“I DO NOT FEEL CONFIDENT AND UNCOMFORTABLE DISCUSSING PATIENTS’ SEXUALITY CONCERNS”: A THEMATIC ANALYSIS OF INDONESIAN NURSES’ EXPERIENCES IN DISCUSSING SEXUALITY WITH PATIENTS

Despite the increasing complexity of the tasks and responsibilities in providing nursing care to patients, many Indonesian nurses may not possess adequate knowledge and skills to discuss sexuality with their patients. The purpose of this study is to explore the experience of Indonesian nurses in providing nursing care to patients regarding sexual problems. This research adopted a descriptive qualitative design to explore the experiences of Indonesian nurses in solving their patient’s sexual problems. Ten nurses working in a general hospital in Indonesia participated in this work. These nurses were interviewed extensively, and the data were transcribed and analyzed thematically. Four main themes were identified in this study: (1) Nurses believe that discussing a patient's sexual problems as part of their professional responsibility, (2) discomfort and embarrassments are barriers to providing adequate solutions to help resolve a patient's sexual problems, (3) nurses assume that most patients are not interested in discussing sexual problems because of illness, and (4) nurses do not have the confidence to discuss the patient's sexual problems. The findings of this study confirm that many nurses feel hesitant and uncomfortable when addressing patients' sexual problems. Thus, Indonesian nurses require more training related to providing nursing care to patients with sexual problems.


Introduction
Sexuality is a basic human need. Sexual health is defined as a state of physical, mental, and social well-being concerning sexuality. It requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination, and violence (WHO, 2013). Promoting sexual health may improve the quality of life and wellbeing of an individual and their family (Khosla, Say, & Temmerman, 2015). Sexuality is a complex issue that nurses should consider among their concerns (Hendry, Snowden, & Brown, 2018). Nurses should promote sexual health as a basic aspect of holistic nursing care (Evans, 2013). Holistic nursing is defined as "developing a relationship with patients in which the nurse honors and promotes consideration of the wholeness of persons, authentic presence, and facilitation of healing while incorporating the physical, emotional, spiritual, social and psychological aspects of the patient's existence in supporting, guiding, and assisting patients in gaining self-knowledge and in co-creating a plan of care" (Kinchen, 2015). Holistic nursing care is provided when nurses acknowledge the significance and meaning of sexuality to their patients.
Despite the emerging significance of fulfilling the sexual needs of patients, incorporating sexual health assessment and intervention in basic clinical health services remains a challenging issue. Assessments and interventions to overcome sexual problems are not often implemented by professional healthcare providers, including nurses, in spite of the increasing frequency of patients reporting sexual issues or dysfunction (Hendry et al., 2018).
There is an unmet need for healthcare providers to help patients overcome sexual problems. Professional healthcare providers often assume that sexual issues are unimportant or taboo; thus, they do not discuss such issues with their patients. Other care providers are unable to per-form assessments and interventions for sexual problems because of limited knowledge on the matter. Social constraints and internalized values also present barriers to seeking and providing care for sexual problems in many countries, including Indonesia (Fitch, Beaudoin, & Johnson, 2013;Ferreira, Gozzo, Panobianco, Santos, & Almeida, 2015;Hordern & Street, 2007;Saunamäki, Andersson, & Engström, 2010).
As an Eastern culture, Indonesia adopts many Eastern values, including humility and personal conduct. In Eastern values, sexuality is considered a shameful and sensitive topic that should not be discussed openly; indeed, sexuality is regarded as a private matter between partners (Lieber et al., 2009). Indonesian nurses grow with these values and, hence, adopt the beliefs of their culture in their nursing practice. This situation contributes to the complex experience of nurses practicing in Indonesia. Despite the increasing complexity of their experiences, many Indonesian nurses may not possess adequate knowledge and skills to discuss sexuality with their patients (Afiyanti, 2017). However, patients with sexual problems need help, regardless of their culture (Afiyanti & Milanti, 2013;Afiyanti, Setyowati, Milanti, & Young, 2020). In light of these challenges to the implementation of sexual health nursing assessment and intervention in Indonesia, improving the understanding of current practices and identifying gaps between ideals and reality in the field is of great importance. Hence, the purpose of this study is to explore the experiences of Indonesian nurses in providing sexuality care.

Methods
Design. We applied a qualitative descriptive (QD) approach to capture and understand the experiences of nurses in providing sexuality care. Sandelowski and Barroso (2006) described this approach as one with a naturalist perspective that assumed the data as the truthful index of reality, therefore, producing data-near interpretations. The QD approach has been used extensively in evaluation studies to achieve a clear and detailed narration of actual events concerning participants and refine their experiences. Ten nurses were recruited from a general hospital in Indonesia. Data were collected through in-depth interviews for around 60-90 minutes during which the field notes were also made, which were audio-recorded after the participants provided consent.
Data Analysis. This study employed the thematic analysis technique (Braun & Clarke, 2006). We reviewed all recorded interviews to ensure the accuracy of their transcripts. During data analysis, the researchers attempted to bracket their personal interpretations of the experiences of nurses in addressing the sexual concerns of their patients. Each narrative in the transcribed interviews was carefully and systematically examined for emerging themes through data coding. Data were transcribed verbatim in Bahasa Indonesia after each interview. The transcribed text of the interviews was read and reread to capture patterns of meaning and reveal the experience of nurses participating in this study.
Ethical Considerations. Ethical clearance was provided by the Ethical Committee of the Faculty of Nursing, Universitas Indonesia. We adhered to all required ethical principles, including the right to self-determination, anonymity, and confidentiality, and protection from discomfort and harm. Information sheets were provided, and nurses completed written consent forms prior to the interviews. Voluntary participation in the interviews was emphasized. The nurses were reminded that they could withdraw from the study at any time they chose. It contained a thorough explanation of the objectives and procedures of this qualitative study, including the risks and benefits of participation. Transcripts were made anonymous through coding.

Rigor.
In enhancing the trustworthiness of the findings, a number of means of credibility were established. The credibility of this study is established by prolonged engagement with the participants and member checking. Furthermore, the participants are considered as experts in ac-curately describing and interpreting their data (Leech & Onwuegbuzie, 2007), so they were asked to verify the accuracy of the findings to enhance data credibility, confirmation, and member-checking of the established themes.

Results
Participant Background. Using a purposive sampling method, we invited the ten participants. They are nurses from General Hospital in North Jakarta. The inclusion criteria were: married and ranged in age from 25 years to 45 years with a mean age of 40 years. The educational background of the participants showed some variation. Five participants graduated with a nursing diploma, while five graduated with a bachelor's degree in nursing. The number of years of service of the participants was between 3 and 20 years. The participants worked in different hospital units, namely, the surgical inpatient, neurology inpatient, obstetric and neonatal emergency, hemodialysis, and internal medicine units.
Four themes describing the participants' experiences of sexual assessment and intervention were elicited: (1) Nurses believe that sexuality care is part of their professional responsibility, (2) discomfort and embarrassment are barriers to providing adequate solutions to patient's sexual problems, (3) nurses assume that most patients lack interest in sexuality-related areas because of illness, and (4) nurses are not confident discussing patients' sexuality concerns.
Nurses Believe that Sexuality Care is Part of Their Professional Responsibility. All participants stated that providing sexual care is part of a nurse's responsibilities. All nurses believed that they could not be considered professional nurses if they are unable to resolve their patients' sexual problems despite not knowing if they could correctly assess these problems to begin. One participant (P2) said: "… providing nursing care to overcome the sexual problem is my professional responsibility as a nurse mmm (laugh). ..."

Discomfort and Embarrassment are Barriers to Providing Adequate Solutions to Patient's Sexual Problems.
Without exception, all participants shared their discomfort and feelings of embarrassment when conducting assessment and intervention to address their patients' sexual problems. The nurses felt uncomfortable when talking about sex because they were not accustomed to talking about reproductive organs. They expressed discomfort when exposing sexual problems and feared they would be considered rude. Below are the thoughts of two nurses: "… there is just discomfort ... when I said vagina mmm or that (small laugh) mentioning male genitalia mmm afraid to be viewed as rude by the patient ..." (P10) "… since small, I was prohibited from mentioning genital mmm taboo from the parents, eh so sometimes uncomfortable when talking about the sexual problem of patient mmm because having to mention that …" (P8) Nurses Assume that Most Patients Lack of Interest in Sexuality-Related Areas Because of Illness. Without exception, the participants believed that their patients do not think about their sexual problems because they are more focused on their illness and symptoms. Three nurses working in the cancer unit opined that many of their patients are frequently breathless and powerless; as such, these patients are unlikely to be thinking of their sexual needs. Below is an experience expressed by a participant (P5): "… cancer patients in my unit mmm many are already not active, mmm instead many are out of breath... would they still think about sexual relations... I don't think so mmm they are more focused on their physical complaints …" Nurses are Not Confident Discussing Patients' Sexuality Concerns. Besides feeling discomfort and fearing taboos when discussing their patients' sexual problems, most participants expressed a lack of confidence. They stated that sexual topics were not taught over the course of their education. Thus, they do not feel confident discussing sexual problems with their patient, even when they are certain that the patient has such a problem. A nurse (P6) working in the postpartum ward revealed:

Discussion
The description of discussion of the sexuality concern by the Indonesian nurses in General Hospital in Jakarta extends our understanding of the experiences of Indonesian nurses in providing sexual care. Four themes were identified in this study. First, all participants in this study were aware that providing care for a patient's sexual problems as part of their professional responsibility as a nurse. This finding shows that sexuality is gradually being acknowledged as an essential part of the provision of care for patients and a fundamental need that must be met. Participants indicated a positive attitude toward discussing sexual problems even when they doubted their competence in meeting patients' needs. Studies exploring the attitudes and beliefs of nurses in Indonesia and Turkey showed similar findings (Afiyanti, 2017;Oskay, Can, & Basgol, 2014). For example, Turkey's study reported that 87.4% of the participants considered discussing a patient's sexual health as part of the nursing profession, and 88.5% of the participants expressed through of patients' sexual health in practice The contradiction between their sense of responsibility and non-action toward discussing sexual problems is an issue faced by nurses in many settings (Fitch et al., 2013;Oskay et al., 2014;Zeng, Li, Wang, Ching, & Loke, 2011). Nurses are beginning to understand the sexual aspect of their patient's conditions, and this awareness could pave the way for efforts to include sexual problem assessment and intervention in primary healthcare practices and make these services available in general healthcare facilities. These findings highlight the urgency of bridging the gap between ideal and actual nursing practices.
The related theme, "Discomfort and embarrassment are barriers to providing adequate solutions to patient's sexual problems," was used to explain the challenges of the nurses participating in this study. The participants expressed difficulties in helping patients solve their sexual problems because they felt uncomfortable and embarrassed discussing them. Several studies on nurses in various settings revealed similar results (Dyer, & das Nair, 2013;2013;Fitch et al., 2013;Saunamäki et al., 2010). The participants in this study admitted that discomfort and feelings of embarrassment were the main factors preventing them from conducting sexual problem assessment and intervention.
The discomfort and embarrassment felt by nurses could be caused by various factors. Recent research revealed that values; social, cultural, and religious influences; and a lack of knowledge, coaching, and experience could contribute to the discomfort of nurses in discussing sexual problems with their patients (Bdair & ConsTantino, 2017;Ferreira et al., & Almeida, 2015;Abimbola & Margaret, 2018).
A study by Bdair and ConsTantino in 2017 showed that the internalized values of nurses influence the way they view sexual problems. Nurses believing in a set of values that consider sexual problems as taboo are likely to be averse to discussions on sexual issues. The dissonance between accepted values and the obligations of a nurse's duty could result in an internal dilemma and give birth to feelings of discomfort. A study in 2013 (Saunamäki et al., 2013) obser-ved that values and beliefs influence nurses' views on sexuality.
Besides, values, social, cultural, and religious factors contribute to barriers preventing nurses from conducting assessment and nursing interventions for sexual problems. Certain cultures and religions identify sexuality as a sensitive topic (Bdair & ConsTantino, 2017;Zeng et al., 2011). Consequently, some nurses with a particular cultural or religious background are likely to feel uncomfortable and embarrassed when discussing sexual problems. The Indonesian social construct, in combination with the Malay and Islamic cultures, considers sexuality a sensitive topic inappropriate for open discussion (Jong, 2016;Muñoz & Qureshi, 2017). In this study also reported that nurses in Indonesia might feel embarrassed and uncomfortable when talking about sexual problems with patients because their beliefs limit their perceptions of sexuality.
A lack of knowledge, coaching, and experience in addressing sexual health problems contributes to the discomfort felt by nurses performing assessment and intervention for sexual problems (Zeng et al., 2011). This issue is particularly evident among interning nursing students, young nurses, and nurses working in units or clinics that do not specialize in resolving sexual health problems.
Besides feelings of discomfort and embarrassment, this study found that nurses often assume that clients do not feel sexual interest as a consequence of illness. A study in China involving nurses in oncology units showed that nearly two-thirds of the participants assume that their patients lack sexual interest because of their illness (Zeng et al., 2011). This assumption is harmful and directly contradicts the expectation of patients. Patients with illness still possess sexual interest and need the help of healthcare professionals, including nurses, to solve their problems (Fitch et al., 2013;Zeng et al., 2011). Because of their belief, the participants of this study described how they often form the opi-nion that patients with serious illnesses would not think about sexual problems and focus instead on the illness at hand when they are admitted to the hospital.
Sexuality is a basic human need and contributes to the quality of life and well-being of an individual (Khosla et al., 2015;Tucker, Saunders, Bulsara, & Tan, 2016). Regardless of an individual's state of health, their sexual needs are still present and must be fulfilled. Sexual health needs are not limited to penetrative sex and may include problems related to intimacy, emotional closeness, and other sexual activities. Patients expect to be able to fulfill their sexual health needs even when changes in their sexual interest or reproductive organs occur. Thus, nurses, as health professionals with the most contact with patients, must understand these needs and find ways to help their patients express and solve their problems. Moreover, nurses must work together with their patients to find solutions or alternative actions to address the latter's sexual problems.
The fourth theme identified in this study reveals that nurses do not feel confident when discussing patients' sexual problems. Participants openly admitted that they were uncertain about discussing sexual issues with their patients because their theoretical knowledge is lacking; thus, they feel that they will be unable to help their patients effectively. Earlier studies reported similar findings and indicated that nurses feel a lack of confidence in helping their patients address sexual health problems (Arikan, Meydanlioglu, Ozcan, & Canli Ozer, 2014).
The lack of confidence felt by nurses is directly related to their level of knowledge, experience, and competence. A lack of knowledge of the pathophysiology of an illness negatively contributes to the self-confidence of nurses trying to help patients meet their needs. The age gap between nurses and patients could generate a difference in values that may influence the former's confidence. The participants of this study were aged between 25 and 45 years. Younger nurses generally have shorter clinical experiences than older nurses; hence, when faced with older patients, the former are likely to feel that their experience is lacking and may lose confidence in their ability to provide solutions to problems.
These combined factors raise concerns among nurses. The worry of being unable to answer patients' questions or provide solutions to their problems, feeling that sexuality is an unfamiliar topic, and lack of experience in performing nursing care for sexual problems, whether directly or in a coaching setting, can generate feelings of incompetence when nurses care for patients with sexual problems. The findings also indicate how Indonesian social culture influences the nurse's experiences.
This study has limitations: The first includes, in general, sexual care remains an uncommon practice for Indonesian nurses, especially those who have the educational level of at least diploma of nursing. The participants of this study might be unfamiliar and failed to express their feelings freely when discussing their experiences and preferences related to sexual concerns. Furthermore, discussion on sexuality issues is taboo and sensitive and tend to be ignored in Eastern culture, including for Indonesian nurses. The second is the small sample size, which may cause the study to be limited to a certain population, that is, in nurses who attending the sexual training at the hospital and also have a similar demographical background, which may not represent the general population that limits the transferability of the findings.

Conclusions
This study highlights Indonesian nurses' experiences in providing sexual care to their patients. The participants strongly emphasized their responsibility for delivering sexual care despite the presence of barriers. The findings of this study confirm that most nurses feel hesitant and uncomfortable when addressing patients' sexuality concerns. Although they are professional healthcare providers, nurses are often embar-rassed to talk about sexual issues with their patients. Unfortunately, the sexual problems of a patient cannot be identified if this situation persists. Thus, Indonesian nurses require more training related to sexuality care, so they have more confidence, having knowledge, and skills to be able to provide sexual assessment and intervention, but the sociocultural and religious elements should be considered in the training of sexual care. Future studies to evaluate the effectiveness of the strategies and training of sexual care for nurses to enhance good nursing practices would be important.