494802 research-article2013 JAH25710.1177/0898264313494802Journal of Aging and Health X(X)Di Napoli et al. Article Staff Knowledge and Perceptions of Sexuality and Dementia of Older Adults in Nursing Homes Journal of Aging and Health 25(7) 1087­–1105 © The Author(s) 2013 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0898264313494802 jah.sagepub.com Elizabeth A. Di Napoli, MA1,2, Gloria Lauren Breland, BA1,2, and Rebecca S. Allen, PhD1,2 Abstract Objectives: Adults hold negative attitudes toward sexual expression in late life. We investigated knowledge and attitudes about older adult sexuality and dementia among staff in nursing homes (NHs). Method: We acquired staff demographics, knowledge of dementia and sexuality, and attitudes of sexuality. Staff participated in focus groups and received continuing education credit. Results: The three NHs had an average census of 178 beds. Participants’ (N = 100) mean age was 38.53. The most common type of sexual contact reported was nondemented male with nondemented female (67.5%), followed by demented male with demented female (53.6%). Participants endorsed neutral attitudes about late-life sexuality. Focus groups revealed a need for more training and effective interventions to balance resident safety and autonomy. Discussion: Staffs’ knowledge of sexuality and dementia, desire for guidance in “managing” sexual expression, and neutral attitudes toward late-life sexuality supports the need for educational interventions on sexuality and dementia in NH. Keywords sexuality, religion and spirituality, dementia, nursing home care, attitudes toward aging 1Department 2Center of Psychology, The University of Alabama, Tuscaloosa, AL, USA for Mental Health and Aging, The University of Alabama, Tuscaloosa, AL, USA Corresponding Author: Elizabeth A. Di Napoli, MA, Department of Psychology, The University of Alabama, Box 870348, Tuscaloosa, AL 35487-0348, USA. Email: eadinapoli@crimson.ua.edu 1088 Journal of Aging and Health 25(7) Recent literature has spurred an awareness of sexuality in late life (Ginsberg, Pomerantz, & Kramer-Feeley, 2005), yet the assumption that older adults are sexually undesirable, incapable of sex, or asexual remains widespread (Benbow & Jagus, 2002; Bouman, Arcelus, & Benbow, 2006). For example, older adults are often stigmatized as being highly inhibited or sexually inactive (Hodson & Skeen, 1994). Attitudes and perceptions about late-life sexuality tend to become even more complicated by the presence of cognitive impairments or dementia (Allen, Petro, & Phillips, 2009). Unfortunately, caretakers of individuals with dementia, such as nursing home (NH) staff, often endorse negative attitudes (e.g., embarrassment, confusion, and helplessness) about late-life sexuality (Ehrenfeld, Bronner, Tabak, Alpert, & Bergman, 1999; Gilmer, Meyer, Davidson, & Koziol-McLain, 2010). In turn, these negative attitudes directly impact the expression of sexuality and quality of care provided to older adults (Tabak & Shemesh-Kigli, 2006). This problem is expected to increase substantially because the older adult segment of the U.S. population is the fastest growing demographic (U.S. Census Bureau, 2009) and therefore, a greater number of older adults will be living in settings with direct-care staff. Consequently, there is a need to elucidate factors that contribute to negative stereotypes of late-life sexuality in order to protect the autonomy of this increasing population. This project aimed to investigate staff knowledge and attitudes about older adult sexuality and dementia in NHs. Notably, the presence of a dementia diagnosis does not preclude sexual consent capacity (American Bar Association and American Psychological Association [ABA/APA], 2008; Lyden, 2007). Holmes, Reingold, and Terisi (1997) describe sexually oriented behaviors as “words, gestures, or movements (including reaching, pursuing, or touching) which appear motivated by the desire for sexual gratification.” Even though research has found that frequency of sex decreases with age, 16.8% of women and 38.9% of men aged 75 years and older remain sexually active (Lindau et al., 2007; Lindau & Gavrilova, 2010). Among couples in which one partner has Alzheimer’s disease (AD), 70% reported engaging in physically intimate activities (Davies, Sridhar, Newkirk, Beaudreau, & O’Hara, 2012). These percentages support the notion that sexuality is an integral part of human life at any age or level of cognitive functioning and expressing it is a natural and healthy contribution to one’s overall quality of life. Furthermore, sexual activity has been found to contribute to the overall health, prolonged longevity, maintenance of healthy interpersonal relationships, connected self-concept, and sense of integrity in older adults (Zanni, Wick, & Walker, 2003). Sexual satisfaction has even been found to be linked to successful aging and quality of life (Thompson, Charo, Vahia, Depp, Allison, & Jeste, 2011). Identifying contributing factors to successful aging is particularly important Di Napoli et al. 1089 because aging is associated with increased prevalence of chronic disease and disability (Hung, Ross, Boockvar, & Siu, 2011). These physical health conditions often interfere with older adults’ ability to complete daily activities, which in turn requires many older adults to seek direct-care assistance from institutional settings, such as NHs. In fact, approximately 1.5 million older adults have been estimated to receive care in NHs (National Center for Health Statistics, 2005). However, sexual behaviors and desires of older adults do not cease upon NH admission. In fact, Bretschneider and McCoy (1988) found that 70% of male and 50% of female NH residents had thoughts about being close or intimate (to the authors’ knowledge, more recent estimates are not available). Furthermore, Hubbard, Tester, and Downs (2003) reported that institutional care residents’ often engage in intimate touch, kissing, sexual talk, flirting, and teasing. A review of literature spanning from 1996 to 2009 found that there is a dearth of research on the factors influencing sexual expression in care homes (Elias & Ryan, 2011). Some NH barriers to older residents expressing their sexuality have been identified, such as myths regarding aging/sexuality, sexual dysfunction, lack of privacy in NH, and loss of a partner (Bauer, McAuliffe, & Nay, 2007; Rheaume & Mitty, 2008). Another obstacle for NH residents’ expressing sexuality begins at the first line of contact; that is with NH staff. For instance, nursing staff generally have limited knowledge of late-life sexuality (Mahieu, Van Elssen, & Gastmans, 2011). Many NH staff view late-life sexuality as a problem that should be prevented or eradicated from the NH system altogether (Hajjar & Kamel, 2003). Ehrenfeld et al. (1999) found that staff members often expressed anger and revulsion when presented with erotic encounters between residents, often voicing hostility toward the individuals engaging in this behavior. Some in-patient care staff ignore the activity because they are uncomfortable with the topic or do not know how to approach the subject with the residents involved (Hayward, Robertson, & Knight, 2013). Due to continuous worker–resident interaction and access to intimate detail, NH staff can have a heavy impact on a resident’s thoughts and behaviors. Therefore, NH staffs’ negative attitudes about sexuality may give older adult residents the message that sexual expression is not an important aspect to successful aging. This zeitgeist of protection can interfere with resident-centered care and the rights and privileges of residents under the law to express their sexuality (Lyden, 2007). Sexuality among NH residents with dementia remains an extremely sensitive topic, particularly because national guidelines do not exist for determining sexual consent capacity among severely demented residents (ABA-APA, 2008; Allen et al., 2009; Livni, 1994; Lyden, 2007). Yet, more individuals with 1090 Journal of Aging and Health 25(7) moderate to severe cognitive impairment are being transferred to staffinvolved settings (e.g., approximately 2/3 of residents in NH; Zimmerman et al., 2005). NH staff can become preoccupied with dementia patients’ ability (or inability) to consent to sexual activity. Ehrenfeld et al. (1999) found that NH staff perceived demented males’ sexual behavior with female residents or staff as sexual harassment. In addition, sexual behavior between two cognitively impaired residents poses a dilemma for NH staff response; specifically, whether to prioritize the autonomous behavior of the individual or the practice ethic of beneficence (e.g., do no harm). This dilemma may result in residents being patronized, staff being inconsiderate, and the couple’s erotic needs being disregarded (Ehrenfeld et al., 1999). Moreover, cognitive impairments and dementia might be accompanied with disinhibition and inappropriate sexual behavior (Alagiakrishnan et al., 2005) that requires staff response. Need for Study NH staff often experience difficulties and confusion regarding sexual behavior between residents, particularly among demented residents. For example, there are often difficulties encountered by NH staff in trying to balance protecting the client from harm, determining the client’s capacity to consent to sexual behaviors, maintaining the patient’s privacy, and promoting autonomy (Parker, 2007). In addition, older adults’ cognition complicates this balancing process for staff, which in turn influences emotional and behavioral responses of staff. Therefore, it is essential to determine factors that are predictors of staff acting in an antidiscriminatory manner. The aim of the current study is to determine the effect of staff demographic variables, sexuality knowledge, and dementia knowledge on staff perceptions and attitudes of late-life sexuality. Awareness of staff biases about the intimacy and sexual needs of older people, particularly those disabled by dementia, is necessary to address these needs in a sensitive and respectful manner. Such results would be helpful in identifying staffing personnel that may be at increased need for educational interventions. With this information, staff training programs that increase staff understanding of sexuality, the ability to assess for mental capacity and consent capacity can be designed to ultimately prevent the influence of staff perception as a limitation to older adult sexual expression. Current Study The present study investigated the relations of NH staff demographics, staff knowledge of sexuality and dementia, and perceptions of sexuality of older adults in NHs. First, the study explores which staff characteristics are Di Napoli et al. 1091 associated with staff knowledge of sexuality and dementia, and with reported prevalence of late-life sexuality. No a priori hypotheses are offered regarding specific relations. Second, the study describes NH staff attitudes toward sexual expression among residents, as well as examines the association between staff characteristics and NH staff attitudes. In addition, researchers wanted to test the hypothesis that staff’s knowledge of dementia and sexuality will be positively associated with attitudes toward late-life sexual behaviors. Third, the researchers hope to describe staff perceptions about decision-making capacity and discuss their current means of managing sexual expression. Lastly, we hope to summarize the enriching qualitative information that was gathered from focus group discussions at each facility. Method Design Overview The current project included three components: (a) a questionnaire acquiring staff demographics, knowledge of AD and sexuality, as well as attitudes of sexuality; (b) the opportunity for staff to receive educational information about late-life sexuality and dementia; and (c) a focus group discussion. During the study, participants were instructed to complete the aforementioned questionnaire. After completing the questionnaire, staff were provided educational materials as a way for them to obtain continuing education credits for their participation. Staff were provided educational information on the following topics: explanation of dementia, dementia versus normal aging, causes/treatments of dementia, sexuality within NHs, how dementia can affect sexuality, challenging sexual behavior, and ethical implications. Lastly, participants engaged in a focus group discussion in which staff were given time to ask questions of research staff trained in long-term care and share experiences. Study Sample Participants were staff members from three specified skilled nursing facilities in Birmingham and Northport, Alabama. Requirements for participation included being an employed staff, with at least minimal daily contact with residents, at one of the three skilled nursing facilities, two of which were owned and operated by the same company. Initial telephone or face-to-face meetings were held with administrators of each facility to explain the project and obtain letters of support and administrative “buy in.” Multiple strategies were used to recruit participants, including poster advertisements and facility-specific sign-up through staff development. NH directors were also 1092 Journal of Aging and Health 25(7) presented with a description of the study and urged to discuss participation with staff. All potential participants reviewed an informed consent document describing the procedures and potential risks (e.g., mild discomfort or tiredness from paperwork). Participants who voluntarily agreed to be in the study completed the protocol described above, which generally took 30 min to 2 hr to complete. Continuing education credits (CEs) were offered as an incentive for staff members to participate, in compliance with each of the NH facilities. An appropriate sample size for this study was based on a power analysis performed using the G*power program (Faul, Erdfelder, Lang, & Buchner, 2007). It was established that approximately 100 NH staff would be needed for the study to reach an overall power level of .85 using an alpha of .05 and an effect size of d = .60. The effect size for this study was determined by averaging the main effect size from prior research (Allen et al., 2009) indicating that among college students, the effect size for sexual consent capacity decisions among hypothetical NH residents described in vignettes ranged between η2 = .08 to η2 = .10. Setting The three skilled nursing facilities utilized in this study had an average census of 178 beds. The American Health Care Association reported that the national turnover rate is 71% for certified nursing assistants (CNAs; Hegeman, 2005); therefore it was important to gather the CNA-to-resident ratios on both the day and evening shift from each skilled nursing facility. We were able to offer our study during at least one evening shift for two of the three facilities. The CNA hours per resident per day average for Facility A was 2 hr and 35 min, 2 hr and 31 min for facility B, and 3 hr and 11 min for Facility C (Nursing Home Compare, n.d.). Measures A 79-item questionnaire (Sexuality in Older Adults Questionnaire) was devised from measures used in prior research to assess staff perception and knowledge of late-life sexuality and dementia. The questionnaire was divided into five sections. First, demographic characteristics included age, sex, race/ ethnicity, months in that facility, educational attainment, marital status, sexual preference, and whether they currently have older relatives engaging in sexual activities (8 items). Next, the questionnaire had items from the following measures: (a) Duke University Religion Index (5 items; DUREL; Koeing, Parkerson, & Meador, 1997); (b) Alzheimer’s Disease Knowledge Scale (12 Di Napoli et al. 1093 items; Werner, 2002); (c) Aging Sexual Knowledge and Attitudes Scales (12 items; White, 1982); (d) Holmes Questionnaire (26 items; Holmes et al., 1997); and (e) a researcher created assessment of staff perception about what is needed for decision-making capacity in older adult residents (8 items). An additional 8 items regarding the percentages of sexual activity in older adults that require staff intervention were not included in the current analyses. Demographic Variables. Demographic variables included age (in years), sex (male = 1, female = 2), race/ethnicity (Caucasian = 1, African American = 2, other = 3), marital status (never married = 1, currently married = 2, partner = 3, separated = 4, divorced = 5, widowed = 6), time in current facility (in months), education (in years), sexual orientation (heterosexual = 1, homosexual = 2, bisexual = 3, refused = 4), and whether staff had relatives living in a NH care facility that are engaging in sexual activities (yes = 1, no = 2, don’t know = 3, refused = 4). Duke University Religion Index (DUREL; Koenig, Parkerson, & Meador, 1997). The DUREL is a 5-item scale designed to measure three aspects of religiousness: organizational (e.g., attending church), nonorganizational (e.g., reading the bible or prayer) and intrinsic (e.g., incorporation into daily life). Organizational and nonorganizational are on a 6-point Likert-type scale (More than once a week = 1, once a week = 2, few times a month = 3, few times a year = 4, once a year or less = 5, never = 6) whereas the three items comprising intrinsic religiosity are on a 5-point Likert-type scale (definitely true for me = 1, tends to be true = 2, unsure = 3, tends not to be true = 4, definitely not true = 5). Lower scores on all three factors indicate greater religiosity on that domain. Koenig et al. (1997) reported a Cronbach’s α of .75, which is similar to that found in this study (œ = .70). The DUREL has high test-retest reliability (intraclass correlation = 0.91) and convergent validity with other measures of religiosity (r’s = 0.71-0.86; Koenig & Büssing, 2010). Alzheimer’s Disease Knowledge Scale (ADKS). Twelve questions featured in a study by Werner (2002) were used to assess dementia knowledge possessed by participants in this study. Closed-ended items were scored Incorrect = 0, Correct = 1, rendering scores ranging from 0 to 12 for each participant, with higher scores reflecting a greater amount of knowledge about dementia. Since the overall Cronbach’s α was low (œ = .48), two items were removed from the total score (i.e., AD is fatal; Most cases of AD are hereditary) to improve internal consistency. When these items were removed the Cronbach’s α was .57, which is similar to the modest (œ = .65) internal consistency found by Werner (2002). Therefore, scores on this measure ranged from 0 to 10. The ADKS has 1094 Journal of Aging and Health 25(7) adequate test-retest reliability (.81, p < .001), as well as predictive, concurrent, and convergent validity (Carpenter, Balsis, Otilingam, Hanson, & Gatz, 2009). Aging Sexual Knowledge and Attitudes Scales (ASKAS; White, 1982). For brevity and to have consistency with the number of administered ADKS questions, our study used 12 of the 35 questions from the knowledge assessment portion of the Aging Sexual Knowledge and Attitudes Scale. This measure assesses an individual’s cognizance of physiological changes that occur in later life (true/false questions). Correct answers were scored as 1, while incorrect answers were valued at 0; the scoring ranges from 0 to 12. Therefore a higher score reflects greater knowledge of aging sexuality. In this study, the Cronbach’s α was .68. Reliability and validity of the scale were previously established (White, 1982). Holmes Questionnaire (Holmes et al., 1998). From the Holmes Questionnaire (26 items), 15 questions were chosen to assess staff attitudes toward various instances of sexual expression in both cognitively intact and impaired residents. The research team added an additional two questions to evaluate staff attitudes regarding sexual expression between same-sex individuals. Responses were based on a 5-point Likert-type scale with response options ranging from –2 “Strongly Disagree” to +2 “Strongly Agree.” Items were reverse coded so that high scores indicated more positive attitudes and beliefs toward sexuality in older adults. Internal consistency as reflected in Cronbach’s α analyses yielded alphas of 0.95 for the 17 questions assessing staff attitudes about sexuality. Another section taken from the Holmes questionnaire assessed prevalence of sexual expression (8 items). Lastly, one question was asked about what was tried as a first means of managing sexual behavior. Data Analysis Data were double-entered and analyzed in a password protected database using SPSS Version 19.0 for Windows. For all analyses, a significance level of p < .05 was used. A defined value (e.g., 998) was chosen to stand for missing values, so SPSS would omit these values from any of the following analyses. Simple bivariate correlations were conducted to explore which staff characteristics were associated with staff knowledge of sexuality and dementia, reported prevalence and attitudes of late-life sexuality. When results revealed multiple significant correlations with a criterion variable, interactions between predictor variables were tested. Interaction variables were Di Napoli et al. 1095 combined into a new variable, and a multiple regression analysis was run using all three variables. A linear regression analysis was used to examine the association of the predictor variables (Alzheimer’s Disease Knowledge and Aging Sexuality Knowledge) with the criterion variable (participants’ attitude of sexuality in late life). Linear regression analyses were repeated controlling for demographic variables (race/ethnicity, total years of education, and time in particular facility). These demographic variables were chosen as potential confounds because they had significant associations with participants’ attitudes of latelife sexuality in descriptive analyses. Hierarchical linear regression analyses were run with chosen covariates entered together on Step 1 and predictor variable (Alzheimer’s Disease Knowledge and Aging Sexuality Knowledge) entered on Step 2. The project and planned analysis was approved by The University of Alabama Institutional Review Board. Results Data were collected from 100 staff members of the three specified locations (42% at A; 49% at C; 9% at B). The participants ranged in age from 20 to 67, with a mean age of 38.53. The sample was primarily female (93%), African American (83.2%), and heterosexual (88%). Marital status varied amongst participants with 40.4% being never married, 32.3% being currently married, and 17.2% being divorced. The average amount of education was 12.86 years (SD = 1.86), with a minimum of 10 years and a maximum of 19 years. Participants’ worked at their respective facility on average for 50.42 months (4.20 years; SD = 69.49 months; .03-276 months). Only 3% of the participants reported that they currently have a relative that is engaging in sexual activities and living in a NH facility. Participants’ scores on the three aspects of religiousness were 4.33 for organizational (1-6), 4.72 for nonorganizational (1-6), and 4.35 for intrinsic (1-5). Staff Characteristics Knowledge of Late-Life Sexuality and Dementia. The participants’ mean score on the dementia knowledge portion of the questionnaire was 6.13 (SD = 2.03) out of 10, with a range of 0 to 10. Similarly, the mean score on sexuality knowledge was 6.03 (SD = 2.78) out of 12, with a range of 1 to 12. There was a positive association between participants’ dementia and sexuality knowledge scores (r = .46, p < .01), indicating greater knowledge of AD was associated with greater knowledge of sexuality. In addition, both dementia (r = .27, p = .01) and sexuality (r = .31, p < .01) knowledge scores 1096 Journal of Aging and Health 25(7) Figure 1. Participant level of intrinsic religiosity (DurIn) by ADKS (Alzheimer’s Disease Knowledge) scores interaction for ASKAS (sexuality knowledge) scores. were positively associated with participants’ years of education. Sexuality knowledge scores were positively associated with nonorganizational religiosity (r = .31, p < .01) and intrinsic religiosity (r = .24, p = .02), showing that less engagement in such activities as prayer and self-reported importance of religion were associated with greater knowledge of sexuality. Furthermore, dementia knowledge scores were positively associated with age of participant (r = .23, p = .03). Lastly, there was a significant intrinsic religiosity by dementia knowledge score interaction for sexuality knowledge (β = –.19, p = .04). More specifically, as participants’ level of intrinsic religiosity decreased, the positive association between dementia knowledge and sexuality knowledge became stronger (low intrinsic religiosity, r = .63; medium intrinsic religiosity, r = .62; high intrinsic religiosity, r = .24; see Figure 1). Di Napoli et al. 1097 Prevalence of Sexual Expression Among Residents. The most common type of sexual contact reported was nondemented male with nondemented female (67.5%), followed closely by demented male with demented female (53.6%). In terms of reported prevalence, there was a significant positive association with participants’ total years of education (r = .28, p = .01), such that higher educated participants tended to report more prevalence of nondemented male with nondemented females than less educated participants. In addition, there was a positive association with organizational (r = .23, p = .04) and nonorganizational (r = .23, p = .04) religiosity with reported prevalence of sexual expression. As such, participants who spend less time in private religious activities, as well as time in church or other religious meetings, tended to report more prevalence of contact between nondemented males with nondemented females. Conversely, Caucasian participants (r = –.24, p = .04) tended to report less prevalence of contact between nondemented males with demented females. Attitudes Toward Sexual Expression Among Residents In general, participants’ endorsed neutral attitudes (M = .24; SD = .41) about late-life sexuality in NH facilities. In fact, participants’ reported that sexual behaviors routinely occur in NH (M = .44) and such sexual feelings or emotions should be encouraged among residents with dementia (M = .46). The most endorsed item was that participants’ agreed that clinical staff working with demented residents should receive specific instructions for dealing with resident sexuality and sexual expression (M = .95). However, participants’ reported more negative attitudes about interactions between same-sex couples than opposite-sex couples. For instance, participants were rather neutral about dealing with sexual behaviors among demented residents (M = –.02), but reported greater difficulty when sexual behaviors were between same-sex couples (M = .38). Similarly, participants’ reported that sexual behavior amongst same-sex couples should be discouraged (M = .21), whereas sexual expression amongst dementia residents should not be discouraged (M = –.19). There was a negative correlation between participants’ race/ethnicity (r = –.28, p < .01) and time in particular facility (r = –.29, p < .01) with reported attitudes about late-life sexuality. On the contrary, there was a positive correlation between participants’ total years of education (r = .31, p < .01) and reported attitudes about late-life sexuality. To summarize, Caucasians, higher educated participants, and participants that had less time in a particular facility reported more positive attitudes toward resident sexuality. None of the criterion variable interactions were significant for the above analyses. 1098 Journal of Aging and Health 25(7) Knowledge of Late-Life Sexuality and Dementia. There was a significant positive association between sexuality knowledge scores and reported attitudes about late-life sexuality (β = .34, SE = .01). In addition, staffing knowledge of sexuality accounted for 11.3% of the variance in attitudes of late-life sexuality. After controlling for covariates (race/ethnicity, total years of education, and time in particular facility), results indicate the association between sexuality knowledge scores with reported attitudes about late-life sexuality was reduced by 35%, but it remained significant (β = .22, p = .045). Contrary to hypotheses, participants’ dementia knowledge scores were not related to attitudes toward sexuality among NH residents (p = .23). Staff Perceptions About Decision-Making and Management of Sexual Expression As a first means of managing resident sexual behavior, participants’ reported that they typically use direct intercession (37%), call the family (24%), or call a staff meeting (11%). The questionnaire also asked questions to assess participants’ beliefs about decision-making capacity for sexual activity in NH residents. Overall, participants’ believed that residents: (a) should have a neuropsychological assessment to evaluate their current cognitive function (M = .69, SD = 1.14); (b) should be aware of who is initiating sexual contact (M = .83, SD = 1.11); (c) behaviors should be consistent with former beliefs (M = .29, SD = .96); (d) should be able to state level of sexual intimacy they would be comfortable with (M = .52, SD = 1.14); (e) must realize that the relationship may be time-limited (M = .29, SD = 1.14); (f) need to think about how they would react if the relationship ends (M = .29, SD = 1.20); and (g) should not engage in sexual activity if they believe that the other person is their spouse (M = –.78, SD = 1.17). In addition, participants’ agreed that staff should ask resident permission to discuss sexuality (M = .80, SD = 1.13). Focus Group Discussions Initially, the research team led focus group sessions by presenting a case scenario and facilitating discussion among participating staff about the case, ethics, and considerations of decisional capacity to engage in sexual behavior. At subsequent focus groups, however, the research team noted that staff predominantly spent time discussing cases within their own facility or in other facilities in which they had worked. Therefore, focus group discussions associated with the educational information provided to staff were refocused on Di Napoli et al. 1099 facilitating consideration of existing situations within their own NH facility and the research team served as expert consultants (RSA is a licensed psychologist and EAD is a master’s prepared clinical psychology student). Groups and individuals within groups varied in their openness to discussing issues of sexuality and sexual expression in NHs. Staff indicated awareness that sexual expression was happening in their facilities and readily identified residents who engaged in such expression. Some of these residents were noted to have cognitive impairment. Both resident-to-resident and resident-to-staff expressions of sexuality were discussed. Notably, incidents of same-sex sexual expression were rare in group discussions. Resident-to-staff expressions of sexuality were common and handled with care while maintaining firm boundaries that “we don’t do that.” On the questionnaire staff reported that sexual feelings should be encouraged among residents with dementia; however, in focus group discussion most indicated that sexual expression should be ignored, “. . . pull the curtain.” The disagreement between survey report and narrative expression in focus groups may indicate greater discomfort in responding to incidents of sexual expression than reported on the questionnaire. Notably, a social desirability bias in responding to the questionnaire could be operating. Staff indicated a desire for more guidance in “managing” sexual expression among residents. Questions regarding consent capacity for sexual expression and concerns about the reaction of residents’ families were common. These questions were more poignant when the resident in question had a cognitive impairment. In these cases, it was more common for staff to express a tone of disapproval regarding sexual expression. Staff clearly indicated a need for more training and the creation of effective interventions to balance resident safety and autonomy regarding sexual expression in NHs. Discussion This study adds to the body of knowledge regarding NH staff experience in managing late-life sexual behaviors in NHs by examining relations between staff characteristics, knowledge of late-life sexuality and dementia, attitudes toward late-life sexuality, and understanding of the relation between cognitive ability and sexual expression. The results of our study highlight the importance of providing training interventions for NH staff. Such interventions should focus on increasing staff knowledge of sexuality and dementia, as well as on improving attitudes and reducing stigma about sexuality and dementia, particularly among same-sex residents. Overall, the results of this study elucidate many staff characteristics that are associated with knowledge of sexuality and dementia, as well as reported 1100 Journal of Aging and Health 25(7) prevalence and attitudes of late-life sexuality. Participants’ total years of education had a positive relation with all criterion variables (e.g., Alzheimer’s Disease Knowledge and Aging Sexuality Knowledge scores, reported prevalence, and attitudes of late-life sexuality). Caucasian participants tended to report more positive attitudes toward resident sexuality and less prevalence of contact between nondemented males with demented females. Participants that had less time in a particular facility reported more positive attitudes toward resident sexuality. Age was positively associated with Alzheimer’s Disease Knowledge scores, but none of the other criterion variables. Nonorganizational religiosity was positively associated with many of the criterion variables (e.g., Aging Sexuality Knowledge scores, reported prevalence of sexual expression, and staff attitudes about late-life sexuality). In addition, organizational religiosity had a positive association with reported prevalence of sexual expression, whereas intrinsic religiosity had a positive association with Aging Sexuality Knowledge scores. Furthermore, intrinsic religiosity was a moderator between Alzheimer’s Disease Knowledge and Aging Sexuality Knowledge scores. It may be that an underlying personality variable such as openness to experience or agreeableness underlies these observed associations, raising a question for future research. Not surprisingly, Aging Sexuality Knowledge scores were positively related to reported attitudes of late-life sexuality. Controlling for participants’ race/ethnicity, total years of education, and time in particular facility decreased, but did not render nonsignificant, the association of Aging Sexuality Knowledge scores with reported attitudes of late-life sexuality. This may indicate a level of health literacy with regard to sexual expression among NH residents, but to the authors’ knowledge no direct measure of sexual health literacy exists. This presents a topic for future research. Participants’ Alzheimer’s Disease Knowledge scores, however, were not related to attitudes toward sexuality among NH residents. As revealed in focus group discussions, staff perceived conflict in their roles to protect the autonomy of NH residents while maintaining the ethic of beneficence in regard to responding to resident sexual expression. This was particularly true when one of the residents had dementia, as staff indicated a desire for testing to determine residents’ sexual consent capacity. Staff training interventions regarding resident autonomy of sexual expression and the need for clear communication among residents, family members, and staff regarding desire for sexual expression are clearly indicated. In general, participants’ endorsed neutral attitudes about late-life sexuality in NHs, particularly if they were in accordance with traditional norms (nondemented male with nondemented female). However, participants’ attitudes were more negative when interactions were between same-sex couples. Hash Di Napoli et al. 1101 (2006) reported that NH staff is more likely to stigmatize same-sex activity between residents than opposite-sex activity. While NH staff may not directly exhibit homophobic attitudes, many gay and lesbian older adults have reported “slighting remarks” or “rude” behavior while addressing alternative sexualities (Hash, 2006). These issues of stigma need inclusion also in staff training interventions, as future cohorts of NH residents will be more vocal and diverse in their need for sexual expression (Frost, 2011). Study Limitations Although the results of the current study are informative, there were several limitations as with any research. First, the study results were mostly correlations between variables measured at one point in time, precluding interpretation of causation between associated variables. Similarly, it is unknown if educational materials were effective because staff were not given a pre- and post-assessment to examine whether there were changes in knowledge and attitudes of sexuality and dementia. Second, the analyses are based upon a convenient sample of NH staff from Birmingham and Northport, Alabama who were predominantly female, African American, and heterosexual. Therefore, the findings may not be generalizable to a more diverse sample or different geographic locations. Because it is likely that many of the staff have worked in similar NH settings, it may have been informative to inquire also about the overall time in the nursing sector in addition to time in the current facility. Third, researchers were not able to procure as many questionnaires from participants who worked during the evening shift as from the day shift, possibly skewing the resulted prevalence reports. Future Directions Despite these limitations, our mixed method results suggest that NH staff were only moderately knowledgeable about dementia and aging sexuality. Moreover, they indicated a desire for further training in managing late-life sexuality, particularly in the context of cognitive impairment. These data provide preliminary evidence that NH staff should be given educational intervention strategies or training on sexuality and dementia. The majority of participants agreed with the notion that NH staff need specific instructions for dealing with resident sexuality and sexual expression. In fact, educational intervention strategies have proven to have positive effect on both staff knowledge and attitudes toward late-life sexuality (Livni, 1994; Walker & Harrington, 2002). Given our findings, it would be beneficial for interventions to not only target increasing knowledge, but also improve attitudes 1102 Journal of Aging and Health 25(7) about same-sex sexual behaviors. Such intervention efforts, however, need to consider staff members’ nonorganizational religiosity (e.g., prayer and meditation) and intrinsic religiosity’s potential moderating effect in relation to dementia knowledge and knowledge of late-life sexuality (see Figure 1). Future studies should (a) continue to examine the role of staff demographic variables on knowledge and attitudes toward late-life sexuality; (b) build on NH ethics policies concerning late-life sexuality and consider the impact of resident representation on NH ethics committees; (c) explore different assessments and factors necessary for decision-making capacity for sexual expression in older adults; and (d) investigate different interventions for increasing staff knowledge of dementia and sexuality, as well as improving attitudes toward late-life sexuality and the concomitant impact of these interventions on resident quality of life and, subsequently, successful aging over time. Summary and Implications This series of cross-sectional analyses demonstrated that certain staff demographics are positively related to knowledge and attitudes of late-life sexuality and dementia. In combination with the imminent, substantial growth in the number of older adults in NH and the established relations between sexual expression, overall health, and quality of life, this investigation provides further justification for determining the nature of the relations between staff characteristics and attitudes of late-life sexuality. It is our hope that NH facilities will use results such as these to generate educational interventions to improve staff attitudes and knowledge of late-life sexuality and dementia. Acknowledgment The authors wish to thank the administrators and staff of the three skilled nursing facilities that participated in this study. Declaration of Conflicting Interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. 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