Barriers for the inclusion of sexuality in nursing care for women with gynecological and breast cancer: perspective of professionals

AIM: qualitative study, which aimed to identify the barriers that influence nursing care practices related to the sexuality of women with gynecological and breast cancer. METHODS: the study was conducted with 16 professionals of the nursing area (nurses, nursing technicians and nursing assistants) from two sectors of a university hospital situated in the state of São Paulo, Brazil. The data was collected using semi-structured, in-depth individual interviews. All the interviews were recorded and the participants' responses were identified and categorized using Content Analysis. RESULTS: three major themes were identified. These are as follows: 1) barriers related to the biomedical model; 2) barriers related to institutional dynamics and 3) barriers related to the social interpretations of sexuality. CONCLUSIONS: the results of this study showed that the systematized inclusion of this issue in nursing care routines requires changes in the health paradigm and in the work dynamic, as well as reflection on the personal values and social interpretations related to the topic. A major challenge is to divest sexuality of the taboos and prejudices which accompany it, as well as to contribute to the nursing team being more aware of the difficulties faced by women with gynaecological and breast cancer.


Introduction
Gynecological and breast cancer not only represent public health problems, but also affect organs to which important symbolic values are attributed in the Brazilian culture, mainly related to the area of sexuality and body image. The disease itself, along with its treatment, frequently entails significant and long-lasting poor sexual health (1)(2)(3)(4) , with changes in relationships -principally in the relationship with the sexual partner -occurring during and after the treatment (5)(6)(7)(8)(9)(10)(11)(12) .
In spite of the fact that the sexuality of the women affected is compromised, health professionals often fail to adequately assess such problems, or even address them at all. It is rare for there to be open discussion and exploration of alternatives -not limited to the sexual relationship -for promoting the expression of affective-sexual intimacy between the woman and her partner (5,(13)(14) . Even recognizing that the assessment of sexuality is an intrinsic part of the care, for various reasons, many nurses do not address these questions in care practice (5,13,(15)(16) .
Although studies highlight the difficulties in communication related to the subject of sexuality in the practice of the oncology nurse, gaps remain in the knowledge regarding the barriers which impede the topic's inclusion in the nursing care. The relationship between oncology nurses' attitudes and perceptions regarding sexuality in care practice must be explored, in order to possibly understand why they so often fail to conclude an assessment of the patient's sexual health during the care (5) . It should be noted that in the institution where the present study was undertaken there is no formal sexual counselling service, which becomes more serious when considering that the body occupies a central position in Brazilian culture, principally among women. There is a particular body model held in high regard, and the continuous preoccupation with obtaining a perfect body is notorious (17) .
A broader focus on this problem is needed, so that the experiences and meanings of these women can be valued and considered in nursing care practices. This is because the concept of sexuality cannot be separated from health, as sexuality and intimacy-related issues are fundamental to maintaining the well-being and self-esteem of women affected by cancer (6,18) .
Considering that sexuality cannot be neglected in care, which barriers hinder the inclusion of the topic in nursing care? This study aimed to identify the barriers which influence nursing care practices related to the sexuality of women with gynecological and breast cancer.

Methods
As the study addresses the universe of meanings, motives, aspirations, beliefs, values and attitudes of Brazilian nursing professionals, a qualitative approach was selected.

Participants, setting and sample
The sample was selected by convenience, in which the informants were chosen to meet the objective of the study. It should be noted that in Brazil, nursing work is undertaken by different categories of workers.
These professional categories (nursing assistant, nursing technician and nurse) have distinct training processes and distinct sets of professional activities and responsibilities. The Nurse performs all nursing activities, the Nursing Technician performs mid-level activities, involving the guidance and monitoring of nursing work in a support role, and participation in the planning of the nursing care. The Nursing Assistant performs mid-level activities of a repetitive nature involving nursing support services under supervision, as well as participates in the execution of simple treatment processes (19) . The professional functions of the nursing assistant are characterized by a set of technical procedures (20) . It is the responsibility of the nurse to exercise the functions of organizing and managing the service, coordinating the actions of the nursing team professionals.  was made with the nurses responsible for the two fields of investigation, so as to gain their participation in the undertaking of the study. Next, each nursing professional selected as a source of information was individually invited to participate and the aims of the study were explained to them. The terms of consent were explained and signed by all participants.
To preserve the identities of the nursing professionals, an alpha-numerical system was chosen, with the codename 'I' (for 'Interviewee') followed by an

The interview process
Data were collected between May and July 2011. To identify the barriers which influence nursing practices related to sexuality and care for women with gynecological and breast cancer, the aim was to understand the cultural context in which this care is produced, starting from the premise that this context determines the actions and perceptions of nursing professionals in relation to this issue. Thus, the professional work spaces and the interactions established by the subjects involved in this process were taken into account.
Once this backdrop for supporting the analysis had been developed, the material itself was explored. To guide the work, Content Analysis methodology (21) was adopted. Through specialized and scientific procedures,

Barriers related to the health model
The health institution where the study was  importance for the wellbeing of the patient (7) .
Focusing on the cure, and based on the delivery of a technical view of care, nursing fails to value the subjective aspects of care, and denies the holistic nature of the subjects. Similar characteristics were found in a study undertaken with nurses in six hospitals in China.
Although healthcare in that country is changing, the current practice still follows the biomedical model. Thus, Chinese nurses were not autonomous and felt insecure to address subjective issues, such as sexuality in care delivery to gynecological cancer patients (23) .

Barriers related to the institutional dynamics
The organizational culture of the institution contributes to the nursing team neglecting to address sexuality. Bonding difficulties develop from the work organization, which represents a decisive barrier to addressing sexuality with women undergoing cancer treatment. This difficulty is partially perceived by the nursing professionals, who explain its existence by indicating the staff turnover within the work sectors as one of the aspects that interferes negatively in bonding with the patients. The professionals interviewed frequently alternate between sectors, shifts and even workplaces, this being the situation on the wards as well as at the outpatient clinic.  highlights the lack of private areas as an obstacle to patients being able to freely air their concerns. It can be seen that the dimension of sexuality is understood as an aspect that demands greater contact with professionals if it is to be expressed comfortably.
Thus, the work dynamics at the institution do not allow women undergoing cancer treatment to be sufficiently close to the team to express their subjective needs.
Difficulties in establishing bonds derive from a lack of time, as well as the high turnover rate of professionals within the different sectors. The need to rely on good bonds to allow sexuality-related issues to emerge in health practices was also reported in another study (16) .
In this study, the comfort levels Turkish nurses experienced during clinical experiences were assessed, which included sexuality topics. Nurses from clinical units felt more comfortable than nurses working with surgical patients. The author explained this finding by suggesting that, probably, long periods of hospitalization favor addressing these topics, strengthening the intimacy between professionals and patients, which is frequently the case in clinical units. More than 80% of the nurses who participated in a study undertaken in China agreed that having a good relationship with the patient and being able to communicate facilitate the inclusion of the issue of sexuality in nursing practices (23) .
The vulnerability of the nursing professionals is provoked by their physical closeness and involvement with the women with gynecological and breast cancer, leading them to construct barriers to avoid becoming closer and bonding with the service users. Reflecting on experiences of pleasure and suffering in nursing team work, one study (24) mentioned that the work of the team creates ambiguous feelings, which can contribute to experiences of pleasure as well as suffering. If, from one perspective, workers feel useful when serving and comforting, from another, they suffer when they are that there was no time to discuss sexuality with their patients (25) . Similar characteristics were also reported in the hospital context in China. Chinese nurses believed that insufficient staff -resulting in a lack of time and energy -and insufficient resources were the main barriers to addressing sexuality (23) .
The results of a study (26) that explored the sexuality-related experiences of 52 patients during cancer treatment showed some reasons perceived by the patients for sexuality not being considered in the nursing care. One of the aspects highlighted was the assertion that nurses are too busy to sit down and talk about these issues with the patients. In addition to the lack of time, the organization of institutional spaces did not provide places where dialogues could take place in private. This can represent an important barrier for women with gynecological and breast cancer to express their sexuality, given that cultural values still permeate the issue and place it in the private sphere. Privacy makes it possible to address sexuality, as it creates a favorable climate for confidentiality (7) . Chinese nurses were also aware of the need to offer an environment that favors having these discussions with the patients (23) .   The nursing professionals also explained the absence of addressing sexuality in nursing care as being due to the women undergoing cancer treatment reproducing, in the hospital environment, the cultural issues they experience in the process of constructing their female identity. Due to current gender standards, women learn to isolate themselves early, therefore they do not raise the issue with the team. Corroborating this perception of the professionals, the results of a study involving 202 Chinese nurses showed that 77.7% of them saw sexuality as an issue which is too private to discuss with the patient and 63.4% assumed that most hospitalized patients are too ill to take interest in sexuality related issues (23) . Similar results were found by a study conducted in a large metropolitan medical center in the USA with nurses, which showed that they believed sexuality to be a private matter which, therefore, should not be addressed. They were more inclined to believe that hospitalized patients were too ill to be interested in sexual issues (25) . Regarding privacy and comfort, the majority of the nurses (81.7%) did not believe that sexuality was an issue too private to discuss; however, nearly half of the nurses (47.9%) felt uncomfortable talking about sexual issues (25) .

Barriers related to the social interpretations of sexuality
These attitudes of the nursing team are related to professional education, with cultural influences originating from values, meanings, symbols and specific concepts. Nurses have learned the basic rule that care delivery is natural, serious and without embarrassment.

Difficulties in interacting with the sexuality of others
are associated with the suppression of sexuality in the profession and with the adoption of behavioral standards through morality rather than what is considered to promote health (27) . According to the authors, nurses working with cancer patients have difficulty in exploring the issue and tend to avoid it, leaving patients with many unanswered questions.
Nurses who believe that sexuality is a topic too private to discuss with their patients also feel that sexual issues should only be addressed if and when patients initiate the conversation. These same nurses usually postpone these discussions and hope that another professional, whom they consider better trained to address this issue, might take the initiative and offer patients advice (5) . As sex is linked with the idea of pleasure, patients often feel guilty and ashamed to think about sex at such a time. They do not question health professionals about these issues because they think it is inappropriate (7) .
In the interpretation of the professionals, the women have difficulty disconnecting from the personal and family issues in their environment and are unable to think about sex naturally amidst so many adverse consequences originating from the disease and treatment process.

Conclusion
This study allowed the identification of the barriers knowledge produced up to this moment has neglected the importance of investigating the processes that lead nurses to avoid the issues of sexuality in care practices. Elucidating these barriers is an important step to sensitize professionals to the needs of the patients for integral healthcare in the oncology setting.