health with patients. These health
formation from Healthy People 2020 (2016) emphasising the impor‐ issues include breast cancer, prostate cancer, myocardial infarction,
tance of those in the nursing profession developing a competent rectal cancer, rheumatoid arthritis and other illnesses. The research‐
level of sexuality education in order to be more proactive and pre‐ ers also discussed the importance of sexual health for patients with
venting outcomes related to sexually transmitted infections (STIs), diabetes. Klaeson, Hovlin, Guva, and Kjellsdotter (2017) provided
human immunodeficiency virus and acquired immunodeficiency syn‐ information on the per cent of patients with these conditions who
drome (HIV/AIDS), and unintended pregnancies (Office of Disease have reported negative impacts on their sexual health, including
Prevention & Health Promotion, 2017, 2018). Ford, Barnes, Rompalo, lack of desire and impotence. The research highlights the negative
and Hook (2013) explain that the best outcome for nurses and pa‐ impacts of not discussing sexual health but there is a gap in the re‐
tients would be to maintain sexual health throughout the lifespan search as to what are the causes of nurses not engaging in these
and for this to be seen as a routine part of health care. This could conversations.
decrease stigma and encourage more patients to seek care or more The purpose of this systematic review of the literature was
comfortably discuss concerns. Additionally, Evcili and Demirel (2018) to explore current and relevant evidence regarding factors that
explain that “this approach is seen as an important element in the influence the provision of sexual health education for patients.
promotion and protection of sexual health and development of qual‐ Researchers need to identify specific barriers nurses face when
ity of life” (p 1282). attempting to deliver sexual healthcare education. Furthermore,
Several researchers have published on the benefits for patients many nurses tend to neglect sexual health care because they do
if nurses had comprehensive training on topics related to sexual not feel they have sufficient education, experience or confidence
health care (Sung, Jiang, Chen, & Chao, 2016; Yingling, Cotler, & to properly engage with patients (Martel et al., 2017; Schub &
Hughes, 2017). Furthermore, nurses who were formally trained on Lawrence, 2018; Sung et al., 2016). Klaeson et al. (2017) explain
how to best deliver sexual health information were more effective that “this avoidance forms a barrier between the patient and the
in addressing patients’ sexual health concerns proactively instead nurse which prevents nurses from giving satisfactory sexual health
of reactively (Sung et al., 2016). Thus, positive benefits of nurses care to patients” (p. 11).
FENNELL and GRANT | 3067

TA B L E 1 Inclusion and exclusion criteria of the study

Selection criteria Inclusion criteria Exclusion criteria

Language English Non‐English

Dates Publications from January 2012–January 2017 Publications prior to 2012
Publications after 2017
Study type Quantitative research Editorials/commentaries
Qualitative research News articles
Systematic reviews Theses/Dissertations
Meta‐analysis Conference abstracts
Population Participants in studies 18 years and older Participants in studies 17 years old and younger
Nurses Physicians (MD/DO) Physician Assistant (PA) Nurse
Practitioners (NP)
Topics Human sexuality Domestic violence
Sexual health education Sexual abuse
Lesbian, gay, bisexual and transgender (LGBT) Rape
Condom use Incarcerated patients
Sexually transmitted infections (STI) Psychiatric patients
Contraceptive use

This systematic review could help to identify the perceived gaps

3.3 | Data collection
and areas that need to be addressed when creating educational
programmes for nurses. This could help nurses become more com‐ The search results yielded 532 articles. These articles were further
fortable discussing sexual healthcare education with their patients. delineated using the inclusion and exclusion criteria for the study.
Thus, this research focuses on an important question that merits in‐ Based on the criteria of English language articles and research subjects
vestigation. What factors either influence or contributes to barriers 18 years and older, this resulted in 201 articles. The two researchers
to nurses’ provision of sexual health education to patients? independently reviewed each of the 201 articles based on the title
and abstract to determine whether each met the criteria for the study.
Next, the authors reviewed the articles together to reach final agree‐
3 | M E TH O DS
ment on the inclusion of the ten articles in this systematic review.
The researchers agreed upon twenty‐seven articles that were
3.1 | Design
retained for more in‐depth review. Each researcher independently
Using the PRISMA guidelines, a systematic literature review was reviewed the twenty‐seven articles and entered information into a
conducted (see Appendix S1; PRISMA, 2018). The systematic review shared Microsoft Excel file that charted yes, no or unsure for the
began with an in‐depth and comprehensive review of the literature. categories meeting inclusion criteria and sufficient quality. The re‐
This review found articles that discussed sexuality in health care. searchers discussed review outcomes and reached consensus on
The findings confirmed there were sufficient studies to conduct a the ten studies included in this systematic review. Figure 1 depicts a
literature review. flowchart of the process for the literature search and determination
of the articles included in the final systematic review.

3.2 | Search strategy

3.4 | Analysis
A computerised literature review was completed with the assistance
of a research librarian. The databases used in the search were CINAHL The Melnyk and Fineout‐Overholt (2015) quality assessment frame‐
Complete, ERIC, LGBT Life with Full Text, MEDLINE and PsycINFO. work was used to define the levels of evidence for each article. This
The keywords used were (nurs*) AND (knowledge OR attitudes OR framework is used in nursing to rate the levels of evidence for thera‐
beliefs OR comfort) AND (sexuality education OR sexual health educa‐ peutic interventions. The scale has seven levels: Level I: Evidence
tion OR sexual health). The search included the years 2012–2017. from a systematic review or meta‐analysis of all relevant randomised
Table 1 describes the inclusion and exclusion criteria for this control trials (RCTs), Level II: Evidence obtained from well‐designed
study. As an initial investigation into this subject, the authors nar‐ RCTs, Level III: Evidence obtained from well‐designed controlled tri‐
rowed the topic to articles in English, as this is the first language of als without randomisation, Level IV: Evidence from well‐designed
the authors. The other inclusion criteria provided a method to sys‐ case–control and cohort studies, Level V: Evidence from systematic
tematically include articles on the topic of nurses and sexuality. The reviews of descriptive and qualitative studies, Level VI: Evidence
authors chose to exclude research with populations that were incar‐ from single descriptive or qualitative studies and Level VII: Evidence
cerated and psychiatric patients, in addition to other related themes from the opinion of authorities and/or reports of expert commit‐
as these were beyond the scope of this research. tees. The two researchers assessed the studies, and there was an
3068 | FENNELL and GRANT

F I G U R E 1 Flow diagram based on

Records identified from database search: CINAHL PRISMA guidelines and the review
complete, ERIC, LGBT Life with Full Text, process
MEDLINE, PsycINFO
(N = 532)

Records excluded, did not meet

inclusion criteria of 18 years and
older and english language
(N = 331)

Independently screened title and abstract for inclusion

criteria by two researchers
(N = 201)

Articles excluded after team

meeting
(N = 174)

Independently screened full article

(N = 27)

Articles excluded after

team meeting
(N = 17)

Studies include in the synthesis

(N = 10)

Qualitative (n = 2)
Quantitative (n = 6)
Mixed Methods (n = 2)

agreement in regard to the decisions made about the quality of the Sample sizes ranged from 9 (Klaeson et al., 2017)–477 (Krouwel et
studies. al., 2015). Two studies evaluated the effectiveness of sexual health‐
All of our studies were rated Level VI. These studies are im‐ care training programmes for student nurses (Jonsdottir et al., 2016;
portant, as they can provide qualitative data that can be essential Sung et al., 2016). A majority of the studies were conducted to ex‐
in research. Table 2 outlines the ten selected articles based on the plore and describe nurses’ attitudes, knowledge, experiences and
following: (a) first author, year of publication and title, (b) aim of the barriers in regard to discussing sexuality and sexual health care with
research, (c) level of evidence, (d) sample size and characteristics, patients (Arikan et al., 2015; Hoekstra, Lesman‐Leegte, Couperus,
(e) sampling, (f) practice setting, (g) country where the research was Sanderman, & Jaarsma, 2012; Huang, Tseng, & Lee, 2013; Klaeson
conducted, (h) study design and (i) conclusions. et al., 2017; Krouwel et al., 2015; Moore, Higgins, & Sharek, 2013;
Saunamäki & Engström, 2014; Sung, Huang, & Lin, 2015).
The key research topics and findings were organised based on
4 | R E S U LT S four themes identified in the studies reviewed: (a) knowledge (b) atti‐
tudes and beliefs, (c) nurses’ comfort and (d) perceived barriers. The
The final analysis included ten studies. There were two qualita‐ four themes provided insight into what factors influenced nurses’
tive, six quantitative and two mixed methods studies. Table 2 de‐ provision of sexual health education and the barriers nurses expe‐
scribes the major components of the studies. All the studies were rienced when attempting to deliver sexual health information to
conducted outside of the United States: Two were reported in each patients.
of the following countries: Taiwan, Sweden, the Netherlands and
Iceland. Also, one study was conducted in Turkey and one in Ireland.
4.1 | Knowledge
These articles included diverse specializations within the different
areas of nursing (cardiology, oncology, radiology, palliative care, pri‐ Eight studies focused on the knowledge of nurses and how knowl‐
mary care, surgery, psychiatry, women's health and student nursing). edge is a critical factor in providing sexual healthcare education to
TA B L E 2 Overview of included qualitative, mixed methods and quantitative studies

First Author/year/ Level of Sample Size/

title Aim evidence Characteristics Sampling Practice setting Country Design Conclusions
FENNELL and GRANT

Arikan (2015). Assess attitudes and Level VI RN (N = 162) Convenience University Turkey A descriptive In this study, it was established
Attitudes and be‐ beliefs of nurses as Female (n = 154) sample hospital and compara‐ that nurses were aware of the
liefs of nurses re‐ it relates to discuss‐ Male (n = 8) Internal medi‐ tive design concerns of the patients about
garding discussion ing sexuality with Mean age 30.5 years old cine, surgical, sexuality, but their practi‐
of sexual concerns hospitalised patients psychiatry, and cal attempts to relieve those
of patients during OB setting concerns were not adequate.
hospitalization In view of these results, it is
recommended that sexual‐
ity should be discussed more
openly in basic education
curriculum and that in‐ser‐
vice training on the issue of
sexuality and health should be
addressed
Hoekstra (2012). To examine the Level VI RN (N = 146) Convenience Heart failure Netherlands Questionnaire Although heart failure nurses
What keeps current practice of Female (n = 121) sample clinics feel responsible for discussing
nurses from the discussing sexual Male (n = 25) sexuality, this topic is rarely
sexual counseling health by heart Age range 37–53 years addressed in clinics. Several
of patients with failure nurses, and old barriers were identified, relat‐
heart failure? to explore which ing to personal, patient and
barriers prevent organisational factors
nurses from discuss‐
ing sexuality?
Huang (2013). To investigate nursing Level VI Senior nursing students Convenience School of Taiwan Descriptive Nursing students had different
Nursing students’ students’ attitudes (N = 142) sample Nursing at cross‐sectional attitudes towards different
attitudes towards towards providing Female (n = 120) two Medical survey levels of sexual health care.
provision of sexual sexual health care in Male (n = 22) Universities Attitudes were associated
health care in clinical practice and Age range 20–25 years with age and gender. The
clinical practice to identify associ‐ old Nursing Attitudes on Sexual
ated factors Health Care scale is useful and
reliable for identifying nurses’
attitudes towards providing
sexual health care. A bet‐
ter understanding of nurses’
attitudes towards provisional
sexual health care will provide
information needed to develop
appropriate education pro‐
grammes to improve delivery
|

of sexual health care

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TA B L E 2 (Continued)

First Author/year/ Level of Sample Size/

title Aim evidence Characteristics Sampling Practice setting Country Design Conclusions

Jonsdottir (2016). To examine the at‐ Level VI Nurses and physicians. Convenience University Iceland A comprehen‐ The project somewhat improved
Changes in at‐ titudes, practices January 2011 (T1): Total sample Hospital sive long‐term both perceived knowledge and
titudes, practices and perceived participants (N = 136), Medical, radia‐ educational practices of staff, but probably
and barriers barriers in relation RN (N = 108), Female tion palliative intervention to the benefit for a minority of
among oncology to a sexual health (n = 119), Male (n = 17). care, surgical project. This patients. To further increase
health care profes‐ care educational November 2011 (T2): and gynaeco‐ study was a the comfort levels and skills of
sionals regarding intervention among Total Participants logical oncol‐ quasi‐experi‐ health care staff in discuss‐
sexual health care: oncology health (N = 97), RN (n = 78), ogy settings mental, pre– ing sexual health issues with
Outcomes from care professionals Female (n = 89), Male post‐test time patients, it is crucial to provide
a 2‐year educa‐ at the Landspítali‐ (n = 19). series design ongoing educational oppor‐
tional intervention National University May 2012 (T3): Total with a baseline tunities in practicing such
at a University Hospital of Iceland. Participants (N = 64), RN measure before discussions. Specific training
Hospital A comprehensive (n = 52), Female (n = 57), the start of the in sexual health care including
long‐term educa‐ Male (n = 7). Age range intervention workshops and group work
tional intervention 25–67 years old at Time 1 (T1), where reflection is central
project. The aim 10 months are important and should be
was that they would later at Time regularly available to staff. It is
do so with more 2 (T2), and at also of key importance to ad‐
than 50% of their 16 months at dress the issues from as many
patients Time 3 (T3) angles as possible and include
(Table 1) structural, organisational and
personal factors
Klaeson (2017). To illuminate nurse' Level VI RN (N = 9) Purposeful Primary care Sweden Qualitative Fear, prejudice, personal beliefs
Sexual health in experience and Female (n = 8) sampling descriptive and organisational design con‐
primary health opportunities to dis‐ Male (n = 1) design, semi‐ tribute to the nurse's feeling
care—A qualitative cuss sexual health Age range 41–63 years structured uncertainty about bringing up
study of nurses’ with patients in old interviews human sexually. Lack of knowl‐
experiences primary health care edge but would like training
Krouwel (2015). To establish oncology Level VI RN (N = 477) Convenience Hospital, oncol‐ Netherlands Cross‐sectional The findings of the survey em‐
Addressing nurse's knowledge Female (n = 429) sample ogy inpatient survey phasise the potential benefit of
changed sexual about and attitudes Male (n = 48) and outpatient providing knowledge, including
functioning in to sexual function Age range 19–62 years. practical training and a com‐
cancer patients: in oncology care Old plete department protocol
A cross‐sectional and identify their
survey among perceived barriers
Dutch oncology to addressing the
nurses subject
FENNELL and GRANT

(Continues)
TA B L E 2 (Continued)

First Author/year/ Level of Sample Size/

title Aim evidence Characteristics Sampling Practice setting Country Design Conclusions

Moore (2013). To investigate Level VI RN (N = 89) Convenience Oncology Ireland Questionnaire There is need for more compre‐
FENNELL and GRANT

Barriers and oncology nurses All female sample Centers with a quan‐ hensive education on sexuality
facilitators for self‐perceived Age range 20–60 years titative and issues and testicular cancer.
oncology nurses knowledge and com‐ old qualitative Nurses need to take a more
discussing sexual fort in relation to component proactive approach to sexual‐
issues with men discussing sexuality ity care, as opposed to the
diagnosed with concerns with men “passive waiting stance” that
testicular cancer diagnosed with tes‐ permeates the current culture
ticular cancer and to of care. Education programmes
identify the barriers need to include specific infor‐
and facilitators to mation on sexual issues associ‐
such discussions ated with testicular cancer, and
oncology nurses must subsume
sexuality as an essential aspect
of their role through changes
in policies and nursing care
planning
Saunamäki (2014). To describe reg‐ Level VI RN (N = 10) Maximum varia‐ Hospital Sweden Qualitative, Patients’ sexuality is still
Registered nurses' istered nurses' Female (n = 8) tion sampling descriptive surrounded by silence. But
reflections on reflections on Male (n = 2) design factors exist that can facilitate
discussing sexual‐ discussing sexuality Age range 25–62 years discussion of sexuality. Nurses
ity with patients: with patients old have a key role in detecting ill
responsibilities, health. When nurses use their
doubts and fears knowledge and go beyond
their comfort zone and address
sexuality, they can identify
patients’ sexual problems
Sung (2015). The purpose of the Level VI Senior nursing students Purposeful Nursing college Taiwan Cross‐sectional Nursing educators need to teach
Relationship be‐ study is to address (N = 190). sampling survey the students both knowledge
tween the knowl‐ the need for nursing All female. and skills on sexual health care
edge, attitude, education on sexu‐ Age range 20–23 years old as well as educate them about
and self‐efficacy ality by exploring positive attitudes on sexual‐
on sexual health the relationship ity to enhance their efficacy
care for nursing between nursing to deal with the patients'
students students' knowl‐ sexuality matters in the future
edge, attitude, and nursing practice
self‐efficacy for
patients' sexual
health care
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 3072 | FENNELL and GRANT

patients. Two cross‐sectional studies of student nurses and one

comforting patients. There is a

sexual health care but lack the

leading to discomfort to when

qualitative study of hospital nurses suggested that nurses with a

gap in providing a supportive

knowledge and skill to do so
higher level of knowledge equated to more positive attitudes and

are responsible to deliver

Nurse are aware that they increased comfort in discussing sexual health care with patients

learning environment
(Huang et al., 2013; Saunamäki & Engström, 2014; Sung et al.,
2015). Furthermore, the qualitative research study conducted by
Conclusions

Saunamäki and Engström (2014) added more depth by explaining

nurses reported that knowledge gave them a reason to discuss sex‐
uality with patients. Three other studies that used different study
designs (mixed method, interventional and cross‐sectional survey)

researchers. An
programme de‐
researched the same population of nurses (oncology) and concluded
Mixed methods.

veloped by the

control group
an evaluation

experimental
focus groups
session. Two

Phase 2 was
exploratory,

of a training

group and a
nurses who provided their patients with sexual healthcare educa‐
descriptive

were used.

were used
Phase 1—

tion had a higher level of knowledge of sexual health due to years

Design

of nursing experience, recent training in the past 5 years and/or

are graduate prepared (Jonsdottir et al., 2016; Krouwel et al., 2015;
Moore et al., 2013). However, in two studies, nurses reported a lack
of education, in‐service and training about sexual health that lead
Country

Taiwan

to knowledge and skill deficits in providing sexual healthcare infor‐

mation (Jonsdottir et al., 2016; Sung et al., 2016). Nurses were will‐
ing and wanted more knowledge, in‐services and training to engage
Practice setting

teaching and

in more meaningful conversations with patients (Jonsdottir et al.,

community
psychiatric
Integrated

2016; Saunamäki & Engström, 2014).

hospital

Training programmes can assist nurses (both current practicing

nurses and nursing students) to be more assertive in addressing sex‐
ual health care with improvements in knowledge, attitudes, ability
the division of
dom sampling
stratified ran‐
of the 2 focus
signed to one
participate at

randomly as‐

groups (n = 7

to ask patients about their sexual health problems and a decrease

Nurses were

proportional

according to
seminar and
recruitment

and n = 9)
invited to

in barriers over time (Jonsdottir et al., 2016; Sung et al., 2016).

Sampling

Stage 2:
Stage 1:

wards

However, Jonsdottir et al. (2016) noted a training programme did not

show a statistically significant increase in the frequency of sexual
health discussions. Furthermore, sexual health discussions remained
Age range 27–59 years old

low despite training efforts and the majority of nurses did not reach
the stated goal regarding the frequency of sexual health discussions,
Stage 1 RN (N = 16)

that is, discussing sexual health issues with more than 50% of their
Characteristics

Experimental
Sample Size/

patients (Jonsdottir et al., 2016). Therefore, to further increase their

RN (N = 58)
RN (N = 59)

All females

sexual health knowledge, nurses’ comfort and skills of nurses in

Stage 2:

Control

discussing sexual health issues with patients, it is crucial to provide

ongoing educational opportunities that provide an opportunity to
practice these discussions (Jonsdottir et al., 2016).
evidence

Level VI
Level of

4.2 | Attitudes and beliefs

To evaluate the effec‐

programme for clini‐

spect to knowledge,

efficacy concerning
tiveness of a sexual

Attitudes and beliefs of nurses regarding discussing sexual health

healthcare training

attitudes, and self‐

cal nurses with re‐

sexual health care

care with their patients were examined in five of the studies re‐
viewed. Researchers in two of these studies reported on attitudes
of nursing students. Huang et al. (2013) surveyed nursing students
enrolled in two medical schools in Taiwan. The researchers were in‐
Aim
(Continued)

terested in the attitudes of the nursing students towards providing

sexual health care. In this descriptive study, the authors found that
Bridging the gap in

tice: implementing
sexual healthcare
First Author/year/

care training pro‐

gram to improve
a sexual health‐
in nursing prac‐

nursing students, as had been found with nurses in other studies,

lacked the training, had negative attitudes and the sexual comfort to
Sung (2016).

outcomes
TA B L E 2

discuss the topic. Likewise, Sung et al. (2015) surveyed senior female
nursing students. The researchers noted students who reported
title

higher knowledge, self‐efficacy and more positive attitudes based

FENNELL and GRANT | 3073

on three different tools used to assess these issues were correlated or providers (physicians, physician assistants and nurse practitioners),
with higher knowledge levels regarding sexual health care. it was to discuss sexuality‐related topics with patients. Three addi‐
Researchers in three studies reported on the attitudes and beliefs tional studies highlighted barriers experienced by nurses were the
of practicing nurses. Krouwel et al. (2015) conducted a cross‐sec‐ lack of policies about the role of nurses in discussing sexual health
tional survey of oncology nurses in the Netherlands using a Likert care with patients, in addition to organisational and management
scale measuring practices, attitudes, the content of sexual counsel‐ support to allow nurses the time to engage with patients about their
ling, responsibility, need for education and barriers regarding discuss‐ sexual health (Jonsdottir et al., 2016; Krouwel et al., 2015; Moore
ing sexual function and fertility issues. Attitudes and beliefs of nurses et al., 2013). This lack of support lead to role confusion, decreased
working in oncology ranged from the belief that patients would feel comfort and the belief sexuality is not an essential aspect of the nurs‐
embarrassed or offended, sexual health is a difficult issue to address, ing assessment (Moore et al., 2013). Without this support, there was
there is not a need to discuss sexual health with older patients, a lack little reinforcement that sexuality is an important nursing discussion.
of privacy, and/or there is not enough time to discuss sexual health Time constraints and privacy concerns were expressed as bar‐
(Jonsdottir et al., 2016; Krouwel et al., 2015; Moore et al., 2013). riers in several of the research studies. The attitudes and beliefs of
Additionally, Saunamäki and Engström (2014) conducted a qual‐ nurses working in oncology related to sexual health ranged from
itative study of Swedish hospital nurses in order to gain an in‐depth a belief there is a lack of privacy and there is not enough time to
understanding of registered nurses’ reflections on discussing human discuss sexual health (Jonsdottir et al., 2016; Krouwel et al., 2015;
sexuality with patients. The nurses that addressed sexuality with Moore et al., 2013). Huang et al. (2013) noted “(sexual) health care
their patients the most were motivated based on the desire to help can be highly problematic within primary care because of its sen‐
patients. Several attitudes and belief themes emerged from inter‐ sitivity, complexity and the constraints to time and expertise of
views conducted with these nurses. The themes were that patients healthcare professionals” (p. 3582). Klaeson et al. (2017) suggested
do not expect nurses to discuss sexual health, and if patients are time, lack of education and nursing profession regulations were con‐
sick, they do not want to talk about sex or sexual needs. Additional tributing factors that were a barrier to delivering sexual health infor‐
themes were that discussing sexual health is an invasion of patient mation to patients.
privacy, sexuality is taboo and/or there is not enough time because However, Arikan et al. (2015) surveyed nurses and found that
there are more important tasks to complete in daily nursing routines. a lack of time was not the issue with those surveyed, as the major‐
ity surveyed did not agree with spending more time with patients
to discuss sexual health. Instead, the majority of nurses viewed the
4.3 | Nurses’ comfort
subject as a private issue. Those nurses who viewed the topic as pri‐
Four studies focused on nurses’ comfort when discussing sexual vate were more likely to refer the patient to providers for answers
health care with patients. In a cross‐sectional survey of nurses work‐ to questions.
ing in cardiology, it was noted that the topic of sexual health made A barrier to discussing sexual health care was education and train‐
nurses feel uncomfortable (Hoekstra et al., 2012). However, Klaeson ing. According to some nurses, there was a paucity of education and
et al. (2017) conducted semi‐structured interviews of nurses in the training that was provided on the topic of sexual health care. The
primary care setting and reported that nurses felt more comfortable nurses had neither sexuality education training in their programme of
talking with some patient populations compared to others. The au‐ study nor their work setting. The nurses felt there was a lack of train‐
thors reported there was more comfort talking about sexual health ing from the primary care training organisation and except for specific
care with patients who were younger compared to older patients care issues (e.g., diabetes and STIs), and sexual health information
(>80). In a cross‐sectional survey of student nurses, some felt discom‐ was not shared with patients. If a nurse had an interest in a specific
fort with addressing psychosocial issues, talking with patients about area of sexual health, he/she would search for information. However,
sexual health fantasies and patient referrals (Huang et al., 2013). Klaeson et al. (2017) noted this would result in patients getting dif‐
However, the student nurses reported they felt comfortable with pa‐ ferential information. One nurse stated, “…we are so pressed for time
tients expressing sexual concerns, initiating discussions and encour‐ today, so you don't have the time. One does not see the whole person
aging patients to talk regardless of the age of the patients (Huang in that way, one sees a knee or a wound” (p. 1549).
et al., 2013). Moore et al. 2013 used simulated role‐play to increase Another barrier that influenced nurses’ comfort in discussing
nurses’ comfort around the more intimate aspects of sexuality. sexual health care was ageism. In a study conducted in Sweden,
some nurses did not feel comfortable speaking on the topic of
sexual health with patients more than 80 years old (Klaeson et al.,
4.4 | Perceived barriers
2017). The age range of the nurses in this study was 41–63 years
Responsibility and scope of practice were barriers to delivering sex‐ old. The authors acknowledged that Sweden is a progressive coun‐
ual health information to patients that were seen in several studies. try, and nurses still had these concerns. Researchers in three addi‐
Klaeson et al. (2017) reported nurses had questions regarding how tional research studies also noted the belief there is not a need to
sexual health was part of their scope of practice. It was reported discuss sexual health care with older patients, that patients would
there was not a clear understanding of whose responsibility, nurses feel embarrassed or offended, and sexual health is a difficult issue
3074 | FENNELL and GRANT

to address with older adults (Jonsdottir et al., 2016; Krouwel et al., Policy changes that focus on developing nursing interventions, man‐
2015; Moore et al., 2013). agement and workplace support could be beneficial to help address
In addition to time and education, concerns were also expressed barriers that prevent nurses from working to their full scope of prac‐
that sexual health care was not viewed as a medical problem. tice when addressing sexual health concerns (Jonsdottir et al., 2016;
Medicalisation of this topic has a focus on erectile dysfunction and Klaeson et al., 2017; Krouwel et al., 2015; Moore et al., 2013).
STIs. The authors concluded, “(people) need help with their sexual The two qualitative studies provided insight after in‐depth in‐
problems, and they expect health care professionals to have knowl‐ terviews with nine and ten nurses (Klaeson et al., 2017; Saunamäki
edge about this topic” (Klaeson et al., 2017, p. 1553). & Engström, 2014). Six of the studies used convenience sampling of
student nurses, oncology nurses and primary care nurses (Arikan et
al., 2015; Hoekstra et al., 2012; Huang et al., 2013; Jonsdottir et al.,
5 | D I S CU S S I O N 2016; Krouwel et al., 2015; Moore et al., 2013). Additionally, given the
questionnaire format of these six studies, nurses who did not believe
The systematic literature review was guided by the following sexual health care is an essential aspect of their nursing role could
question: What factors either influence or contribute to barriers have opted not to participate. With the lack of participation, it is un‐
to nurses’ provision of sexual health education to patients? The clear if some additional barriers or concerns were not discovered in
Melnyk and Fineout‐Overholt (2015) seven levels of quality assess‐ these studies. However, the state of the current evidence about nurs‐
ment framework were used to grade each article. The ten articles ing practice and providing sexual healthcare education is sufficient to
reviewed were all Level VI, meaning the articles were from single help inform education, practice and policymaking. Although currently,
descriptive or qualitative studies. there are no standard educational policies and procedures concerning
The key findings were categorised into four themes: (a) knowl‐ sexual health care at the student and practicing nurse level.
edge (b) attitudes and beliefs, (c) nurses’ comfort and (d) perceived Three of the studies consisted of all female subjects (Moore
barriers. Nurses have multiple barriers leading to gaps in educating et al., 2013; Sung et al., 2015, 2016), and six studies consisted of
their patients about topics related to sexual health. Thus, it is im‐ >80% female subjects (Hoekstra et al., 2012; Huang et al., 2013;
portant for researchers to identify specific barriers nurses encoun‐ Jonsdottir et al., 2016; Klaeson et al., 2017; Krouwel et al., 2015;
ter, as well as influencing factors when attempting to deliver sexual Saunamäki & Engström, 2014). Future research is needed to inves‐
healthcare education. tigate whether the findings in these studies would be replicated
Patients would like access to reliable and nonjudgmental care across male and female nurses with respect to knowledge, atti‐
and education about sexual health. The findings, from this system‐ tudes and beliefs, nurses’ comfort, and perceived barriers to dis‐
atic review, indicated there was consistent evidence that nurses de‐ cussing sexual health care.
sired more sexual healthcare training. This training could improve
knowledge, attitudes and beliefs, and nurses’ comfort to increase
5.1 | A North American Perspective
the confidence of nurses to engage in sexual healthcare conversa‐
tions with patients. Quinn, Happell, and Welch (2013) suggested Numerous professional associations recognise the importance
that even brief training about the importance of acknowledging sex‐ of sexual health for patients. In the United States, the American
ual health concerns of patients could result in practice changes by Academy of Pediatrics (AAP) has a clinical report that provides pae‐
increasing the nurse's confidence, skill and value of including human diatricians information relevant for sexual and reproductive health
sexuality into practice. education. This report highlights the paucity of information that is
Furthermore, a recommendation of educational programmes being provided to patients. Evidence shows that one of three ado‐
focused on competencies was suggested by Moore et al. (2013). A lescent patients were provided information on human sexuality, and
theme that emerged and was noted in several of the articles, includ‐ when information was provided, it was <40 s. (Breuner & Mattson,
ing the nurses working in oncology and cardiology, was that hospital 2016). Physicians for Reproductive Health (PRH) (2018) has an evi‐
nurses felt as though there was a lack of support and policies in the dence‐based curriculum titled “Adolescent Reproductive and Sexual
workplace. Health Education Program” (ARSHEP) that is relevant for nurses and
Management support, both verbal and written, would help to in‐ providers. The Association of American Medical Colleges (2018) also
crease the comfort of nurses in allowing time to discuss sexual health has resources that could help nurses and providers improve their
with patients (Saunamäki & Engström, 2014). Nursing managers and skills in assessing patients regarding sexual health. The Gay and
educators need to take more responsibility for providing consistent Lesbian Medical Association (GLMA) (2018) is another organisation
training programmes. Organisational policy and management sup‐ on the forefront of providing resources for medical professionals.
port could increase nursing comfort and willingness to address sexual Also, the Association of American Medical Colleges has published a
health, as well as clarify role responsibilities. Jonsdottir et al. (2016) document that provides guidelines on professional competencies to
reported that sexual health care of patients should be emphasised as provide care to LGBT patients (2014).
a legitimate concern when the issue of sexual health care is put on The American Nurses Association (ANA) (2018) has several
the agenda, with support from hospital administrators and directors. Official ANA Position Statements including on topics related to
FENNELL and GRANT | 3075

blood‐borne diseases. However, there are no specific position state‐ delivery. Integrating sexual health education into the practice of
ments on the education of nurses regarding human sexuality and nurses could support holistic nursing care. Furthermore, Quinn et al.
sexual healthcare information that nurses should be able to pro‐ (2013) reported the need to include human sexuality in nursing cur‐
vide to their patients. Likewise, there are no specific position state‐ ricula. This inclusion in the nursing curricula would help to highlight
ments found in the White Papers of the Institute for Healthcare the importance of sexual issues and provide nurses with skills and
Improvement (IHI) (2018). The American Association of Nurse knowledge to fulfil the role of nurses in this domain.
Practitioners (AANP) (2018) has several Specialty Practice Groups
(e.g., Endocrinology) with none related to sexual health care. These
are organisations that have significant influence on health care and 6 | CO N C LU S I O N
nursing practices. The leadership in these organisations should in‐
clude sexual health care in policy positions to advance the prepara‐ Nurses work in a myriad of clinical settings. Many are in community
tion of current and future nurses and providers. settings including public health, primary care clinics and other set‐
tings. Often these, healthcare workers are on the frontlines of public
health. It is important that they have the knowledge, skills and abili‐
5.2 | Limitation
ties to comfortably and appropriately discuss topics related to sexual
The authors conducted a systematic and rigorous approach to iden‐ healthcare with their patients. Also, there is an expectation from pa‐
tify the studies included in this review. However, this search was tients that nurses are knowledgeable and will initiate conversations
limited to articles published from 2012–2017, and perhaps there about sexual health care.
were relevant articles published outside of this time frame. The ten The researchers utilised a 5‐year time span that included a vari‐
articles reviewed for the systematic review were all descriptive and ety of nursing settings and original refereed research. It is evident
qualitative studies. None of the studies were from higher levels of from the research reviewed that knowledge, attitudes and beliefs,
research such as randomised control trials (RCTs), evidence obtained nurses’ comfort, and perceived barriers need to be addressed at
from well‐designed RCTs or evidence obtained from well‐designed the educational level, workplace level and professional society
controlled trials without randomisation. level in order to increase nurses’ engagement of patients’ sexual
Six countries were represented in this systematic review. It is ev‐ health care. Leaders in professional societies could have key lead‐
ident this information is not being widely addressed by nurses based ership roles by publishing guidelines and white papers on expec‐
on the levels of quality assessment of the current studies on this tations for nursing programmes as well as practicing nurses. These
topic (Ford et al., 2013). Furthermore, Ford et al. (2013) explain that guidelines also should address the roles of physicians, physician
in order “to reduce current stigma regarding health issues related assistants (PAs) and nurse practitioners (NPs), as we work collabo‐
to sexual behavior, promoting the positive aspects of sexual health ratively to improve the health and well‐being of our patients.
could be beneficial on multiple levels” (p. 97).

7 | R E LE VA N C E TO C LI N I C A L PR AC TI C E
5.3 | Implications for research
It is paramount to have more rigorous international research conducted The ten studies included in this systematic review were completed
on the topic of nursing and sexual health care. We need to better un‐ in six countries. This indicates there is a need to globally address
derstand whether there are cultural barriers related to nurses engaging patient sexual healthcare education. The International Nurses
in sexual healthcare discussions with patients. The ten research studies Association (INA) is another organisation that could also take a
in this systematic review were conducted in six countries. Additionally, leadership role (INA, 2018). The WHO provides information re‐
Hughes and Wittmann (2015) stated sexual health is often overlooked garding sexual health and other topics related to sexuality. Leaders
and the state of medical education on sexual health in North America in professional organisations and community‐based organisations
has recently been described as being in crisis. should be on the forefront of making recommendations and pro‐
viding guidance to nurses, so they could improve their ability to
provide sexual healthcare information to their patients.
5.4 | Implications for education
There is a need for training programmes for nurses that address
AC K N OW L E D G E M E N T S
knowledge, attitudes, beliefs and comfort, as well as a component
that provides role‐playing practice to discuss sexual health conver‐ The authors would like to thank the faculty members Mary Hodge
sations (Jonsdottir et al., 2016). Integration and delivery of profes‐ and Roseann Barrett for their review and guidance of our manuscript.
sional development and continuing education for nurses providing
sexual healthcare education are needed. The need for standardised
C O N FL I C T O F I N T E R E S T
curricula in sexual health care is indicated, but questions remain
regarding the information to include, in addition to the method of The authors have no conflicts of interest to declare.
3076 | FENNELL and GRANT

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