CHAPTER 1: INTRODUCTION

SMI Severe Mental Illness

RMN Registered mental health nurse
STI
Sexually Transmitted Infection
HIV Human Immunodeficiency Virus
UK
United Kingdom
NIC National Insitute for Health and Care Excellence
E
DH
Department of Health
WH World Health Organisation
O
1.1 List of Abbreviations
Table 1: Abbreviations
1.2 Introduction
Sexuality is a complex concept to define, but is more than simply
engaging in sexual activity. The World Health Organisation (WHO),
(2006) conceptualises sexuality as a central aspect of being human
throughout life (and) encompasses sex, gender identities and roles,
sexual orientation, eroticism, pleasure, intimacy and reproduction...
Sexuality is influenced by the interaction of biological, psychological,
social, economic, political, cultural, legal, historical, religious and
spiritual factors.
Sexuality is a complex yet fundamental aspect of a persons health
and mental well-being (Davison & Huntington)
With an increasing focus on transforming mental health care into a
more holistic one, sexuality is one aspect of care that is frequently
ignored.
-STATISTICS ON SEXUALITY IN MENTAL HEALTHHow many patients are sexually active?
Themes of qualitative studies?

RMNs generally seem reluctant to discuss sexuality related issues

(Davison & Huntington 2010) despite frequently being contronted

with client issues related to sexual health. It is argued nurses need
to recognise their own sexual dimensions and build personal insights
in their own sexual health, in order to provide sexuality-related
interventions. Mental health professionals, in general, do not often
concern themselves with the sexual functioning of their
schizophrenic patients... Mental Health Nurses frequently feel great
discomfort in discussing sexuality with their patients (Assalian et al.
1999)

In response to this, the present work reviews the literature on the

attitudes and practice of RMNs towards addressing sexuality in
people with Severe Mental Illness (SMI) and is written in the context
of identifying to barriers to providing sexuality-related
assessments/interventions and how to overcome these. First, a
background exploring the existing policies and relevant literature
will be provided. This will support the development of the review
and inform the interpretation of the findings. Secondly, the
methodological processes will be explicity outlines. The main
findings will be illuminated with regard to the strengths and
weaknesses of the literature and will then be synthesises in relation
to the wider literature and UK policy. This will enable a discussion of
implications for nursing practice and recommendations for further
research.

1.3 Operational Definitions

Table 2 presents the key terms and how they will be defined
throughout this review.
Table 2: Operational definitions

Mental Health
Nurse

A registered nurse trained specifically in

mental health

Attitudes

An organisation of beliefs, which can be

positive or negative, about addressing
sexuality in mental health care. For the
purpose of this review, attitudes, views,
knowledge, beliefs and understanding are
used interchangeably.

Practice

Practice is defined as any nursing

intervention addressing the sexuality of the
client. For the purpose of this review
practice is split into two categories:
1. Assessment of sexuality in which
the nurse asks questions in order to
explore any issues regarding sexuality.
2. Sexuality inteventions - ?
CHAPTER 2: BACKGROUND

This chapter will underpin the rational for exploring the evidence
base on the attitudes and practice of RMNs towards addressing
sexuality in people with SMI (Severe Mental Illness). It will provide a
broad overview of the literature surrounding the research question,
and identify with main policy drivers and empirical evidence.
2.1 Sexuality and Severe Mental Illness
It is well known that sexuality is a fundamental need that influences
the quality of an individuals life. A recent study in England found
that ? % of nurses address sexuality?
Study indicating high rates of STIs/ HIV?
Most studies focus primarily on high-risk sexual behaviours and
rates of HIV and STIs (Davison & Huntington 2010: Meade & Sikkema
2007, Randolph et al. 2006).

Great number of women hospitalised with Schizophrenia had been

sexually abused during childhood?

Women with Schizophrenia are more likely to have had coerced or

unwanted sexual relations that women without mental illness.
Women experiencing manic episodes, prone to sexual implusivity,
which has a detrimental effect on their exisiting interpersonal
relationships leading to feelings of stress, guilt and negatively
effects self-image and self-esteem as they reflect on their manic
behaviour in their post-manic period.
Severe Mental Illness has profound negative affects on relationships
and sexual satisfaction of consumers and partners.
Relationships of people with SMI are characteristised by having less
intimacy and committment that the general population.
Individuals with Severe Mental Illness more likely to have long-term
relationships that do not culminate in cohabitation or marriage.
Theories
In period of psyhotic symtpoms typically emerging (16-25) is at the
same time individuals develop their psychosexual skills and begin
experimenting, exploring their sexuality and understanding sexual
norms and appropriate sexual behaviour.
Sexuality of individuals with SMI is historically a neglected area,
however, the recent focus on holistic care means that the recent UK
policy directives have began exploring the importance of addressing
sexuality in this client group (National Institute for Health and Care
Excellence [NICE] 2013). In England a ain objective of the national
mental health strategy No Health Without Mental Health
(Department of Health [DH] 2011) is that more people with SMI
experience holistic mental health care.
2.2 Sexuality The Personal Impact (self-esteem and
identity)
2.3 Sexuality The Impact of SMI on Relationships
2.3 Sexuality How does sexuality affect individuals with
SMI? the biopsychosocial factors

2.4 Rational for Undertaking the Research

Although several studies have investigated RMNs attitudes and

practice towards addressing sexuality in people with SMI, no review

exists that collects, describes and synthesises the evidence,
therefore this review aims to fill this gap in the literature.
Furthermore, the fact that RMNs are in a unique position of being
able to build up key therapeutic relationships with clients, in order to
address sensitive issues regarding sexuality and this needs to be
exploited. The author believes that a review on the attitudes and
practice of RMNs towards addressing sexuality in people with SMI is
well needed in order to progress the mental health care in this
aspect of holistic care.
CHAPTER 3: METHODS
This chaper will present the methods used to undertake the
systematic literature search. It includes the adopted search
strategy, along with the inclusion and exclusion criterea and an
outline of how the papers will be critically appraised and analysed.
3.1 Aims and Objectives
The overall aim of this literature review is to explore RMNs attitued
and practice towards addressing sexuality in individuals with SMI.
The objectives are to:
- Identify and synthesise relevant quantitative and qualitative
literature of an international scope to gain a deeper understanding
of the topic and inform further practice and further research.
- Synthesise the literature on the attitues and practice to explore
whether there is a correlation between RMNs attitudes and what
they do in clinical practice
- Synthesise the literature on the attitudes and practice to explore
whether there is a correlation between RMNs views of what they do
and the consumers experience of what RMNs do.
- Clarify the patterns of RMNs attitudes and practice and the
methods by which they have been studied.

3.2 Definining the Research Question

Definingg a clear research question provides structure and guidance
to the whole review process (Aveyard 2010). Initially a mind-map
was created to indentify the sub-topics the literature offered
regarding sexuality within the broad subject which was, how can
mental health nurses address sexuality in clinical settings? Pope et
al. (2007) recommended this to search for areas where literature has
not previously been reviewed. Based on these findings, the scope of
the review was then refined, and the research question derived. The
author then adapted the elements of a PICO (Population,
Intervention, Comparison, Outcome) framework (Sackette et al.
1997) to fit the specific research question in order to formulate a
searchable question (see Table 3).
Table 3: Components of the PICO search strategy addapted
to fit the research question (Sackett et al. 1997).
Acrony
m
P
I
C
O

Definition
Population, Patient or
Problem
Intervention
Control or Comparison
Outcome

Adapted to Research
Question
Registered Mental Health Nurses
Addressing sexuality
None
Attitudes and practice of RMNs

3.3 Inclusion and Exclusion Criteria

Applying inclusion and exclusion critera ensures a systematic
approach is emplyoed when selecting relevant studies form the
literature search. It enables the researcher to focus the search and
make an informed decision as to whether the literature is relevant to
the research question (Aveyard 2010). Articles were reviewed if
they met the criterea listed in Table 4.
Table 4: Inclusion and exclusion criteria
INCLUSION CRITERIA

EXCLUSION CRITERA

English language

Non-English language

From 1997?-2015?
(Post the ? paper that arguably
brought sexuality firmly into the
mental health agenda).

Primary research that is peer

reviewed
(This is because primary
research provides evidence
written by the original
investigators wheas secondary
sources are an authors
interpretation of the evidence
and may be misinterpreted or
leave out important information
[Nieswiadomy 2008])

Literature reviews, grey

literature, discussion papers and
commentaries
(Obtained only for the
background and discussion)

Papers that report on the

attitudes and/or practices of
qualified mental health nurses

Papers where mental health

nurses data were not reported
independently to other
healthcare professionals

Adult studies (19-65)

Papers that report on nurses

attitudes and practice towards
addressing sexuality in child and
adolescents or in older adult
services with SMI

Qualitative and quantitative

research
(Allowing for a more rounded,

holistic, understanding of the

phenomena under investigation
[Hayes et al. 2013).

3.4 Search Strategy

A well-defined search strategy is crucial for enhancing the rigour of
any literature review (Pope et al.2007).