**4. A pilot study of nursing care professionals attitudes toward sexuality among institutionalized elderly: Nursing home facilities**

### **4.1. Problem statement**

other resident, even partner. This is supported also by Mahieu et al. [38] who claim that principle of respecting the autonomy is most mentioned factor in assessing the permissibility for sexual behavior in institutionalized elderly persons, but only when elderly person is still capable to make decisions. If elderly suffer from mental and/or physical deterioration their need and desire for sexual fulfillment and intimacy is being denied – resident is seen only as a patient [38] in which we think that the physical needs must be fulfilled first and that only physical needs should be met. This (medical) point of view does not support a holistic approach in nursing care of elderly. It shows that nursing staff is thinking about sexuality in elderly as unimportant and useless and consequently would not promote this area of life of the elderly. Even more, caregivers think that nothing bad happens if this area remains neglected [1, 11]. This avoidance is consistent with the findings of Villar et al. [39] that under the pretext of "ensuring safety" lays tendency to avoid problems regarding sexual behavior and to satisfy

**3.4. Nursing care professionals' attitudes towards sexuality among institutionalized elderly**

It is already clear that the sexuality among institutionalized elderly is a delicate topic from many aspects. Therefore, at the beginning we must always ask, what is our position on the topic – and therefore what is the point of view about sexuality in nursing homes among employees. In nursing homes residents and staff are in constant contact so they both develop strong interpersonal relationships which affect sexual expression in elderly [13]. In the field of exploration the nursing care professionals' attitudes towards sexuality among the elderly in nursing homes suggest a certain discrepancy between different authors. Bouman et al. [8] have found both positive and negative staff attitudes. More likely to have a positive attitude are employees with higher educational level, higher socio-economic status and many years of work experience. But on the other side, a predictive of negative attitude to late life sexuality are younger staff, less than five years experiences of working in nursing home, working with high dependent residents and also in the case of strong religious beliefs [41]. On the other hand, Madsen [37] finds no relationship between staff age, years of working experience and attitudes, although it considers that this could be expected because of similar life-stage and consequently experiencing to be peers by age. Nevertheless Mahieu et al. [13] draw attention to the potential impact of methodological approaches in research-studies with a quantitative approach show more positive attitudes and those with qualitative approach more negative attitudes. On their opinion the negative climate and the lack of privacy is typical for a nursing home environment, but in spite of this the methodological approach is the factor that need to be considered as a possible cause for discrepancy in the results. In this context Bouman et al. [41] point out the inconsistency in attitude-behavior relationship as the important phenomenon that must be kept in mind when we talk about discrepancy in results. Elias and Ryan [36] emphasize that research about sexuality in elderly is not so much focused on late life sexuality as well, but rather in sexuality and dementia because of concerns and ethical dilemma nursing staff is faced

Nevertheless, many authors [13, 37, 38] are uniform in the claim that nursing care professionals still have a rather negative attitudes toward sexual behavior of elderly in institutional care

expectations of relatives.

198 Sexology in Midwifery

with.

Limited numbers of studies assess attitudes toward sexuality among elderly in nursing care homes [36]. Sexuality of elderly in nursing homes is determined by complex relations between several variables, pertaining to the individual, institution, social milieu and societal culture. The question of how nursing care professionals evaluate sexuality among elderly in the nursing home facilities and which underlying meaning they assign to sexuality among residents of nursing homes can have an important impact especially on institutional practices and policies related to sexual intimacy of the elderly. With the aim to assess nursing care professionals' attitudes toward sexuality of elderly in nursing homes, we performed a pilot study on a sample of Slovenian nursing homes workers. The study had two goals: i) to develop an instrument to assess nursing care workers attitudes toward sexuality among institutional‐ ized elderly and to ii) determine how nurses that work in nursing home facilities evaluate the expression of sexuality among residents of nursing homes.

The instrument for measuring attitudes toward sexuality among institutionalized elderly scale was developed as a semantic differential scale. A semantic differential technique [42, 43] is a multi-item measure used to obtain a relative direct indication of attitude [44] in measuring meaning of objects and concepts. Although a review of methodological research on semantic differential [45] show its limitations, semantic differential is a technique widely utilized in studies examining attitudes and stereotypes toward different objects and concepts, especially in relation to age [46-48] and questions that incorporate stronger affective component, such as the women's attitudes toward menopause [49]. Ajzen [50] notes that semantic differential has been in previous studies employed as a measure of affect toward the object and also as a measure of cognition, and concludes that "it is thus possible, by carefully selecting appropriate scales, to use the semantic differential to assess and attitude's cognitive or affective compo‐ nent." [50]. Since previous studies [37] show that sexual behavior of elderly in institutional care settings is connected with rather negative reactions of nursing staff and with stereotypes toward older people, we can expect a stronger affective component of nursing staff attitudes toward perceived sexuality among elderly in nursing care facilities. The differential scale technique is therefore a good approach for the development of a scale that measures evalua‐ tions and reactions of nursing care professionals toward sexuality of elderly. In the next section we present the procedure of the development of the attitudes toward sexuality among institutionalized elderly scale.

### **4.2. Method**

### *4.2.1. Instrument: Scale development and scale description*

The attitude toward sexuality among institutionalized elderly scale development process included three stages: i) the identification of adjectives through which nursing care professio‐ nals describe and evaluate perceived expressions of intimate relations between elderly in nursing homes, ii) the formation of a list of adjectives that represent evaluations of perceived intimate relations between elderly in nursing homes, and iii) the formation of a list of bipolar sets of adjectives that describe attributes and behavioural characteristics of intimate relations between institutionalized elderly from the perspective of nursing care professionals.

The adjectives through which nursing care professionals describe and evaluate perceived expressions of intimate relations between elderly in nursing homes were identified through a focus group with students, enrolled in the second cycle bologna study programme of nursing care. In the focus group 15 students participated, the majority of them already employed and with experience in nursing practice, two of them also in nursing home facilities. Two questions were discussed with focus group members: i) how do you, as a nursing care professional, evaluate different forms of expression of intimacy and sexuality between elderly in nursing home facilities, ii) is there any discrepancy between your evaluations as a person and as a nursing care professional – if yes; why such differences in evaluations exists? Examples of evaluations of the theme that have emerged during the focus group are: "Well, it is god for their health, although sometimes disturbing for us, as health care workers", "It's embarrass‐ ing."…"It can be perceived aggressive or better determinant… but on the other hand it is their intimacy… until it is spontaneous or honest...". "It's not easy; we know that this is something ordinary, spontaneous, frequent." From responses of focus group interview 51 adjectives through which nurses evaluate perceived sexuality and intimacy of elderly in nursing home facilities were identified. From the list, synonyms and similar adjectives were excluded, resulting in a list of 31 adjectives.

In the second step the list of 31 adjectives was discussed with the second group of 21 nursing care students, enrolled in the second cycle bologna study programme of nursing care. Also the second group of students included participants with experience in nursing care practice, also in nursing home and other forms of health care facilities for older people. The discussion was directed toward the validation of identified adjectives (comparison with personal experience) and overall evaluation of the list of adjectives. In the second step a list of 26 adjectives was identified.

From the final list of 26 adjectives we formulated a list of bipolar sets of adjectives (26 items) that describe evaluations intimate relations between institutionalized elderly (older than 75 years) from the perspective of nursing care professionals. The adjectives incorporate the evaluations of behavioural characteristics of the object of evaluations (*strong, frequent, intensive, spontaneous*) and the attributes assigned to the object from the perspective of nursing care professionals that perceive intimate relations (*tolerant, liberal, disrupting, acceptable*). The instruction for respondents was developed in accordance to the Rosencranz and McNevin's [48] formulation, adapted to the object of evaluations. Each of the 30 scales was scored from 1 to 7, for example: Healthy 1-2-3-4-5-6-7 Un-healthy; Frequent 1-2-3-4-5-6-7 Seldom; Intimate 1-2-3-4-5-6-7 Public.

### **4.3. Sample**

we present the procedure of the development of the attitudes toward sexuality among

The attitude toward sexuality among institutionalized elderly scale development process included three stages: i) the identification of adjectives through which nursing care professio‐ nals describe and evaluate perceived expressions of intimate relations between elderly in nursing homes, ii) the formation of a list of adjectives that represent evaluations of perceived intimate relations between elderly in nursing homes, and iii) the formation of a list of bipolar sets of adjectives that describe attributes and behavioural characteristics of intimate relations

The adjectives through which nursing care professionals describe and evaluate perceived expressions of intimate relations between elderly in nursing homes were identified through a focus group with students, enrolled in the second cycle bologna study programme of nursing care. In the focus group 15 students participated, the majority of them already employed and with experience in nursing practice, two of them also in nursing home facilities. Two questions were discussed with focus group members: i) how do you, as a nursing care professional, evaluate different forms of expression of intimacy and sexuality between elderly in nursing home facilities, ii) is there any discrepancy between your evaluations as a person and as a nursing care professional – if yes; why such differences in evaluations exists? Examples of evaluations of the theme that have emerged during the focus group are: "Well, it is god for their health, although sometimes disturbing for us, as health care workers", "It's embarrass‐ ing."…"It can be perceived aggressive or better determinant… but on the other hand it is their intimacy… until it is spontaneous or honest...". "It's not easy; we know that this is something ordinary, spontaneous, frequent." From responses of focus group interview 51 adjectives through which nurses evaluate perceived sexuality and intimacy of elderly in nursing home facilities were identified. From the list, synonyms and similar adjectives were excluded,

In the second step the list of 31 adjectives was discussed with the second group of 21 nursing care students, enrolled in the second cycle bologna study programme of nursing care. Also the second group of students included participants with experience in nursing care practice, also in nursing home and other forms of health care facilities for older people. The discussion was directed toward the validation of identified adjectives (comparison with personal experience) and overall evaluation of the list of adjectives. In the second step a list of 26 adjectives was

From the final list of 26 adjectives we formulated a list of bipolar sets of adjectives (26 items) that describe evaluations intimate relations between institutionalized elderly (older than 75 years) from the perspective of nursing care professionals. The adjectives incorporate the evaluations of behavioural characteristics of the object of evaluations (*strong, frequent, intensive, spontaneous*) and the attributes assigned to the object from the perspective of nursing care

between institutionalized elderly from the perspective of nursing care professionals.

institutionalized elderly scale.

resulting in a list of 31 adjectives.

identified.

*4.2.1. Instrument: Scale development and scale description*

**4.2. Method**

200 Sexology in Midwifery

In the pilot study 106 nursing care professionals participated, employed in 5 different nursing homes in Slovenia. In the sample 88 % nursing care professionals were female. The majority of participants were aged between 35 and 50 years (56 %). Participants with finished at least secondary nursing education (88 %) are working in nursing homes as nurse assistants; participants that have finished at least a bachelor nursing study programmes (12 %) are working as registered nurses.

### **4.4. Data analysis**

In the pilot study we performed the reliability and dimensional structure analysis (varimax and oblimin exploratory factor analysis) of the attitudes toward intimate relations between institutionalized elderly scale and calculated the descriptive statistics of the 26 items.

### **4.5. Results**

We performed exploratory factor analysis (principal component) with varimax and oblimin rotation. The factor analysis produced two factors (Table 3) that explain 46,7 % of variance in evaluations of intimate relations between institutionalized elderly. Correlation between factors is 0,26. During the factor analysis two adjectives were excluded from the scale: *friendly* and *aggressive*. Both loaded strongly on separate factors and lowered the level of internal consistency of the scale. The final version of the scale (presented in the Table 3), with 23 items and two-dimension structure has appropriate level of internal consistency (Chronbach's alpha=0,91). The first factor (34,8 % of explained variance) includes adjectives, such as: *safe, healthy, acceptable, spontaneous, pleasant, ordinary*. The second factor (11,9 % of explained variance) includes adjectives, such as: *exciting, intensive, active, frequently*. In accordance with basic three dimensional structure of attitudes – evaluation, potency, activity [50], confirmed also in studies utilising semantic differential scale as a measure of attitudes [45], the first factor obtained in our study incorporates mainly the evaluation dimension of attitudes structure, and the second factor incorporates the activity and the potency dimension. From a more detailed analysis of the adjectives indicating both factors, it is also evident, that the first factor incorporates adjectives that mainly describe the pleasant–unpleasant dimension of reactions toward the studied concept, and the adjectives describing the second dimension includes adjectives that indicate the arousal-activation reactions. The pleasant-unpleasant and the arousal-activation have been consistently found as dimensions describing the emotional terms or the affective component of attitudes [50]. The adjectives included in the attitudes toward intimate relations between institutionalized elderly scale represent evaluations strongly connected to affective responses toward the studied attitudinal object.

Table 3 also shows the descriptive statistics for the scales; the mean values for the items range from M=3,21 (bipolar adjective: *intimate-public*) to M=4,66 (bipolar adjective: *frequently-rarely*); with standard deviations from SD=1,45 (adjective: *beneficial-detrimental*) to SD=1,74 (adjective: *honest-dishonest*). Ratings of bipolar sets of adjectives show neither extremely positive and neither extremely negative, but rather moderately positive evaluations.


**Table 3.** Dimensional structure and descriptive statistics of attitude toward sexuality among institutionalized elderly scale
