Thursday, 26 May 2016

Sexual expression in long-term care

Roger Watson, Editor-in-Chief

Sexual expression among older people remains a taboo subject and sexual expression among older people in long-term care is virtually ignored.  Yet, as nurses, part of our regular assessment of patients - young and old - is about sexuality; a line we often simply leave blank in assessment forms.

This study from the USA by Syme et al. (2016) titled: 'Recommendations for sexual  management in long-term care: a qualitative needs assessment' and published in JAN aims: 'To conduct a qualitative needs assessment of Directors of Nursing  regarding challenges and recommendations for addressing sexual expression and consent.'  Twenty Directors of Nursing across a range of long-term care facilities were interviewed.  The topics they discussed were  around raising awareness of the issue, educating staff and actually carrying out initial assessments of sexuality.  They also said that national guidelines were required.  One interviewee said: 'I think that level of connection with another human being changes a lot about your demeanor and how you move through life and long-term care is so isolating to begin with. You’ve left your home, you’ve  just enough belongings in a box to take up half of only an 80  foot room and so, so many things are lost and disconnected.  But if we had a better way to maintain intimate relationships with people, that would change the perception of long-term care to some.'  Another said: 'We have to realize that the residents that we have are our primary focus. Family is second. We have to stand our ground when it  comes to what the residents wants versus what the family wants. And at facilities we have to have that ability to stand our ground. To know that, even if somebody took us to court, we have a better chance of winning because we are meeting the needs of the resident.'

As explained by the authors: 'Despite numerous challenges identified, all DONs interviewed in this study were supportive of sexual expression, and they had many suggestions to successfully tackle these challenges, both locally and system-wide. First and foremost is the need to address sexual expression and consent openly in LTC, which has been largely ignored due to issues such as stigma and legal worries.'  In conclusion, they state: 'Sexual expression and consent among LTC residents
can no longer be ignored.'

You can listen to this as a podcast.


SYME M.L., LICHTENBERG P. & MOYE J . (2016) Recommendations for sexual expression management in long-term care: a qualitative needs assessment. Journal of Advanced Nursing doi: 10.1111/jan.13005

Tuesday, 24 May 2016

Recommendations for sexual expression management in long-term care

Maggie L. Syme, PhD, MPH
Peter Lichtenberg, PhD, ABPP
Jennifer Moye, PhD

Syme M.L., Lichtenberg P. & Moye J. (2016) Recommendations for sexual expression management in long-term care: a qualitative needs assessment. Journal of Advanced Nursing. DOI: 10.1111/jan.13005

Intimacy and sexual expression in later life is consistently reported as important to older adults. Also, we continue to engage in intimate and sexual activities across the lifespan, and it continues to provide physical, psychological, and social benefits, regardless of how old you are, where you live, or if you have physical and/or cognitive limitations (DeLamater 2012, Doll 2013, Nay 1992, Syme et al. 2015). Unfortunately, the privileged, and often limited, way in which Western values have framed sexuality has many individuals, healthcare providers, and older adults themselves believing that sexual activity is not for the aged (Bouman et al. 2006, Hinchliff & Gott 2011, Hillman 2012).

Nowhere is this a bigger reality than in nursing home settings. Sex is even more taboo for older adults living in long-term care (LTC) with dementia, and the sexual rights of elderly LTC residents are often unacknowledged (Roach 2004, Frankowski & Clark 2009). This is partially due to difficulties reported in managing sexual expression among LTC residents (Elias & Ryan 2011, Lester et al. 2015). Sexual expression management among long-term care residents is a complex issue for nursing home staff, and there is little to no guidance available for many wanting to follow a person-centered approach. Policies and procedures are needed, and must be usable across long-term care settings.

Balancing challenges of supporting sexual and intimate expression with residents’ rights and autonomy is an ongoing struggle for homes. The purpose of this study is to explore both the challenges LTC facilities face in addressing sexual expression and consent and their subsequent recommendations for improving care.

A qualitative design was followed, with semi-structured interviews were conducted with 20 Directors of Nursing in the spring and summer of 2013. Interview questions prompted them to identify recommendations that address their key challenges to improving sexual expression management within long-term care settings.

Comparative thematic analysis resulted in several codes, which were grouped into eight overall categories. Recommendation categories that addressed key challenges included: address the issue, make environmental changes, identify staff expertise, provide education and training, assess sexuality initially and recurrently, establish policies/procedures for sexual expression management, develop assessment tools for sexual expression and consent, and clarify legal issues. The recommendation to develop national guidelines was observed across categories.

Directors of Nursing report several challenges to sexual expression management within their facilities, and perceive their current methods to be ad hoc versus proactive. They report that residents’ sexual rights should be seen as important, and recommend that more training and tools be provided from the top (e.g., national organization such as Centers for Medicare and Medicaid in the US) down to the local homes.


Bouman W.P., Arcelus J. & Benbow S.M. (2006) Nottingham Study of Sexuality & Aging (NoSSA I). Attitudes regarding sexuality and older people: a review of the literature. Sexual and Relationship Therapy 21(2), 149–161. DOI:10.1080/14681990600618879

DeLamater J. (2012) Sexual expression in later life: a review and synthesis. Journal of Sex Research 49(2–3), 125–141. doi:10.1080/00224499.2011.603168.

Doll G.M. (2013) Sexuality in nursing homes: practice and policy. Journal of Gerontological Nursing 39(7), 30–37. doi:10.3928/00989134-20130418-01.

Elias J. & Ryan A. (2011) A review and commentary on the factors that influence expressions of sexuality by older people in care homes. Journal of Clinical Nursing 20, 1668–1676. DOI: 10.1111/j.1365-2702.2010.03409.x

Frankowski A.C. & Clark L.J. (2009) Sexuality and intimacy in assisted living: residents' perspectives and experiences. Sexuality Research and Social Policy 6(4), 25–37. DOI: 10.1525/srsp.2009.6.4.25

Hillman J. (2012) Sexuality and Aging: Clinical Perspectives. Springer, New York, NY.
Hinchliff S. & Gott M. (2011) Seeking medical help for sexual concerns in mid- and later life: a review of the literature. Journal of Sex Research 48(2–3), 106–117. doi:10.1080/00224499.2010.548610.

Lester P.E., Kohen I., Stefanacci R.G. & Feuerman M. (2015) Sex in nursing homes: a survey of nursing home policies governing resident sexual activity. Journal of the American Medical Directors Association 000, 1–4. doi:10.1016/j.jamda.2015.08.013.

Nay R. (1992) Sexuality and aged women in nursing homes. Geriatric Nursing 13(6), 312–314.

Roach S. (2004) Sexual behavior of nursing home residents: staff perceptions and responses. Journal of Advanced Nursing 48(4),371–379. DOI: 10.1111/j.1365-2648.2004.03206.x

Syme M.L., Cordes C.C., Cameron R.P. & Mona L.R. (2015) Sexual health and well-being in the context of aging. In: APA Handbook of Clinical Geropsychology (Lichtenberg P.A. & Carpenter B., eds), American Psychological Association, Washington, DC, pp.395–412.

Friday, 20 May 2016

Multidimensional symptom clusters: An exploratory factor analysis in advanced chronic kidney disease

Robyn Gallagher, Editor

One of the hallmarks of  chronic diseases is the presence of multiple symptoms, the severity of which increases as the disease progresses or exacerbation occurs. In chronic disease these symptoms often occur together in a relatively predictable way, yet research persistently focusses on single entities such as breathlessness or pain for example. However, the patient experience is of a cluster of symptoms, and it is this cluster that can impact their lives profoundly. In the study by  Almatury et al., the most common clusters of symptoms are identified in patients who have chronic kidney disease and the relative influence of severity, distress and frequency. They found that while some symptoms clustered around distinct aspects of the underlying disease process, such as excess fluid volume, there were other symptoms, such as fatigue, sleep disturbance and restless legs, that were present in several of the clusters. Symptoms did not occur in isolation. This means that clusters of symptoms should not only be assessed comprehensively, and that treatments should aim to by synergistic so that multiple benefits can be experienced. Finally, as patients with chronic disease, as in this study, often have concurrent conditions, treatment of symptom clusters may also benefit patients' experience of other conditions.


Almutary H, Douglas C, Bonner A (2016) Multidimensional symptom clusters: An exploratory factor analysis in advanced chronic kidney disease Journal of Advanced Nursing doi: 10.1111/jan.12997

Wednesday, 18 May 2016

Commentary on Empathy and stress in nurses working in haemodialysis

Comment on: Vioulac C., Aubree C., Massy Z.A. & Untas A. (2016) Empathy and stress in nurses working in haemodialysis: a qualitative study. Journal of Advanced Nursing 72(5), 1075–1085

Nakisha Ice, BSN, RN
The University of Texas at Arlington

The article by Vioiulac et al. (2016) was eye-opening and very true to the past and current issues in the field of dialysis. The chronic haemodialysis setting continues to suffer from increased nurse burnout and turnover due to the demands of the work environment. As an eleven-year dialysis nurse, I have experienced burnout personally and have been impacted by increased rates of nursing turnover. Böhmert et al. (2011) discuss how the lack of knowledge and education related to dialysis contributes to the increased turnover rate of dialysis nurses. Nurses want to be comfortable in their role and feel they are providing safe care to their patients. The field of dialysis has experienced such high rates of nursing turnover the education and orientation to dialysis is little to be desired. The inability to troubleshoot the technical issues and have adequate training on how to handle emergent situations in the dialysis setting increases the stress level of dialysis nurses (Vioulac et al. 2016).

The rising demands and expectations set forth by regulatory entities continue to increase the already heavy workload of haemodialysis nurses. Researching and investigating the demands of companies’ expectations to manage a successful, profitable business while striving to meet the stringent guidelines of federal and state regulations, as well as following a strict budget that requires the dialysis team to provide exceptional quality care based on the bundled reimbursement rate will be beneficial to the field of dialysis. The federal and state guidelines are necessary for quality patient care; however, the implementation and continuous improvement comes with a price. The cost of living fluctuates as does the cost of adequately caring for the end-stage renal disease population. Medication costs increase, employee salaries increase and the overall cost to operate a facility continues to rise. While so many aspects of the business are becoming more costly the expectation of caring for more patients with limited resources tends to be the accepted norm.


Vioulac, C., Aubree, C., Massy, Z. A., & Untas, A. (2016). Empathy and stress in nurses working in haemodialysis: A qualitative study. Journal of Advanced Nursing, 72, 1075-1085. doi:10.1111/jan.1289

Böhmert, M., Kuhnert, S., & Nienhaus, A. (2011). Psychological stress and strain in dialysis staff‐a systematic review. Journal of Renal Care, 37, 178-189. doi:10.1111/j.1755-6686.2011.00236.x

Wednesday, 11 May 2016

Thoughts on International Nurses Day

Cathy Catrambone PhD, RN
President, The Honor Society of Nursing, Sigma Theta Tau International

As a lifelong nurse and nurse educator, I have always respected Nurses Week and International Nurses Day. Throughout my career, I have taken advantage of that day each year to celebrate my profession and the impact it has made on world health. This year continues the theme of Nurses: A Force for Change. And while the official theme concentrates on improving health systems resilience, I think of that in terms of influence.

In my current role as President of the Honor Society of Nursing, Sigma Theta Tau International (STTI), International Nurses Day takes on additional significance. As all STTI presidents before me, I created a Presidential Call to Action to guide my biennium of service; the theme of that Call to Action is Influence to Advance Global Health and Nursing. In my call, I identified four ways that nurses can develop influence through advocacy, policy, philanthropy, and lifelong learning. I believe the theme of influence is relevant to today’s celebration of International Nurses Day, and relevance, when it comes to nurses, can be traced back to one woman.

We celebrate International Nurses Day on Florence Nightingale’s birthday. If you want an example of influence in its purest form, look no further. Florence Nightingale was a woman whose life, work, and writings transformed the profession of nursing and forever impacted healthcare. She was so influential that the humble utilitarian lamp most associated with her has become a time-honored icon of the nursing profession, with its image on countless logos and seals of nursing schools and organizations. If one person can have that kind of influence, imagine the possible influence of millions of nurses today. That’s right – millions. The World Health Organization estimates that there are 19.3 million nurses and midwives woven into every element of healthcare worldwide.
One of the great gifts that my STTI leadership position has afforded me is the opportunity to travel to many regions of the world, from Asia to the Middle East to Europe and Latin America. This summer, I will add South Africa and Australia to that growing list. In every one of my travels, no matter the cultural differences, I have been thrilled to meet passionate, masterful nurses and midwives who care deeply about their profession and their colleagues, but most importantly, about the lives and health of those they serve. They are influencing nursing and healthcare in their own way every day.

Given the global nature of our work, I am delighted to share a new publication that provides a definition of global health and global nursing. I hope this will be useful in providing a framework to guide your work in the many arenas in which we practice and influence.

As I consider the impact that Florence Nightingale made on an entire profession and the world, I think about the vast number of nurses serving in various roles today. I will repeat here what I say in my Call to Action: Now is the time for nurses to leverage our expertise to influence the health of the world’s people and to advance the profession. Happy International Nurses Day!

Residents who thrive in nursing homes

Roger Watson, Editor-in-Chief

We tend to hold negative perceptions of nursing homes and, generally, envisage them as places where older people go simply to die and where there is little hope for them. However, this is not always the case; some older people thrive in nursing homes as this study from Sweden by Patomella et al. (2016) titled: 'Characteristics of residents who thrive in nursing home environments: a cross-sectional study' and published in JAN shows.

The aim of the study was to: 'describe what characterizes residents with higher levels compared with
those with lower levels of thriving in nursing homes using the Thriving of Older People Assessment Scale.'  The study involved 191 older people in one large Swedish nursing home.  They were divided into those with higher and those with lower scores on the thriving scale. Gender and age had no influence on thriving but, as explained by the authors: 'the characteristics of residents reported to have higher levels of thriving in relation to those with lower levels of thriving, it was found that residents with higher levels of thriving were more independent in their ADLs (activities of daily living), had a higher quality of life and had less psychological and behavioural symptoms.'

The authors conclude: 'The study show that independence in ADL, higher quality of life, shorter lengths of stay, ability to walk and spend time outdoors are potential characteristics of residents who thrive in nursing home environments. The study contributes to existing knowledge by showing that the experience of thriving in nursing homes seems to be related to residents’ level of functioning and thereby their possibilities to have a varied everyday life in the nursing home. The findings also contribute by highlighting the characteristics of residents with lower levels of thriving. The findings have some clinical implications. The results can be used by nursing home staff to identify residents in risk of not thriving and also be used to initiate interventions such as outside walks, everyday activities, etc. that can improve the level of thriving in residents.

You can also listen to this as a podcast.


PATOMELLA A.-H., SANDMAN P.-O., BERGLAND A. & EDVARDSSON D. (2016) Characteristics of residents who thrive in nursing home environments: a cross-sectional study. Journal of Advanced Nursing doi: 10.1111/jan.12991