A scoping review of education and training resources supporting care home staff in facilitating residents’ sexuality, intimacy and relational needs

Abstract Background Having positive intimate, sexual and relational experiences is an important issue for older adults in care settings, yet little is known on the extent to which nursing staff and care workers have received education or training in addressing and meeting these needs among older residents. This scoping review aimed to identify and examine what education and training resources exist to assist nursing staff and care workers to meet their residents’ needs in this area. Methods and analysis Using the Arksey and O’Malley framework, we systematically searched papers and grey literature to identify education interventions and resources that aimed to facilitate care home staff to meet their residents’ sexuality, intimacy and relational needs. Results Eleven studies (one dissertation) and three education resources met the inclusion criteria; most were conducted in the USA and Australia. Across the studies and resources identified, the education content was mixed and the methodology, presentation, design and duration varied widely. The focus of the education interventions and resources was to increase knowledge and improve and/or change attitudes towards the: (i) sexual expression of older people living in residential aged care, (ii) sexuality and ageing and (iii) expression of sexuality in people with dementia. Conclusion Few education interventions and training resources were identified. The findings suggest that education interventions can improve knowledge and/or change care staff attitudes, in the short-term, towards older people’s sexuality, intimacy and relational needs in care home settings, which can lead to facilitating staff to enhance person-centred care in this area of need.


Introduction
Having positive intimate, sexual and relational experiences is an important issue for older adults. Sexuality and intimacy are an inherent and legal right [1] but remain a neglected area in promoting quality of life, well-being and personal identity [2,3]. This is particularly the case for older adults residing in care settings, such as nursing and care homes [4,5]. In the UK, over 400,000 older people reside in care homes [6]. Studies suggest that sexuality, intimacy and relationship needs still matter to many older adults in care settings [7] and remain an integral part of normal life for many older individuals. One study, drawing on the experiences of community dwelling older adults, found that 19% of men and 32% of women aged 80+ report having frequent sexual intercourse [8]. Intimate behaviours, such as frequent kissing and fondling, were reported by over half of respondents aged 80+ (men 47% and women 62%) [8], suggesting that sexual expression remains important in older age.
Such needs persist even when cognitive and physical decline advances to a stage where residential and nursing care is needed [9,10]. When an older person moves into residential care, private lives are made more public with family members, staff and clinicians becoming increasingly involved in meeting care needs. This is particularly evident in those who have a diagnosis of dementia. The care environment is then perceived as a hindrance to managing intimate relationships. Staff report uncertainty in how to manage the many agendas at play from residents, family and staff, calling for more debate, discussion and training to question the views that residents are asexual and challenge the risk averse positionality in care provision [11]. Surveys suggest that intimate behaviours range from touching and kissing to masturbation and intercourse, which continue to remain important to long-term care residents [12]. However, stigma and stereotypical perceptions of sex and ageing persist [13]. One study sought the views of relatives and care workers of new relationships between residents with dementia whilst still married to another person. None of the care workers in this study referred to sources of advice or information [13], suggesting that staff were not aware of existing training resources in sexuality and intimacy or where to seek guidance. There remains a gap in knowledge in addressing and meeting the sexuality, intimacy and relational needs of older adults residing in residential care settings [14,15].
Research highlights concerns about the ability of nursing staff in residential care settings to provide appropriate provision in this area of need and calls for a holistic approach and to move away from the biomedical and its emphasis on sexual function [15]. Additionally, there is limited research reporting on the extent to which nursing staff have received education or training in this area [4], although a review of knowledge and attitudes of healthcare professionals towards the sexuality of older people highlighted a general lack of knowledge and confidence in the area [16]. This is important as increased knowledge and awareness about the needs of care home residents in relation to sexuality, intimacy and relational needs has been shown to promote more positive and permissive nursing staff attitudes towards this area of person-centred care [17,18].
Evidence suggests that the care home workforce are diverse, with differing educational levels, unclear career paths and varied experience in clinical settings [19]. This makes the development of effective education and training programmes challenging. In a review of dementia training literature relevance to practice, interactive group work with an emphasis on active learning with clear, easy to follow guidance were factors for effective training, which influenced practice [19]. This approach may be more problematic in sexuality, intimacy and relational training as there are 'no right answers', but consideration should be given on a case-by-case basis.
A cross-sectional postal survey of Australian residential aged care facilities found that only 45.6% of respondents reported that staff in their facility had attended training regarding later life sexuality and sexual health within the past 2 years, whilst 40.7% indicated that their staff had never received training in this area [4]. Most of the education and training was delivered by external educators (70.9%), with commonly covered topic areas including attitudes towards aged sexuality (70.0%), sexuality and normal ageing (69.9%), sexuality and dementia (68.7%), definition of sexuality (52.2%), disruptive sexual behaviour (46.3%), consent and legal issues (39.8%), sexual health (17.5%), guidelines/policy (16.3%), assessment (12.0%), sexuality and illness (10.8%) and pharmacological treatments (78%). The most cited 'other' subject area was sexual preference, specifically lesbian, gay, bisexual, transgender, intersex (LGBTI+) sexualities. We recognise that throughout this paper different abbreviations are used to represent the LGBTI+ community. This reflects the abbreviation used within the articles identified in the scoping review. More contemporary abbreviations reflect the broader LBGTI+ community, which is the authors' preference, hence the variation in abbreviations.
Given the need for increased education and training to help staff to support care home residents' sexuality, intimacy and relational needs, the purpose of this scoping review was to identify and examine what education and training programmes and resources (materials used for teaching a course) exist to facilitate care home staff to meet their residents' sexuality, intimacy and relational needs.

Methods
The scoping review follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews (PRISMA-ScR) [20], employing the Arksey and O'Malley methodological framework for scoping reviews [21]. The sequential stages of this framework are to (i) identify the research question, (ii) identify the relevant literature, (iii) select the literature, (iv) chart the data and (v) collate, summarise and report results [22].

Identifying the research question(s)
This scoping review was guided by the following questions: • What existing education and training programmes and resources are there to facilitate care home staff in their support of older care home residents' sexuality, intimacy and relational needs? • What is the nature, extent and range of existing education and training programmes and resources to support care home staff to meet residents' sexuality, intimacy and relational needs? • What are the gaps in the evidence base?

Search strategy
Searches were undertaken using five electronic databases: CINAHL, Embase, ERIC Medline, Scopus and ISI Web of Science, to capture a comprehensive sample of literature, for records published from 1980 to 30 March 2020 in the English language. This extended time period was chosen to identify relevant early education interventions.
To ensure that all relevant information was captured, the grey literature was searched using google (two engines), three health and social care websites (National Institute of Clinical Excellence, Social Care Institute for Excellence and Public Health England), websites of relevant organisations (charities and organisations with an interest in aged care) and the grey literature databases (e.g. OpenGrey). Reference lists of included papers were also searched.

Search terms
Search terms were developed under the headings 'homes for aged', 'Sexuality', 'Nursing' and 'Aged' to ensure that all studies meeting the inclusion criteria were captured. Truncation ( * ) was employed where variations of a search term existed. A copy of the search terms used and modifications necessary across databases is available from the corresponding author upon request.

Selecting the literature
Included sources from the published research were qualitative and quantitative studies that describe or evaluate any resource designed to help/train/educate care home staff to support/manage the expression of sexual or intimate behaviours; written in English and published from 1980. Included sources from the grey literature were theses/dissertations, reports and other sources that identified education and training programmes and/or resources to assist care home staff in their support of older care home residents' sexual or intimacy needs. Excluded sources (from both the published research and grey literature) were those that (i) reported cases of sexual abuse in care homes and (ii) other systematic/scoping reviews.

Charting the data
A data extraction sheet was developed to tabulate data related to study origin, study design, population characteristics, description of educational intervention/resource, outcomes measured and study results. This was undertaken by two authors (M.H. and J.Y.). Quality of study design was assessed using a validated checklist for evaluating studies of diverse designs [23]. Study eligibility was confirmed by two authors (M.H. and J.Y.). There were few initial disagreements related to inclusion or exclusion of the sources; decisions on inclusion/exclusion were achieved through consensus and did not require mitigation by a third author. Each paper was judged against 14-points on the checklist, where a single method was used, and 16-points on the checklist, where multiple methods were used. A percentage score was calculated as a measure of quality; a score of less than 50% was considered poor quality; a score between 50 and 70% was considered to be moderate quality and a score of greater than 70% was considered high quality. Results were synthesised narratively.

Collating, summarising and reporting the literature
For study and training resources, a summary of the structural elements of the intervention as well as the content of the educational resource/training, outcome measures/learning outcomes and main findings were summarised and reported.
Education intervention studies and resources were analysed for type of delivery, aims/learning outcomes of the educational content, outcomes measures, target audience (who it was aimed at), target population, study designs and broad findings (Tables 1 and 2). The study quality of the education interventions was poor to good (Table 1).

Attitude and Knowledge:
(i) sexual attitude survey (ii) individualised interview 5 months post-training Only qualitative statements.
• Need for education to ensure staff are reflective of own biases and misconceptions.
• Training enabled staff to consider ageing and dementia and their attitudes towards older age sexuality.
• The training program on sexuality was quite effective in eliciting interest and participation.
• Methods used to enable staff to discuss the topic openly were well generally accepted. • To equip care staff with a well-rounded understanding of the sensitive issues concerning intimacy, sexuality and the rights of persons with dementia, as well as, how to respond to expressions of sexuality in a manner that promotes both resident dignity and safety.

Continued
• DVDs explore issues of intimacy and sexuality on quality of life, freedom to express sexuality, capacity to consent, resident protections and potential legal ramifications.
• Touches on the needs of lesbian, gay, bisexual, transgender (LGBT) residents, how to address resident-to-resident and resident-to-visitor encounters, and how to find workable solutions with the support of family members.

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M. Horne et al. one in South Africa [28]. Of the three education resources identified through the grey literature/Google search, one pay for workshop was developed and available to purchase in the UK [35]; one free online resource was developed in Australia [36] and one-pay-for-view DVD resource and facilitators guide was developed in Israel [37].

Content coverage
The education content was mixed across education interventions and resources; Tables 3 and 4 summarise the content.
Defining sexuality/sexual behaviour/facts about sex and ageing was a common theme across all the education interventions and resources. Six of the 11 education interventions [25,26,[29][30][31][32] focused on sex and sexuality as opposed to intimacy and relational needs; all the education resources [35][36][37] focussed on sexuality, intimacy and relational needs (Table 4). Dementia and challenging perceptions around sex and intimate relationships of people affected by dementia, featured often in the education interventions [25-28, 31, 33] and resources [35,37]. Most of the education interventions focused on facts around the physiological aspects of sexuality and ageing (Table 3). Two education interventions included nonheterosexuality-related stereotypes [24,25], whilst one education resource touched on the specific needs of LGBTI residents [37], one education intervention included legal issues [25], cultural difference was only addressed in one education intervention [26] and family and personal issues was only mentioned in one education intervention [33].
Three education interventions [25,29,31] and two education resources [36,37] explicitly framed sexuality as a rights-based and legal issue, whilst two education interventions [27,31] and one education resource [36] specifically identified ethical issues in this area. Family and personal issues were only mentioned in one education intervention [33].
Communication was addressed in three of the education interventions [24,26,29] and two education resources [35,37]. Only two education interventions looked at what organisations could do more broadly to support sexual expression [27,31]. Specific sex acts were addressed in three education interventions [24,28,30].

Methodology, presentation and design
Ten of the eleven education interventions [24,25,26,[28][29][30][31][32][33][34] and one pay for education resource [35] used active learning strategies, delivered in a workshop format. Each workshop used a range of methodologies such as presentations, vignettes, facilitated discussions, watching of video/film clips with facilitated group discussions, to explore ideas and develop knowledge. The use of written hand-outs helped to facilitate a better understanding of older people's sexuality. One education intervention [27] and one education resource were delivered via an eLearning platform [36]; a final resource was a pay-for-view DVD set and a facilitator's guide with key lesson points and discussion questions related to sexual expression, sexuality, intimacy and dementia [37].
None of the education interventions or resources explicitly articulated the use of educational theory to guide the design of the courses/resources.

Duration
The education interventions and resources identified were quite varied in their duration of delivery taking the form of a 1-h PowerPoint training program [30]; a 62-min videoguided, facilitated discussion workshop [27]; a one off 3-h workshop [25,29]; a ×14-h workshop over 2 days [24]; a two, one-half day (1 week apart) education session [32]; a 1day, 6-h session [34]; a four 60-min programme topics over a 3-week period [33]; an up to 4-week completion of a selfdirected, eLearning educational resource [27]; a 7-week faceto-face programme, meeting for 2 h/week, each week for a total of 14 h [26] and the duration was not specified in one educational intervention (Table 1) [31].

Aims of education interventions and resources
The focus of the education interventions were to increase knowledge and improve and/or change attitudes towards the (i) sexual expression of older people living in residential aged care [25,26,31,33]; (ii) sexuality of older people/sexuality and ageing [30,32,34]; (iii) expression of sexuality by people with dementia/differing stages of dementia residing in care settings for older adults [27,28] and (iv) need for consideration of sexuality in geriatric programmes [24,29].
The overall aim of the education interventions and resources was centred on what care staff could do to support older adults in their care in this area of need and little about organisational attitude towards supporting the needs of older adults except for one education resource [35].

Staff attitudes, knowledge and understanding
Eight of the 11 education intervention studies used standardised psychometric measures to assess participant attitudes, knowledge and understanding pre-and post-educational intervention: (i) Ageing Sexuality Knowledge and Attitudes Scale [25,27,32,34]; (ii) Staff Attitudes about Intimacy and Dementia Survey [25,27]; (iii) the Ageing and Sexuality Knowledge and Attitude Scale for Dementia [28]; (iv) the Knowledge and Attitudes Toward Elderly Sexuality, developed by the team in previous research [33]; (v) the attitudes towards sexuality in the aged: community aged tool developed by White (1978) [26] and (vi) Sex, Knowledge and Attitude test [24].
One education intervention did not assess staff attitude via a recognised scale but through workshop discussions and a post-training interview [29]. One further study assessed participant attitude via non-validated, researcher-developed questionnaires [30]. One education intervention did not assess staff attitudes as part of their study [32].
Six education interventions reported statistically significant difference in scores towards more permissive attitudes regarding sexuality following the educational interventions [25-28, 30, 34] and one reported more positive changes in attitude towards sexual behaviour of older adults [29].
One education intervention assessed knowledge through a researcher-developed questionnaire [30]. A further study did not assess knowledge via a recognised scale, but through workshop discussions and a post-training interview [29]. Staff knowledge and understanding was not assessed in two education interventions: (i) the focus of the intervention was on permissiveness of staff attitudes towards sexuality of older adults with and without dementia [25] and (ii) staff knowledge and understanding were not assessed as part of the study [31]. 767 Table 3. Summary of education interventions taught content X Addressing resident-to-resident and resident-to-visitor encounters X Sexuality and residents' rights and supporting the rights of older people X Legal issues related to sexuality X Knowledge translation of sexualities and dementia into care practices/settings X How policy can influence practice in supporting the rights of older people X Seven education interventions reported a change in knowledge relating to older people's sexuality following the education intervention [24, 25-28, 32, 34].

Discussion
To the best of our knowledge, this scoping review is the first to identify what education and training resources are available to care home staff to assist them in meeting their residents' needs in this area. This is important given that there remains a gap in knowledge in addressing and meeting the sexuality, intimacy and relational needs of older adults residing in residential care settings [14,15].
The scoping review has identified a number of education interventions and resources aimed at improving awareness, knowledge and understanding about the sexuality and/or intimacy needs of older care home residents and to facilitate care staff to support older care home residents' sex and sexuality needs, but few focussed on intimacy and relational needs or explicitly framed sexuality as a rights-based issue for older adults. Evidence suggests that intimacy is important for relational behaviour in care home settings to reduce loneliness and isolation [38] and therefore is an important consideration when delivering rights based, person-centred care.
The nature, extent and range of existing education interventions and resources to support care home staff to meet residents' sexuality, intimacy and relational needs were varied in their content and delivery; dementia focussed in the main, but very few interventions and resources considered the specific needs of the LGBTQI+ residents. This is an important area of consideration for residential care homes around inclusivity and acknowledging the specific needs of this group of older adults. It should be noted that the scoping review contained papers from the USA, Australia, South Africa, the UK and Israel. The differing organisational cultures of residential care in these locations may have implications for education and training.
This scoping review has also identified that educational interventions have the potential to change care home staff attitudes towards older people's sexuality and intimacy needs in a more permissive direction, supporting previous research in the area that suggested an increase in knowledge about sexuality was linked with more permissive and open attitudes towards sexual expression in older people [39].
Most of the education interventions and resources appear to move beyond simple provision of information and guidance with active learning focussing on developing "common sense" approaches and taking the resident's perspective. Definitions of common sense vary across theoretical frameworks [40]. Common sense implies a shared set of values and beliefs, which guide decisions and practice [41]. However, sexuality and intimacy for older residents is subject to beliefs of ageist erotophobia, which necessitates the need to tackle biases of ageism, heteronormativity and asexuality in ageing [15], thus calling into question the validity of a "commonsense" approach.
Few education interventions and resources specifically looked at communication around how to manage sexuality, intimacy and relational needs with residents, partners and family. Previous reviews have identified that this is an area where care home staff identify that they need further guidance [42]. In addition, what organisations could do more broadly to support sexual expression, intimacy and relational needs was lacking. A supportive culture in the organisation has been identified as an important facilitator to improving care staff attitudes towards resident sexuality [43].
The influence of culture and ethnicity on sexuality [44] was explored in only one education intervention [26]. The impact of organisational culture on the attitudes of residential care staff towards the sexuality and intimacy of care home residents [43] was not explored in any of the education interventions and resources identified.
This scoping review identified and described the nature, extent and state of education and training resources undertaken to assist care home staff in managing older care home residents' sexuality, intimacy and relational needs. This scoping review did not include an optional final step involving key stakeholder consultation, practitioners and policy makers [21]; this may have provided some additional insight into education and training resources. Although a rigorous approach to conducting the scoping review of the peerreviewed and grey literature was undertaken using a recognised framework, it is possible that not all relevant records were identified in this area.

Conclusions
Few education interventions and training resources were identified in this review. The education interventions did show potential in improving knowledge and/or changing nursing staff attitudes, in the short-term, towards older people's sexuality, intimacy and relational needs in care home settings. All the papers identified in the scoping review highlight the importance of training in sexuality and intimacy. This can lead to facilitating staff to enhance person-centred care in this area of need for older adults living with and without dementia. However, the overall quality of five of these interventions was poor; therefore, the findings need to be interpreted with caution.
Future research is needed using prospective longitudinal approaches to assess the medium-to long-term changes in attitudes, awareness and knowledge of care home staff and the impact of changes in attitude and knowledge on care delivery and resident outcomes. In addition, further development of education and training resources that appeal to a diverse workforce and are situated in practice are needed.