Sexual interest and activity persist despite the many physiological and psychological changes that accompany the aging process (Bretschneider & McCoy, 1988). In recognition of this, authors have exhorted health care professionals to be attentive to elderly individuals' feelings regarding various sexual issues (Comfort & Dial, 1991). The tendency for health care professionals to ignore or devalue sexual aspects of personhood in their interactions with elderly individuals has been described, and the process by which sexual expression in care facilities becomes a matter of control with an emphasis on segregation, limit setting, and disapproval has been deplored (McCartney, Izeman, Rogers, & Cohen, 1987; McLean, 1994; Mulligan & Modigh, 1991).
Change is occurring. In the 1990s, there has been a substantial increase in attention to sexual health in elderly individuals (Johnson, 1997; Steinke, 1997; Tunstall & Henry, 1996). An underlying assumption of this literature is that more open, accepting, and uncensored attitudes toward sexuality will enhance quality of life for elderly individuals, especially for those who reside in institutions. This assumption reflects, at least in part, cohort-specific cultural values. Attitudes toward sexual expression and recognition of sexual "rights" have become increasingly liberalized in the past century (Jones, 1994).
Viewed in this context, it is not surprising that staff have been found to be generally permissive in their attitudes toward resident sexuality (Damrosch & Cogitano, 1994; Livini, 1994). Researchers have acknowledged that self-selection and response bias potentially limit the generalizability of these findings, and that liberal attitudes may not translate into permissive behaviors (Hillman & Stricker, 1994).
Conversely, a mix of positive and negative attitudes toward sexuality and aging have been documented among elderly individuals. In an early study of sexuality in a nursing home setting, Wasow and Loeb (1979) found that 81% of the men and 75% of the women residents agreed older people should be allowed to have sex, although individual activity rates were low. Overall attitudes toward various sexual behaviors (e.g., masturbation, fantasy) were categorized globally as permissive, semirestrictive, or restrictive. Attitudes held by more than three quarters of respondents were semirestrictive or restrictive. In general, factual knowledge about sex was poor. Subsequent reports have yielded similar results (Adams, Rojas-Camero, & Clayton, 1990; Paunonen & Haggman-Laitila, 1990; White, 1982a). Spousal attitudes toward sexuality where one marital partner resides in an institution include a mix of positive and negative views, varying from relief that the obligation to participate in sexual activities has ceased to profound loneliness and need for continued intimacy (Ade-Ridder & Kaplan, 1993; Gladstone, 1995; Kaplan, 1996).
The literature suggests that staff, residents, and spouses may disagree about the appropriateness of sexual behaviors in various contexts. These differences are likely to have important implications for efforts to develop an institutional culture that is both steeped in residents' values and supportive of sexual expression. However, only one study (Kaas, 1978), conducted 20 years ago, compared general attitudes toward sexuality held by staff to those held by residents. Kaas (1978) found acceptance of sexual expression for elderly individuals in both groups of respondents; however, acceptance was greater among staff. Both groups cited lack of privacy as a primary deterrent to sexual expression, especially in nursing homes. Feeling physically attractive was identified as a key component in sexual expression for elderly individuals.
While general attitudinal differences between staff and residents have been identified in previous research, differences in expectations or personal standards regarding the expression of sexual behaviors within a defined context have not been evaluated, nor have spousal opinions been included in the comparison. Without this information, it is difficult to develop environmental and clinical interventions that respect resident-centered values. It also is difficult to develop educational initiatives for staff without greater appreciation of differences in expectations that may exist among subgroups. Discrepancies may be expected among staff whose typical interaction patterns with residents are different. Nurses interact with residents on a daily basis and provide assistance with many intimate tasks such as toileting and bathing. Allied health service providers (e.g., occupational therapists, social workers, behavior therapists) tend to interact with residents on a more intermittent but structured schedule for specific treatment-related purposes. Support staff (e.g., housekeepers, food service workers, clerical staff) interact with residents on an ad hoc basis, and interactions are not focused on direct treatment or personal care.
The present study addressed these gaps in the literature by comparing opinions regarding the expression of sexual behaviors among residents, community-dwelling spouses, and staff within a facility, using a study methodology similar to that of Kaas (1978). The specific research questions guiding the study were:
* Are there differences among these groups in the factors considered relevant for determining whether sexual behaviors expressed by residents should be tolerated?
* Are there differences among these groups in the responses considered applicable for addressing inappropriate (according to one's personal definition) sexual behaviors?
Approval for the study was obtained from the Hospital Research Committee and the Ethics Review Board for the authors' affiliated university. All hospital staff N = 1,205), were given the opportunity to complete the survey. Proportionate membership in the three groups of staff respondents was nursing (i.e, RNs and registered practical nurses), 45% (n = 542); allied health, 18% (n = 217); and support staff, 37% (n = 446).
The chronic care hospital in which the study was conducted has 590 beds, 363 of which were occupied by elderly Canadian war veterans - the target population for this study. Veterans unable to provide informed consent for study participation secondary to cognitive impairment were excluded (n = 181), resulting in 182 eligible residents. Approximately one third of the Veteran residents had communitydwelling spouses. Spouses who were not geographically available or not regularly in contact with their institutionalized partners were not asked to participate, resulting in 103 eligible spouses. The resident and spouse participants were recruited independently (i.e., marital status was not an inclusion criterion for residents) and participation of the partner was not an inclusion criterion for either residents or spouses.
Because this study addressed normative standards for specific behaviors rather than knowledge or general attitudes, available data collection tools addressing geriatric sexuality were not applicable (Kaas, 1978; White, 1982b). To develop an appropriate tool for these purposes, two of the authors (M.C.G., N.B.) held 1hour meetings with each nursing unit and hospital department over a 9month period. Twenty-three meetings were held, with approximately 200 total participants. Participation was voluntary and ranged from 10% to 100% of departmental membership. Participants received a handout listing the following as potential discussion topics: sexual value systems held by staff and residents (e.g., knowledge, attitudes, experience); institutional culture regarding sexuality (e.g., tolerance, opportunities, limits); real or anticipated impact of aging and disability on sexuality (e.g., interest, ability, appropriateness); individual sexuality (e.g., needs, expression, meaning); staff expectations for residents' sexual behaviors; and residents' expectations for each others' sexual behaviors.
The discussion sessions were billed as "an opportunity to compare perspectives, discuss management strategies, and identify areas of continuing concern." The investigators facilitated the sessions and took notes. At the end of each meeting, participants were asked if they would find it helpful to have more information regarding how the hospital as a whole viewed the issues being discussed, and the prospect of a study was introduced. All groups expressed support.
Figure 1. Tolerance. Staff were significantly more tolerant of all behaviors compared to residents and spouses (p < .001).
Opinions expressed by staff in the discussion groups were collated thematically to develop the questionnaire. Only staff members participated in the discussion groups. However, the clinical co-investigators systematically reviewed their files to ensure all issues raised by residents and spouses regarding sexuality were addressed in the questionnaire. A draft of the questionnaire was reviewed by all department heads and nursing unit managers (most of whom had attended the focus group in their areas), members of hospital administration, and a representative of the hospital's Employee Assistance Program. Reviewers were asked to identify additional response options, redundant items, and literacy or style concerns. Feedback was incorporated as appropriate.
The research questions presented in this article were introduced in the questionnaire as follows:
* In your opinion, is it potentially excusable for patients to approach staff in a sexual manner?
DIFFERENCES IN OPINION ABOUT THE DETERMINANTS OF TOLERANCE
* In your opinion, is it potentially acceptable for patients to masturbate within this institution?
* In your opinion, is it potentially acceptable for patients to engage in some (if not all) sexual activities with a partner within this institution (e.g., handholdmg, kissing, intercourse)?
* In your opinion, is it potentially acceptable for patients to have sexually explicit material (e.g., magazines, books, movies, videotapes) within this institution?
Forced-choice response options were "yes," "no," or "not sure." Those who answered yes to each question were directed to a list of factors that could be important in evaluating behavioral appropriateness in the individual case (e.g., consent, mental impairment). They were further directed to a list of options for responding to inappropriate behaviors and asked to indicate which interventions they would support (e.g., counseling, distraction, restrictions). Those who answered no to each question were directed to a list of reasons and asked to indicate any that were relevant for them (e.g., disruptive, embarrassing).
Figure 2. Determinants of tolerance: Factors to consider in individual cases (all respondents who endorsed tolerance in principle).
Residents and spouses were interviewed subsequent to the staff survey. The questionnaire format was followed, with wording revised as necessary to reflect context. Care was taken to ensure residents and spouses understood they were being questioned about expectations or personal standards regarding what behaviors were appropriate in the institution, not descriptions of behaviors engaged in by respondents themselves. Wasow and Loeb (1979) found residents' responses varied depending on whether question wording implied sexual behaviors in general versus personal practices.
Design and Procedure
Questionnaires were distributed to all staff through their departments. Respondents were asked to indicate their age and gender. Thirty working days were allowed for questionnaire return, and reminder memos were posted twice during this time period.
Subsequently, residents and spouses were recruited by the clinical co-investigators. Age, gender, and primary admission diagnoses were extracted from hospital charts. Participants were interviewed privately at their convenience by a female research assistant during a 6month period.
Chi-square tests to compare proportions were conducted to detect differences among the three groups (staff, residents, spouses) and among subgroups within the staff category (nursing, allied health, support). Considering that this analysis involved a large number of comparisons and the exploratory nature of this research, the alpha level for statistical significance was set very conservatively ax. p < .001.
The questionnaire return rate for staff was 32%. Return rates relative to distribution rates differed significantly among provider groups (allied health staff, 50% [n = 105]; nursing staff, 34% [n = 184]; support staff, 22% [n = 99]). Participation rates for eligible residents and spouses were 40% (n = 72) and 42% (n = 43), respectively.
Eleven staff respondents failed to indicate their gender. Of the remainder, 19% (n = 70) were men, and 81% (n - 307) were women. Gender was distributed differentially with proportionally more men in the allied health group (31%, n = 32) and proportionally fewer men in the nursing group (12%, n = 21) than in the support staff group (18%; n = 17). These demographics are consistent with overall hospital statistics. Median age for staff respondents was 36 to 40, with the distribution again similar to overall hospital patterns. Overall, 15% (w = 60) of staff respondents indicated they had attended one of the focus groups held prior to the research study. Focus group attendance within staff subgroups was reported at 32% (allied health staff), 15% (nursing staff), and 3% (support staff).
Residents were predominantly men (96%, ? = 69), as expected given the low number of women veterans in residence. Correspondingly, all but one of the spouses were women (w = 42). Eleven couples participated (individually). Primary admission diagnoses were related to physical conditions (e.g., stroke, respiratory disease) for 76% of participating residents; psychiatric conditions (e.g., depression) for 17%; and cognitive conditions (e.g., dementia) for 7%. In most cases, secondary admission diagnoses in one or both of the other categories also were present. All residents had functional difficulties in basic or instrumental activities of daily living.
Determinants of Tolerance
The percentage of respondents in each group who indicated various sexual behaviors are potentially acceptable or excusable are presented in Figure 1. Staff were more tolerant of all behaviors than were residents and spouses. Figure 2 illustrates relative response rates for the determinants of tolerance endorsed by respondents who were tolerant of sexual behaviors in principle. Privacy was the dominant consideration for evaluating the appropriateness of masturbation, sexual relations, and use of sexual materials in the individual case, while mental impairment was paramount for evaluating sexual approaches to staff.
DIFFERENCES IN OPINION ABOUT RESPONSES TO INAPPROPRIATENESS
Determinants of tolerance that received significantly different endorsement rates among respondent groups are presented in Table 1. Staff and residents endorsed intent as an important consideration for masturbation less frequently than spouses, while residents and spouses endorsed age more frequently than staff. Staff and residents more frequently endorsed consent as an important consideration for sexual relations, while residents and spouses more frequently endorsed permanence of the relationship than staff. Residents and spouses endorsed privacy as important for use of sexual materials less frequently than staff. Staff and spouses endorsed mental impairment as important for evaluating sexual approaches to staff more frequently than residents. There were no significant subgroup differences among staff regarding the determinants of tolerance.
Approximately 50% of respondents who had indicated various sexual behaviors were not acceptable in any context endorsed personal beliefs or embarrassment as their reasons regarding masturbation and sexual approaches to staff. Fortyseven percent to 62% of these respondents believed sexual relations and use of sexual materials were unacceptable for the following reasons: potentially disruptive, offensive, and personal beliefs. Sexual materials were considered offensive by 54% of these respondents. There were no significant between-group differences.
Responses to lnappropriateness
Respondents who had indicated various sexual behaviors were acceptable in principle, most frequently endorsed redirection and counseling as responses to behaviors that are inappropriate in a given situation (Figure 3). Between-group differences are presented in Table 2. Staff and spouses endorsed counseling in response to masturbation and use of sexual materials more frequently than residents, while residents and spouses endorsed counseling in response to sexual approaches to staff less frequently than staff. As a response to masturbation and inappropriate sexual relations, residents and spouses more frequently endorsed use of medication than staff. Residents and spouses were more likely than staff to endorse that these behaviors and inappropriate use of sexual materials should be ignored and were less likely to endorse redirection regarding sexual materials. Staff and spouses more frequently endorsed staff training as a response to sexual approaches to staff than residents and less frequently endorsed resident transfers in this context.
Figure 3. Responses to inappropriateness: Recommended strategies (all respondents who endorsed tolerance in principle).
Significant differences were obtained among staff who were tolerant, in principle, of various sexual behaviors in their endorsement of how to respond to inappropriate behaviors (as defined by the individual respondent). Nurses (46%) less frequently endorsed counseling for masturbation than their colleagues in allied health (74%) and support services (66%). Nurses (47%) also less frequently endorsed staff training for sexual approaches to staff than allied health staff (77%) and support staff (67%). Nurses (54%) and support staff (66%) less frequently endorsed counseling for sexual relations than allied health personnel (79%). Nurses (6%) were less likely than allied health staff (20%) and support staff (42%) to report never having been approached sexually by a resident.
Threats to Generalizability
There are several threats to the generalizability of these results that need to be acknowledged to establish an appropriate frame of reference for interpreting the results. Response rate is the most important. The purpose of this study was to compare opinions about sexual behaviors among groups within a chronic care facility, and this objective was achieved for a self-selected subgroup within the facility. However, response rates were 50% or less for each category of respondent. The extent to which the opinions of the silent majority are represented by the study participants is unknown. Because residents and spouses were recruited directly, the authors were able to form an impression that those with opinions were eager to discuss their views, while those who declined participation were disinterested rather than reluctant to disclose. Recruitment among staff was anonymous so the authors cannot speculate on motivational differences between participants and nonparticipants.
Several methodological limitations also should be noted. Only face and content validity were established for the questionnaire developed for this study. Reliability was not determined. It is unclear to what extent the results reflect enduring opinions about the topics of interest or to what extent opinions documented using this tool would be collaborated by other measures or by behavioral evidence. Thus, the results must be viewed as tentative.
Additional methodological concerns include the possibility that the 23 focus groups held during the year prior to data collection could have fostered a response bias on the part of staff, such that more permissive responses were thought to be preferred. Efforts were made to defuse this perception when it arose during the focus groups. Only 60 of the approximately 200 staff who had attended a focus group participated in the study, suggesting individual biases were more influential than focus group attendance in determining participation.
It also is possible that residents and spouses who were interviewed may have been less forthcoming than staff, who were surveyed anonymously. However, residents and spouses almost unanimously selected the interview option rather than independent questionnaire completion, suggesting they were not uncomfortable expressing themselves in this context. Similar to Kaas (1978), in this study, residents who agreed to participate were quite open and apparently comfortable when interviewed about these issues. The interview format actually may have encouraged validity because it was possible in an interactive context to reorient participants to the study agenda (i.e., obtaining generic opinions about resident sexuality) when they digressed to personal behavior patterns or the behaviors of individuals or resident subgroups within the facility.
There are obvious gender considerations impacting the generalizability of these results. The residents in this study were predominantly men. While the female spouses tended to provide opinions congruent with those of the male residents, there is no way to be sure similar results would be obtained in settings where the resident population is predominantly female.
Considering the novelty of this line of research and the identified threats to generalizability, these results have been analyzed conservatively p < .001 significance level). Thus, only the most substantive differences of opinion among participant groups are identified and interpreted.
Determinants of Tolerance
These results support and extend the findings of previous researchers (Kaas, 1978; Wasow & Loeb, 1979). While the majority in each group agreed sexual relationships (i.e., sexual activities with another person) were acceptable within the facility, staff were more supportive than residents and spouses. A much wider margin of disagreement separated staff from residents and spouses regarding other forms of sexual expression (e.g., masturbation, use of sexual materials, sexual approaches to staff). While further research is needed to confirm or disconfirm the reasons for these differences of opinion, viable hypotheses include both cohort and contextual factors.
Cohort effects arise from the different physical and sociocultural environments to which successive generations are exposed, particularly early in life. Attitudes toward sexuality develop partly in response to the norms of the society and culture in which one is raised. Sexual norms at the beginning of the 1900s differed substantially from current standards (Jones, 1994). Cohort effects may account for some of the variability among groups in the importance ascribed to various factors for determining tolerance in the individual case.
The majority of respondents identified only privacy as a determinant of tolerance for masturbation. However, among those who did identify other factors, there were differences of opinion regarding the importance of both intent and age. Staff endorsed these factors with the least frequency, which may reflect cohort-based shifts in the perceived normalcy of this behavior. A cohort/gender interaction is suggested in that residents (predominantly men) and spouses (predominantly women) agreed on the importance of age but disagreed on the importance of intent.
Spouses undervalued consent as a condition for sexual relationships relative to staff and residents. This finding also may reflect a cohort/gender interaction, with some older women less attuned to issues of sexual freedom and choice than either same-generation men or their younger counterparts. Unfortunately, there were too few marital dyads within this sample to investigate difference of opinion within couples. In a related vein, permanence of the relationship was more important to residents and spouses than to staff. This finding also can be understood in terms of changing societal values.
Other findings lend themselves to interpretation in terms of contextual factors. Most notably, the majority of respondents who were tolerant, in principle, of sexual expression identified privacy as a key consideration, consistent with Kaas' (1978) findings from 2 decades ago. That is, behaviors considered acceptable in principle are acceptable or unacceptable in practice, contingent on available privacy. The problems associated with lack of privacy in institutional facilities are well known. These findings suggest that individuals may be caught between community values (which they may support) and personal desires for sexual expression when the environment does not afford adequate privacy.
The findings regarding the use of sexual materials may reflect this conflict. Spouses and residents who were tolerant of the use of sexual materials were less likely than staff to endorse privacy as a condition of use. It may be that the subset of elderly individuals who accept such materials are simply more liberal than staff who accept these materials, although this explanation contradicts other trends toward more conservatism among elderly individuals. Perhaps residents and spouses who are tolerant of these materials are simply more conscious of the limited privacy available within a facility.
Contextual factors also may account for differential endorsement of mental impairment as a relevant factor for evaluating sexual approaches to staff. Staff and spouses were much more likely than residents to see cognitive impairment as an excuse for these behaviors. Perhaps residents, who inhabit the environment that staff and spouses only work in or visit, have lower tolerance for behaviors that undermine the social fabric of the community. Perhaps these residents (male veterans) are inherently less tolerant of breaches of decorum than other groups of elderly people. Clarification awaits further dialogue with the groups whose perspectives the authors would like to understand.
The importance of understanding is underscored in that some individuals were intolerant of sexual behaviors that most others found acceptable. Reasons for intolerance fell largely within the domain of personal or religious beliefs. However, reasons suggesting a role for education also were implicated (e.g., embarrassment, the perception that behaviors are potentially disruptive). Dialogue is essential as a component of education so the beliefs and values of all participants receive due respect and consideration and so program development efforts reconcile rather than exacerbate conflicting viewpoints.
Responses to lnappropriateness
Staff, residents, and spouses concurred that therapeutic responses (e.g., counseling, redirection) were preferred to punitive responses when unacceptable behaviors occurred. Differences of opinion again appeared to reflect a combination of cohort and contextual factors.
Context factors are implicated because staff and spouses were more likely than residents to recommend counseling for problems regarding masturbation or use of sexual materials. That is, the potential recipients of the intervention were the least in favor of it. These findings may reflect resistance to the power differential existing within institutions, contingent on one's role. In keeping with this explanation, there was more support for ignoring problem behaviors among residents and spouses than among staff. Greater support by residents for resident transfers in response to sexual approaches to staff again may reflect context, with those who make the facility their home less willing to accept disruptive influences in their environment.
Cohort factors may underlie differences in support for counseling as an intervention for sexual approaches to staff. It is possible that older adults saw this behavior as more volitional (witness the plots of many World War II movies). This interpretation is consistent with the finding that residents were less supportive of staff training with respect to sexual approaches to staff than were spouses and staff. Residents may have been less likely to attribute control over this behavior to others. Greater support among elderly individuals for medication in response to masturbation and less support for redirection in response to use of sexual materials also may represent a cohort effect, reflecting a more medical than biopsychosocial health care mindset.
Contextual factors may contribute not only to differences between care providers and recipients but to differences among staff as well. Staff were categorized according to an admittedly gross differentiation based on roles. Similarities outweighed differences among staff. Significant differences can be understood in terms of relative experience with the issues and the implications of the suggested interventions. Nurses had the most experience with sexual approaches to staff and, not surprisingly, were the least likely to endorse staff training as an intervention. Both nurses and support staff were less likely to endorse counseling as a response to behavioral inappropriateness in the realm of sexual relationships than were allied health staff. In practice, allied health staff tend to be the counselors in the system, which would suggest they may be more supportive of this intervention.
IMPLICATIONS FOR NURSING
These potentially cohort-related and context-related findings cannot be generalized to other institutionalized populations or to elderly individuals at large without replication. However, at the clinical level, they attest to the importance of resident participation in efforts to set standards for sexual behavior within the community of the long-term care facility. Resident participation should extend to the determination of outcomes when standards for behavior are violated. While it may be unclear exactly what an institutional culture supportive of sexual health for elderly individuals "looks" like, it is obvious elderly individuals are entitled to a major role in the development of that vision.
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DIFFERENCES IN OPINION ABOUT THE DETERMINANTS OF TOLERANCE
DIFFERENCES IN OPINION ABOUT RESPONSES TO INAPPROPRIATENESS