Sexual expression in nursing homes: a neglected nursing ethics issue.

Abstract

What is nursing ethics? This somewhat provocative question was raised by a participant with a medical background during the 2013 Intensive Course Nursing Ethics held in December 2013 at the Catholic University of Leuven, Belgium. My theoretical answer to this question was that nursing ethics concerns a systematic and critical reflection on nursing care practices from an explicit normative perspective. The explicit normativity referred to lies in the following question: does the nursing behavior—attitude or act—contribute to the human dignity of all people involved in a particular care practice? Although the participant theoretically agreed with my answer, he still had doubts about the specific content of nursing ethical problems. Therefore, I continued by illustrating my theoretical characterization of nursing ethics with a concrete example of an ethical problem nurses are regularly confronted with: dealing with expressions of intimacy and sexuality by nursing home residents. Let me focus on this relevant but underresearched nursing ethics topic. Sexuality is an important dimension of human identity. Everyone—young and old—needs love, touch, companionship, and intimacy. In nursing homes, however, intimacy and sexual expression are frequently overlooked by nurses. It seems to be difficult for nursing staff to contemplate older people as sexual beings. This results in a perception of residents’ sexual expression as a behavioral problem rather than an expression of the need for intimacy and sexual engagement. Nurses reported confusion, embarrassment, anger, denial, and helplessness when they discovered that residents were involved in behavior such as kissing, hugging, and holding hands. These negative experiences may also be the result of the rather limited knowledge of nursing staff regarding aged sexuality. Residents with dementia offer a particular challenge for nursing ethics researchers. The behavior of people with dementia may be misinterpreted as sexual in nature when, in fact, it may have a totally different meaning to the residents themselves. The person with dementia, for instance, may not be having sexual thoughts, inasmuch as expressing a desire for intimacy or human connection might be a result of what Higgins et al. called ‘‘iatrogenic loneliness’’—loneliness induced by staff attitudes and organizational structures that fail to accommodate any form of intimacy within the institutional setting. Ethical considerations concerning intimacy and sexual expression in dementia care go beyond the medical ethical principles of respect for autonomy, beneficence, and nonmaleficence for these principles are mainly developed for competent persons who can reason through the steps of ethical decision-making. Ethical issues that are manifest in daily care interactions—for example, dealing with intimacy and sexuality— might be better approached by concepts that are particularly well developed in nursing ethics literature such as moral perception, care, intersubjectivity, respect, dignity, vulnerability, and responsibility. The concrete example of dealing with intimacy and sexuality in a nursing home setting illustrates how nurses