DOI: 10.1111/ajag.12181
Research Assessment of sexual health and sexual needs in residential aged care Linda McAuliffe, Michael Bauer, Deirdre Fetherstonhaugh and Carol Chenco Australian Centre for Evidence Based Aged Care, Faculty of Health Sciences, La Trobe University, Melbourne, Victoria, Australia
Aim: To investigate if, when and how assessments regarding residents’ sexual health and needs occur within Australian residential aged care facilities. Method: A census of all Australian residential aged care facilities was conducted. A survey developed specifically for the project was posted to all 2766 residential aged care services in Australia. Eight weeks were allowed for the return of surveys. Results: A total of 1094 completed surveys were returned, representing a 39.7% response rate. The type of information most often collected concerned disruptive sexual behaviour, and assessments most frequently occurred following disruptive behaviour. One-quarter of facilities reported having a sexual health/needs assessment form, although only 10 facilities provided evidence of this. Conclusion: Survey responses indicated that sexual health and needs are not routinely assessed in residential aged care, and facilities do not commonly have a dedicated sexual health/needs assessment form to guide them through an assessment process. Key words: ageing, assessment, residential aged care, sexual health, sexuality.
Introduction Background According to the World Health Organization, ‘sexual health is a state of physical, emotional, mental and social well-being in relation to sexuality’, where sexuality is defined as ‘a central aspect of being human throughout life [that] encompasses sex, gender identities and roles, sexual orientation, eroticism, pleasure, intimacy and reproduction’ [1]. This inclusive definition of sexual health transcends age and recognises the importance of sexual expression, of which the psychosocial and physical health benefits to older people are well established [2–5]. Older people continue to engage in sexual activity as they age, a fact supported by research conducted in the USA [6], Spain [7], Sweden [8] and Australia [9–11]. Although the frequency of sexual behaviour may decrease with age, many older people Correspondence to: Ms Linda McAuliffe, Australian Centre for Evidence Based Aged Care, Faculty of Health Sciences, La Trobe University. Email: [email protected] Australasian Journal on Ageing, Vol 34 No 3 September 2015, 183–188 © 2014 AJA Inc.
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maintain some level of sexual interest, even if they suffer physical or cognitive impairment [2] or when their care needs change and they require admission to long-term care [12,13]. However, although older people’s interest in sexual expression may not necessarily decrease on admission to residential aged care, they may find that they no longer have the opportunity to express their sexuality [13]. Numerous reasons for this have been identified in the literature and include lack of a partner [14], lack of privacy [15], negative staff attitudes [14], the views of family and other residents [13] and the ethos of the aged care organisation [4]. Unaddressed sexual dysfunction can also play a part [16]. Care staff do not consider sexual health a priority area of care and it is commonly overlooked while sexual behaviour by residents is often labelled by staff as ‘inappropriate’ [2]. Residential aged care facilities in Australia do not typically provide prospective residents with any promotional or written material about how they accommodate needs for sexual expression and intimacy [17], so many residents move into residential care not knowing how or if these needs will be respected. Additionally, a recent study found that while care facility staff expressed positive views about the rights of residents to sexual expression, few facilities were found to have any formal policies or staff training programs in place with regard to sexuality-related issues, which were more often than not dealt with in an ad hoc way [18]. Age-related physiological changes can impact sexual health and function in older adults. For example, hormonal changes in older women can lead to thinning and increased dryness of the vaginal mucosa, which can result in vaginal tears and abrasions (and pain or discomfort) during intercourse, placing older women at increased risk of viral entry [19]. Although shame, fear, and/or embarrassment prevent many older people from expressing sexual concerns [20], most older people hold the view that nurses and physicians should ask about sexual needs and function as part of clinical care; moreover, they would welcome such discussion about their sexual health [21]. However, although aged care staff are well placed to help residents overcome these challenges, they are often reluctant to raise the issue of sexual health or needs with their older residents [22]. The extent to which Australian residential aged care facilities currently assess the sexual health and sexual needs of residents is largely unknown. This is perhaps not surprising given the paucity of published studies investigating sexual health and sexual needs in older Australians more generally. Without appropriate assessment, however, sexual health 183
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needs are unlikely to be met, thereby potentially placing older people at risk of negative psychological and physical health outcomes. Study aims The aim of this study was to investigate if, when and how assessments of residents’ sexual health and needs occur within Australian residential aged care facilities. This information is essential if we are to understand the sexual needs of older people living in Australian residential aged care services, identify gaps in the policies and processes of care provision, and create environments in which older people have the right and opportunity to express themselves sexually.
Methods Design The project was a postal survey of all 2766 Australian residential aged care facilities. A survey was developed specifically for the project and consisted of 21 items, with questions mainly requiring forced-choice tick-box responses. Questions asked whether the facility gathered information about residents’ sexual health, sexual needs, intimacy needs, sexual orientation, disruptive sexual behaviour and/or sexual history and, if so, when the assessment occurred, who conducted the assessment, and how the information was gathered (by using a structured assessment form or by verbal means only). Procedure The project information statement and survey were sent by post to the directors of nursing or nurse unit managers of all 2766 residential aged care services in Australia active in 2011, as listed on the Commonwealth Department of Health and Ageing website. Directors of nursing and nurse unit managers were targeted (rather than centre directors or administrators) due to their experience and knowledge of ‘coalface’ issues. The information statement detailed the purpose of the study and invited anonymous participation by completion and return of the accompanying survey. Participants were also asked to return a de-identified copy of the admission assessment form or sexual health/needs assessment form used by their facility so the form could be analysed for content relating to sexual health and needs. A reminder and another copy of the survey were posted four weeks after the initial mail-out, encouraging recipients to respond if they had not already. Simultaneously with the reminder letter mail-out, reminders appeared in state and national nursing and aged care industry magazines and newsletters. A final deadline of four weeks from the second mail-out was allowed for the return of surveys. Return of completed surveys was deemed consent. In cases where the survey was undeliverable and returned unopened, attempts were made to obtain updated address details for the facility, and the survey 184
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was subsequently re-sent. Approval for the conduct of the study was granted prior to commencement by the La Trobe University Faculty Human Ethics Committee (Approval 11/102). Analysis Survey data were entered into the statistical software package SPSS (version 17) and frequency and descriptive statistics obtained. Chi-squared tests for independence were conducted to examine the relationships between variables. Returned assessment forms were coded using a priori codes (admission assessment form, dedicated sexual health/needs assessment form, behaviour assessment form, other form) prior to entry of data into SPSS.
Results A total of 1094 completed surveys were returned, representing a 39.7% response rate. Participant characteristics and survey responses are presented in Table 1.
Table 1: Characteristics of respondents and facilities n Sex of respondents Female Male Age of respondents 18–30 years 31–50 years 51–60 years ≥61 years Position of respondent in facility Director of nursing Nurse unit manager Manager Other Number of responses by state/territory† Australian Capital Territory New South Wales Northern Territory Queensland South Australia Tasmania Victoria Western Australia Type of facility Profit Not-for-profit Level of care provided Low High Mixed Number of beds in facility 1–30 31–60 61–90 ≥91 Estimated proportion of residents with dementia 0–25% 26–50% 51–75% 76–100%
%
936/1032 96/1032
90.7 9.3
20/1076 408/1076 504/1076 144/1076
1.9 37.9 46.8 13.4
634/1084 163/1084 200/1084 87/1084
58.5 15 18.4 8.1
14/26 337/887 5/14 137/480 109/264 42/81 324/770 106/244
1.3; 53.8 31.4; 38.0 0.5; 35.7 12.8; 28.5 10.1; 41.3 3.9; 51.9 30.2; 42.1 9.9; 43.4
271/1078 807/1078
25.1 74.9
113/1087 280/1087 694/1087
10.4 25.8 63.8
154/1088 375/1088 272/1088 287/1088
14.2 34.5 25 26.4
172/1063 368/1063 408/1063 115/1063
16.2 34.6 38.4 10.8
† First percentage represents percentage of facilities in overall sample that are located in that state/territory; second percentage represents percentage of facilities in each state/territory that responded. n varies due to missing data.
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Table 2: Type of information gathered Sexual health Sexual needs Intimacy needs Sexual orientation Disruptive sexual behaviour Sexual history (before entering care)
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Table 4: How information is collected n
%
258/1046 212/1050 335/1056 214/1044 704/1065 143/1046
24.7 20.2 31.7 20.5 66.1 13.7
Table 3: Timing of assessment On admission When a resident care plan is reviewed When the resident initiates a discussion When family initiates discussion When disruptive behaviour occurs When requested by general practitioner Other
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Admission assessment form Sexual health/needs assessment form Verbal, from resident Verbal, from family Other
n
%
455/622 115/472 429/563 451/578 163/622
73.2 24.0 76.2 78.0 26.2
Table 5: Who performs assessments n
%
593/684 480/596 536/614 541/603 679/701 463/560 71/702
86.7 80.5 87.3 89.7 96.9 82.7 10.1
Registered nurse Enrolled nurse Personal care attendant/assistant in nursing General practitioner/geriatrician Lifestyle/diversional therapist Other
n
%
680/1094 179/1094 87/1094 203/1094 179/1094 62/1094
62.2 16.4 8.0 18.6 16.4 5.7
Most respondents were female (90.7%), aged over 30 years old (98.1%) and held the position of director of nursing in their facility (58.5%). The highest number of returned surveys came from New South Wales (337/1074, 31.4% of the sample), whereas the state/territory with the highest proportion of facilities represented was the Australian Capital Territory (14/26, 53.8% of the sample). Facilities represented were largely not-for-profit (74.9%), provided both high and low levels of care (63.8%), had more than 60 beds (51.4%) and had a proportion of residents diagnosed with dementia of more than a quarter (82.8%). These figures are consistent with national statistics that indicate the majority of residential aged care facilities are not-for-profit (60%), that they have on average 65 beds and that slightly over half (53%) of all residents have a diagnosis of dementia [23].
ment form (73.2%) (Table 4). Around a quarter of facilities (24%) reported using an assessment form specifically for sexual health/needs. A similar percentage of facilities also reported using ‘other’ means for gathering information, the most common of these being a behaviour assessment form/ chart.
By far the type of sexual information most often gathered concerned disruptive sexual behaviour (66.1%) (Table 2). Less than a third of facilities reported gathering information about a resident’s intimacy needs (31.7%), sexual health (24.7%), sexual needs (20.2%), sexual orientation (20.5%) or sexual history (13.7%).
Only 34 respondents (3.1%) returned a de-identified copy of their facility’s assessment form (one respondent returned two different forms). Of the 35 forms, 10 were dedicated specifically to sexual health and needs; eight were admission assessment forms; 13 were behaviour assessment forms; and four were other types of assessment forms.
Assessments most frequently occurred when a disruptive behaviour occurred (96.9%) (Table 3). However, facilities reported that assessments also commonly occurred when a family initiated discussion (89.7%), when a resident initiated discussion (87.3%), on admission (86.7%), when requested by a general practitioner (82.7%) or when the resident care plan was reviewed (80.5%). The most commonly cited ‘other’ occasions when assessments occurred were ‘as required’/‘when necessary’ and ‘when resident becomes sexually inappropriate’.
Post hoc analyses revealed that for-profit facilities were more likely than not-for-profit facilities to gather information about residents’ sexual needs (26% vs 18%; χ2 = 8.4, P < 0.01), intimacy needs (38% vs 30%; χ2 = 6.9, P < 0.01), sexual orientation (26% vs 19%; χ2 = 5.2, P < 0.05) and disruptive sexual behaviour (73% vs 64%; χ2 = 7.0, P < 0.01). For-profit facilities were also more likely than not-for-profit facilities to gather such information during the admission assessment (93% vs 84%; χ2 = 8.0, P < 0.01) and during reviews of residents’ care plans (88% vs 78%; χ2 = 7.5, P < 0.01).
Respondents reported that assessments were frequently based on information gathered verbally from the resident (76.2%), verbally from the family (78%) or from the admission assess-
Larger facilities were more likely to gather information about residents’ sexual orientation (25% for facilities with ≥91 beds vs 16% for those with 61–90 beds; χ2 = 9.0, P < 0.05)
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Assessments of sexual health/needs/preferences were most often performed by registered nurses (62.2%), followed by general practitioners/geriatricians (18.6%), enrolled nurses (16.4%), lifestyle/diversional therapists (16.4%) and personal care attendants/assistants in nursing (8.5%) (Table 5). The most commonly cited ‘other’ people involved in performing assessments were the director of nursing, manager and care coordinator/manager.
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and were more likely to gather information about residents’ sexuality during the admission assessment (≥91 beds, 92%; 75%) were more likely than those with fewer residents with dementia (26–50%) to gather information about residents’ sexuality during the admission assessment (99% vs 83%; χ2 = 15.3, P < 0.05) and when the care plan was reviewed (90% vs 75%; χ2 = 8.0, P < 0.05).
A likely explanation for the lack of assessment of residents’ sexual health and needs relates to the means by which Australian residential aged care providers are currently allocated subsidy – the Aged Care Funding Instrument (ACFI). Two areas covered by the ACFI are verbal and physical behaviour. According to Sections 8 and 9 of the ACFI User Guide [24], a behaviour record must be completed by the facility when any of the following occur: ‘verbal sexually inappropriate advances directed at another person, visitor or member of staff’; ‘physical conduct by a resident that is threatening and has the potential to physically harm another person, visitor or member of staff or property’, including ‘physical sexual advances – touching a person in an inappropriate sexual way’; or ‘socially inappropriate behaviour that impacts on other residents’, including ‘inappropriate sexual behaviour’. It could therefore be argued that the high number of disruptive sexual behaviour assessments stem from this requirement that facilities complete a record when ‘inappropriate’ behaviour occurs (with the definition of what constitutes ‘inappropriate’ behaviour often based on subjective interpretation rather than reference to clear guidelines). Unfortunately, at this time there is no equivalent requirement to conduct assessments regarding residents’ needs for the healthy expression of their sexuality in order to access federal funding.
In response to a question regarding survey format, over a third (39.9%) of respondents indicated they would have preferred an online survey.
Discussion This study found that assessment of sexual health and needs of older people living in residential aged care did not occur routinely in the facilities that responded to our survey; when it did occur, it was more often than not in the context of disruptive sexual behaviour. Information about a resident’s intimacy needs, sexual health, sexual needs, sexual orientation, or sexual history prior to moving into residential aged care, all of which could potentially inform the future care of residents, was collected by less than a third of all facilities surveyed. Assessments were reported to occur at various times, including when requested by family, when requested by residents, when requested by the general practitioner, on admission and when the care plan was reviewed. Assessment information was commonly gathered verbally from the resident, verbally from the family or from the admission assessment form, rather than from a dedicated sexual health/needs assessment form; although around one-quarter of facilities reported using the latter type of form, only 10 facilities (2%) produced evidence of such a document. We would argue that there are two main advantages to using an assessment form for gathering information on sexual health/needs. Firstly, the questions on the form can guide staff through the assessment process and ensure that the assessment is comprehensive. Secondly, documenting information on sexual health/needs ensures that such information (particularly verbal information) is not lost over time and can be communicated discreetly and as appropriate to staff who may need to know. It does not seem unreasonable to assume that if facilities were to introduce a dedicated assessment form, they would be likely to gather more information than they do currently regarding residents’ sexual health, needs and history. Behavioural charts were the most commonly reported ‘other’ means by which sexual health and needs were assessed, which is perhaps not surprising given that facilities reported that the type of information they most often collected was related to disruptive sexual behaviour. It is curious that assessments of 186
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The surveys revealed that a variety of staff are involved in the assessment process, most commonly registered nurses, but also general practitioners, enrolled nurses, lifestyle/ diversional therapists and personal care attendants/assistants in nursing, as well as, to a lesser extent, directors of nursing, managers and care coordinators. This heterogeneity in who performs sexual health and needs assessments parallels the variability in the range of assessment processes reported by facilities. Further research is required to examine whether differences exist among these types of staff in the level of importance they attribute to sexual information gathered from residents or in the ways in which they gather this information. Interestingly, facilities that identified as for-profit or as large were most likely to gather information about residents’ sexual needs, intimacy needs, sexual orientation or disruptive sexual behaviour and conduct assessments so on admission and during reviews of residents’ care plans. It may be that the profit motive makes larger private facilities more likely to accommodate residents’ needs and comfort in this regard. It is also possible that some religious organisations, the most common not-for-profit owners [25], view addressing sexual needs and behaviour as incompatible with their ethos [26] and consequently do not gather this type of information. Future research is needed to more fully explore this discrepancy between for-profit and not-for-profit facilities. Australasian Journal on Ageing, Vol 34 No 3 September 2015, 183–188 © 2014 AJA Inc.
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Future research should also include observational studies regarding the assessment of sexual health and needs in residential aged care facilities, in addition to studies of the perspectives of different categories of staff and, of course, of the perspectives of residents themselves (both potential and current), including couples.
The sexual life of older Australians living in residential aged care is of growing interest, as evidenced by recent media attention. Our research centre has received numerous recent requests to present on the topic at conferences and seminars for various audiences, including in house at residential aged Australasian Journal on Ageing, Vol 34 No 3 September 2015, 183–188 © 2014 AJA Inc.
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The authors would like to gratefully acknowledge the assistance of Sandra Cowen and Joanna Lee from the Australian Centre for Evidence Based Aged Care and the participation of the residential aged care services that responded to the survey mail-out. This project was funded by a La Trobe University Faculty of Health Sciences Early Career Researcher Project Grant.
Secondly, it is possible that many more facilities had relevant assessment forms than provided copies. Nonetheless, we were able to learn from the respondents’ reports that at best, only 52% of the participating facilities assessed residents’ sexual health or needs using a dedicated form or as part of the documented admission assessment.
Conclusion
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Acknowledgements
Firstly, as this survey was addressed to senior staff, we assumed a certain level of health literacy and therefore did not provide definitions for the key terms used in the survey. Some respondents may therefore have interpreted some of the terms used in the narrowest sense, for instance equating ‘sexual needs’ purely with intercourse.
Finally, the rate of response to this study was higher than anticipated given our previous research in this area [17], possibly reflecting a growing recognition that this is an area of care that deserves attention. The response rate was, however, still low, and therefore the generalisability of the findings is somewhat compromised. It is possible that facilities with good practice in this area were more likely to respond to the survey; it is equally likely that facilities with less optimal practice were over-represented in the sample, as staff from such facilities may have responded to the survey in an effort to help highlight the issue.
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care facilities. This paper has provided a snapshot of how resident sexual health and needs are currently addressed in this setting. As such, it provides a starting point for discussions about how we can better meet these needs (for example, through more comprehensive education and assessment) and thereby improve the lives of many older Australians living in residential aged care.
Limitations There are a number of limitations to this study, which are outlined below.
Thirdly, it could be argued that conducting a postal survey rather than a telephone or online survey was limiting and that these alternative methods might have yielded a higher response rate. The choice to conduct a postal survey was made because telephone surveys can be time-consuming and labourintensive given the high likelihood of needing to make multiple calls to reach the targeted person owing to the ‘on-the-floor’ nature of nursing work. Furthermore, email addresses are typically not readily accessible for residential aged care facilities and even less so for directors of nursing and nurse unit managers, making recruitment via email an untenable option. Interestingly, less than half of respondents indicated that they would have preferred to complete the survey online.
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Key Points • Sexual health and needs are not routinely assessed in Australian residential aged care facilities. • When assessments do occur, it is more often than not in the context of disruptive sexual behaviour. • Assessments of a resident’s sexual health, sexual needs, sexual preferences and sexual history can all inform care. • A dedicated sexual health/needs assessment form is needed to help guide staff through a comprehensive assessment process.
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Research Assessment of sexual health and sexual needs in residential aged care Linda McAuliffe, Michael Bauer, Deirdre Fetherstonhaugh and Carol Chenco Australian Centre for Evidence Based Aged Care, Faculty of Health Sciences, La Trobe University, Melbourne, Victoria, Australia
Aim: To investigate if, when and how assessments regarding residents’ sexual health and needs occur within Australian residential aged care facilities. Method: A census of all Australian residential aged care facilities was conducted. A survey developed specifically for the project was posted to all 2766 residential aged care services in Australia. Eight weeks were allowed for the return of surveys. Results: A total of 1094 completed surveys were returned, representing a 39.7% response rate. The type of information most often collected concerned disruptive sexual behaviour, and assessments most frequently occurred following disruptive behaviour. One-quarter of facilities reported having a sexual health/needs assessment form, although only 10 facilities provided evidence of this. Conclusion: Survey responses indicated that sexual health and needs are not routinely assessed in residential aged care, and facilities do not commonly have a dedicated sexual health/needs assessment form to guide them through an assessment process. Key words: ageing, assessment, residential aged care, sexual health, sexuality.
Introduction Background According to the World Health Organization, ‘sexual health is a state of physical, emotional, mental and social well-being in relation to sexuality’, where sexuality is defined as ‘a central aspect of being human throughout life [that] encompasses sex, gender identities and roles, sexual orientation, eroticism, pleasure, intimacy and reproduction’ [1]. This inclusive definition of sexual health transcends age and recognises the importance of sexual expression, of which the psychosocial and physical health benefits to older people are well established [2–5]. Older people continue to engage in sexual activity as they age, a fact supported by research conducted in the USA [6], Spain [7], Sweden [8] and Australia [9–11]. Although the frequency of sexual behaviour may decrease with age, many older people Correspondence to: Ms Linda McAuliffe, Australian Centre for Evidence Based Aged Care, Faculty of Health Sciences, La Trobe University. Email: [email protected] Australasian Journal on Ageing, Vol 34 No 3 September 2015, 183–188 © 2014 AJA Inc.
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maintain some level of sexual interest, even if they suffer physical or cognitive impairment [2] or when their care needs change and they require admission to long-term care [12,13]. However, although older people’s interest in sexual expression may not necessarily decrease on admission to residential aged care, they may find that they no longer have the opportunity to express their sexuality [13]. Numerous reasons for this have been identified in the literature and include lack of a partner [14], lack of privacy [15], negative staff attitudes [14], the views of family and other residents [13] and the ethos of the aged care organisation [4]. Unaddressed sexual dysfunction can also play a part [16]. Care staff do not consider sexual health a priority area of care and it is commonly overlooked while sexual behaviour by residents is often labelled by staff as ‘inappropriate’ [2]. Residential aged care facilities in Australia do not typically provide prospective residents with any promotional or written material about how they accommodate needs for sexual expression and intimacy [17], so many residents move into residential care not knowing how or if these needs will be respected. Additionally, a recent study found that while care facility staff expressed positive views about the rights of residents to sexual expression, few facilities were found to have any formal policies or staff training programs in place with regard to sexuality-related issues, which were more often than not dealt with in an ad hoc way [18]. Age-related physiological changes can impact sexual health and function in older adults. For example, hormonal changes in older women can lead to thinning and increased dryness of the vaginal mucosa, which can result in vaginal tears and abrasions (and pain or discomfort) during intercourse, placing older women at increased risk of viral entry [19]. Although shame, fear, and/or embarrassment prevent many older people from expressing sexual concerns [20], most older people hold the view that nurses and physicians should ask about sexual needs and function as part of clinical care; moreover, they would welcome such discussion about their sexual health [21]. However, although aged care staff are well placed to help residents overcome these challenges, they are often reluctant to raise the issue of sexual health or needs with their older residents [22]. The extent to which Australian residential aged care facilities currently assess the sexual health and sexual needs of residents is largely unknown. This is perhaps not surprising given the paucity of published studies investigating sexual health and sexual needs in older Australians more generally. Without appropriate assessment, however, sexual health 183
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needs are unlikely to be met, thereby potentially placing older people at risk of negative psychological and physical health outcomes. Study aims The aim of this study was to investigate if, when and how assessments of residents’ sexual health and needs occur within Australian residential aged care facilities. This information is essential if we are to understand the sexual needs of older people living in Australian residential aged care services, identify gaps in the policies and processes of care provision, and create environments in which older people have the right and opportunity to express themselves sexually.
Methods Design The project was a postal survey of all 2766 Australian residential aged care facilities. A survey was developed specifically for the project and consisted of 21 items, with questions mainly requiring forced-choice tick-box responses. Questions asked whether the facility gathered information about residents’ sexual health, sexual needs, intimacy needs, sexual orientation, disruptive sexual behaviour and/or sexual history and, if so, when the assessment occurred, who conducted the assessment, and how the information was gathered (by using a structured assessment form or by verbal means only). Procedure The project information statement and survey were sent by post to the directors of nursing or nurse unit managers of all 2766 residential aged care services in Australia active in 2011, as listed on the Commonwealth Department of Health and Ageing website. Directors of nursing and nurse unit managers were targeted (rather than centre directors or administrators) due to their experience and knowledge of ‘coalface’ issues. The information statement detailed the purpose of the study and invited anonymous participation by completion and return of the accompanying survey. Participants were also asked to return a de-identified copy of the admission assessment form or sexual health/needs assessment form used by their facility so the form could be analysed for content relating to sexual health and needs. A reminder and another copy of the survey were posted four weeks after the initial mail-out, encouraging recipients to respond if they had not already. Simultaneously with the reminder letter mail-out, reminders appeared in state and national nursing and aged care industry magazines and newsletters. A final deadline of four weeks from the second mail-out was allowed for the return of surveys. Return of completed surveys was deemed consent. In cases where the survey was undeliverable and returned unopened, attempts were made to obtain updated address details for the facility, and the survey 184
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was subsequently re-sent. Approval for the conduct of the study was granted prior to commencement by the La Trobe University Faculty Human Ethics Committee (Approval 11/102). Analysis Survey data were entered into the statistical software package SPSS (version 17) and frequency and descriptive statistics obtained. Chi-squared tests for independence were conducted to examine the relationships between variables. Returned assessment forms were coded using a priori codes (admission assessment form, dedicated sexual health/needs assessment form, behaviour assessment form, other form) prior to entry of data into SPSS.
Results A total of 1094 completed surveys were returned, representing a 39.7% response rate. Participant characteristics and survey responses are presented in Table 1.
Table 1: Characteristics of respondents and facilities n Sex of respondents Female Male Age of respondents 18–30 years 31–50 years 51–60 years ≥61 years Position of respondent in facility Director of nursing Nurse unit manager Manager Other Number of responses by state/territory† Australian Capital Territory New South Wales Northern Territory Queensland South Australia Tasmania Victoria Western Australia Type of facility Profit Not-for-profit Level of care provided Low High Mixed Number of beds in facility 1–30 31–60 61–90 ≥91 Estimated proportion of residents with dementia 0–25% 26–50% 51–75% 76–100%
%
936/1032 96/1032
90.7 9.3
20/1076 408/1076 504/1076 144/1076
1.9 37.9 46.8 13.4
634/1084 163/1084 200/1084 87/1084
58.5 15 18.4 8.1
14/26 337/887 5/14 137/480 109/264 42/81 324/770 106/244
1.3; 53.8 31.4; 38.0 0.5; 35.7 12.8; 28.5 10.1; 41.3 3.9; 51.9 30.2; 42.1 9.9; 43.4
271/1078 807/1078
25.1 74.9
113/1087 280/1087 694/1087
10.4 25.8 63.8
154/1088 375/1088 272/1088 287/1088
14.2 34.5 25 26.4
172/1063 368/1063 408/1063 115/1063
16.2 34.6 38.4 10.8
† First percentage represents percentage of facilities in overall sample that are located in that state/territory; second percentage represents percentage of facilities in each state/territory that responded. n varies due to missing data.
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Table 2: Type of information gathered Sexual health Sexual needs Intimacy needs Sexual orientation Disruptive sexual behaviour Sexual history (before entering care)
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Table 4: How information is collected n
%
258/1046 212/1050 335/1056 214/1044 704/1065 143/1046
24.7 20.2 31.7 20.5 66.1 13.7
Table 3: Timing of assessment On admission When a resident care plan is reviewed When the resident initiates a discussion When family initiates discussion When disruptive behaviour occurs When requested by general practitioner Other
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Admission assessment form Sexual health/needs assessment form Verbal, from resident Verbal, from family Other
n
%
455/622 115/472 429/563 451/578 163/622
73.2 24.0 76.2 78.0 26.2
Table 5: Who performs assessments n
%
593/684 480/596 536/614 541/603 679/701 463/560 71/702
86.7 80.5 87.3 89.7 96.9 82.7 10.1
Registered nurse Enrolled nurse Personal care attendant/assistant in nursing General practitioner/geriatrician Lifestyle/diversional therapist Other
n
%
680/1094 179/1094 87/1094 203/1094 179/1094 62/1094
62.2 16.4 8.0 18.6 16.4 5.7
Most respondents were female (90.7%), aged over 30 years old (98.1%) and held the position of director of nursing in their facility (58.5%). The highest number of returned surveys came from New South Wales (337/1074, 31.4% of the sample), whereas the state/territory with the highest proportion of facilities represented was the Australian Capital Territory (14/26, 53.8% of the sample). Facilities represented were largely not-for-profit (74.9%), provided both high and low levels of care (63.8%), had more than 60 beds (51.4%) and had a proportion of residents diagnosed with dementia of more than a quarter (82.8%). These figures are consistent with national statistics that indicate the majority of residential aged care facilities are not-for-profit (60%), that they have on average 65 beds and that slightly over half (53%) of all residents have a diagnosis of dementia [23].
ment form (73.2%) (Table 4). Around a quarter of facilities (24%) reported using an assessment form specifically for sexual health/needs. A similar percentage of facilities also reported using ‘other’ means for gathering information, the most common of these being a behaviour assessment form/ chart.
By far the type of sexual information most often gathered concerned disruptive sexual behaviour (66.1%) (Table 2). Less than a third of facilities reported gathering information about a resident’s intimacy needs (31.7%), sexual health (24.7%), sexual needs (20.2%), sexual orientation (20.5%) or sexual history (13.7%).
Only 34 respondents (3.1%) returned a de-identified copy of their facility’s assessment form (one respondent returned two different forms). Of the 35 forms, 10 were dedicated specifically to sexual health and needs; eight were admission assessment forms; 13 were behaviour assessment forms; and four were other types of assessment forms.
Assessments most frequently occurred when a disruptive behaviour occurred (96.9%) (Table 3). However, facilities reported that assessments also commonly occurred when a family initiated discussion (89.7%), when a resident initiated discussion (87.3%), on admission (86.7%), when requested by a general practitioner (82.7%) or when the resident care plan was reviewed (80.5%). The most commonly cited ‘other’ occasions when assessments occurred were ‘as required’/‘when necessary’ and ‘when resident becomes sexually inappropriate’.
Post hoc analyses revealed that for-profit facilities were more likely than not-for-profit facilities to gather information about residents’ sexual needs (26% vs 18%; χ2 = 8.4, P < 0.01), intimacy needs (38% vs 30%; χ2 = 6.9, P < 0.01), sexual orientation (26% vs 19%; χ2 = 5.2, P < 0.05) and disruptive sexual behaviour (73% vs 64%; χ2 = 7.0, P < 0.01). For-profit facilities were also more likely than not-for-profit facilities to gather such information during the admission assessment (93% vs 84%; χ2 = 8.0, P < 0.01) and during reviews of residents’ care plans (88% vs 78%; χ2 = 7.5, P < 0.01).
Respondents reported that assessments were frequently based on information gathered verbally from the resident (76.2%), verbally from the family (78%) or from the admission assess-
Larger facilities were more likely to gather information about residents’ sexual orientation (25% for facilities with ≥91 beds vs 16% for those with 61–90 beds; χ2 = 9.0, P < 0.05)
Australasian Journal on Ageing, Vol 34 No 3 September 2015, 183–188 © 2014 AJA Inc.
Assessments of sexual health/needs/preferences were most often performed by registered nurses (62.2%), followed by general practitioners/geriatricians (18.6%), enrolled nurses (16.4%), lifestyle/diversional therapists (16.4%) and personal care attendants/assistants in nursing (8.5%) (Table 5). The most commonly cited ‘other’ people involved in performing assessments were the director of nursing, manager and care coordinator/manager.
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and were more likely to gather information about residents’ sexuality during the admission assessment (≥91 beds, 92%; 75%) were more likely than those with fewer residents with dementia (26–50%) to gather information about residents’ sexuality during the admission assessment (99% vs 83%; χ2 = 15.3, P < 0.05) and when the care plan was reviewed (90% vs 75%; χ2 = 8.0, P < 0.05).
A likely explanation for the lack of assessment of residents’ sexual health and needs relates to the means by which Australian residential aged care providers are currently allocated subsidy – the Aged Care Funding Instrument (ACFI). Two areas covered by the ACFI are verbal and physical behaviour. According to Sections 8 and 9 of the ACFI User Guide [24], a behaviour record must be completed by the facility when any of the following occur: ‘verbal sexually inappropriate advances directed at another person, visitor or member of staff’; ‘physical conduct by a resident that is threatening and has the potential to physically harm another person, visitor or member of staff or property’, including ‘physical sexual advances – touching a person in an inappropriate sexual way’; or ‘socially inappropriate behaviour that impacts on other residents’, including ‘inappropriate sexual behaviour’. It could therefore be argued that the high number of disruptive sexual behaviour assessments stem from this requirement that facilities complete a record when ‘inappropriate’ behaviour occurs (with the definition of what constitutes ‘inappropriate’ behaviour often based on subjective interpretation rather than reference to clear guidelines). Unfortunately, at this time there is no equivalent requirement to conduct assessments regarding residents’ needs for the healthy expression of their sexuality in order to access federal funding.
In response to a question regarding survey format, over a third (39.9%) of respondents indicated they would have preferred an online survey.
Discussion This study found that assessment of sexual health and needs of older people living in residential aged care did not occur routinely in the facilities that responded to our survey; when it did occur, it was more often than not in the context of disruptive sexual behaviour. Information about a resident’s intimacy needs, sexual health, sexual needs, sexual orientation, or sexual history prior to moving into residential aged care, all of which could potentially inform the future care of residents, was collected by less than a third of all facilities surveyed. Assessments were reported to occur at various times, including when requested by family, when requested by residents, when requested by the general practitioner, on admission and when the care plan was reviewed. Assessment information was commonly gathered verbally from the resident, verbally from the family or from the admission assessment form, rather than from a dedicated sexual health/needs assessment form; although around one-quarter of facilities reported using the latter type of form, only 10 facilities (2%) produced evidence of such a document. We would argue that there are two main advantages to using an assessment form for gathering information on sexual health/needs. Firstly, the questions on the form can guide staff through the assessment process and ensure that the assessment is comprehensive. Secondly, documenting information on sexual health/needs ensures that such information (particularly verbal information) is not lost over time and can be communicated discreetly and as appropriate to staff who may need to know. It does not seem unreasonable to assume that if facilities were to introduce a dedicated assessment form, they would be likely to gather more information than they do currently regarding residents’ sexual health, needs and history. Behavioural charts were the most commonly reported ‘other’ means by which sexual health and needs were assessed, which is perhaps not surprising given that facilities reported that the type of information they most often collected was related to disruptive sexual behaviour. It is curious that assessments of 186
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The surveys revealed that a variety of staff are involved in the assessment process, most commonly registered nurses, but also general practitioners, enrolled nurses, lifestyle/ diversional therapists and personal care attendants/assistants in nursing, as well as, to a lesser extent, directors of nursing, managers and care coordinators. This heterogeneity in who performs sexual health and needs assessments parallels the variability in the range of assessment processes reported by facilities. Further research is required to examine whether differences exist among these types of staff in the level of importance they attribute to sexual information gathered from residents or in the ways in which they gather this information. Interestingly, facilities that identified as for-profit or as large were most likely to gather information about residents’ sexual needs, intimacy needs, sexual orientation or disruptive sexual behaviour and conduct assessments so on admission and during reviews of residents’ care plans. It may be that the profit motive makes larger private facilities more likely to accommodate residents’ needs and comfort in this regard. It is also possible that some religious organisations, the most common not-for-profit owners [25], view addressing sexual needs and behaviour as incompatible with their ethos [26] and consequently do not gather this type of information. Future research is needed to more fully explore this discrepancy between for-profit and not-for-profit facilities. Australasian Journal on Ageing, Vol 34 No 3 September 2015, 183–188 © 2014 AJA Inc.
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Future research should also include observational studies regarding the assessment of sexual health and needs in residential aged care facilities, in addition to studies of the perspectives of different categories of staff and, of course, of the perspectives of residents themselves (both potential and current), including couples.
The sexual life of older Australians living in residential aged care is of growing interest, as evidenced by recent media attention. Our research centre has received numerous recent requests to present on the topic at conferences and seminars for various audiences, including in house at residential aged Australasian Journal on Ageing, Vol 34 No 3 September 2015, 183–188 © 2014 AJA Inc.
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The authors would like to gratefully acknowledge the assistance of Sandra Cowen and Joanna Lee from the Australian Centre for Evidence Based Aged Care and the participation of the residential aged care services that responded to the survey mail-out. This project was funded by a La Trobe University Faculty of Health Sciences Early Career Researcher Project Grant.
Secondly, it is possible that many more facilities had relevant assessment forms than provided copies. Nonetheless, we were able to learn from the respondents’ reports that at best, only 52% of the participating facilities assessed residents’ sexual health or needs using a dedicated form or as part of the documented admission assessment.
Conclusion
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Acknowledgements
Firstly, as this survey was addressed to senior staff, we assumed a certain level of health literacy and therefore did not provide definitions for the key terms used in the survey. Some respondents may therefore have interpreted some of the terms used in the narrowest sense, for instance equating ‘sexual needs’ purely with intercourse.
Finally, the rate of response to this study was higher than anticipated given our previous research in this area [17], possibly reflecting a growing recognition that this is an area of care that deserves attention. The response rate was, however, still low, and therefore the generalisability of the findings is somewhat compromised. It is possible that facilities with good practice in this area were more likely to respond to the survey; it is equally likely that facilities with less optimal practice were over-represented in the sample, as staff from such facilities may have responded to the survey in an effort to help highlight the issue.
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care facilities. This paper has provided a snapshot of how resident sexual health and needs are currently addressed in this setting. As such, it provides a starting point for discussions about how we can better meet these needs (for example, through more comprehensive education and assessment) and thereby improve the lives of many older Australians living in residential aged care.
Limitations There are a number of limitations to this study, which are outlined below.
Thirdly, it could be argued that conducting a postal survey rather than a telephone or online survey was limiting and that these alternative methods might have yielded a higher response rate. The choice to conduct a postal survey was made because telephone surveys can be time-consuming and labourintensive given the high likelihood of needing to make multiple calls to reach the targeted person owing to the ‘on-the-floor’ nature of nursing work. Furthermore, email addresses are typically not readily accessible for residential aged care facilities and even less so for directors of nursing and nurse unit managers, making recruitment via email an untenable option. Interestingly, less than half of respondents indicated that they would have preferred to complete the survey online.
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Key Points • Sexual health and needs are not routinely assessed in Australian residential aged care facilities. • When assessments do occur, it is more often than not in the context of disruptive sexual behaviour. • Assessments of a resident’s sexual health, sexual needs, sexual preferences and sexual history can all inform care. • A dedicated sexual health/needs assessment form is needed to help guide staff through a comprehensive assessment process.
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