According to the American Heart Association, fulfilling sexual activity is an important aspect of the quality of life [21] . Patients with CADs are eager to return to their routine after discharge. However, resuming sexual activities is viewed as a challenging activity by patients and their partners [22] . Miner and Kim found that men and their partners have a great concern when they can resume sexual activity safely after CADs [13] . For example, patients may need to know how their sexual health is being affected by the illness, by medications and associated side effects, when can they resume their sexual activities, what are the warning signs reportable to the physician, what sex enhancing medications can they use and what preparations are available to aid in resuming sexual activities. Byrne and colleagues reported that about half of 382 cardiac patients preferred the opportunity of addressing their sexual health concerns by health care providers [19] . Assessment of sexual matters with patients with acute MI is an important factor to prevent loss of sexual activity [23] . Lack of sexual education for patients with MI was a leading cause of absence or less frequent sexual activity in both male and female patients [23] [24] . Therefore, providing patients with sexual health information aids in improving patients’ sexual interest and satisfaction through decreasing patients’ and partner level of anxiety and fear from engaging in sexual activities and improve patients’ sexual life [22] . Providing sexual health instructions for patients with CADs is an essential nursing task [25] . Despite supporting evidence and increased attention to sexual health assessment over the years, it is still a challenge for many nurses to address sexual health in practice [13] .

Sexual health assessment in clinical practice is viewed as a private matter between partners by nurses and rarely discussed [26] . For example, in the United States, Lindau et al reported that only one-third of women and half of men with MI were educated about sexual health during their hospitalization [23] . In a pheno- menological study, Andersson and colleagues [12] concluded that majority of young adults with MI mentioned that health care providers did not provide them with information about sexual health. Similar results were found by Ozdemir and Akdemir that none of 108 nurses in cardiac units provided sexual education to patients with CADs after recovery [27] . However, sexual health assessment is important to help patients resume their sexual life [28] .

There is an increasing interest in providing holistic care that includes sexual health assessment [29] . Amongst other healthcare professionals, nurses can play a significant role in conducting sexual health assessment [30] . Nurses have good relationships with patients due to their daily contact with patients that facilitate assessment of sexual health [31] . Moreover, nurses documented that sexual health assessment for patients is a part of their professional role [32] . Nurses have shown little competence in sexual health assessment and therefore requires more practice by nurse clinicians [33] . In short, patients’ sexual health assessment is a nursing task but nurses still hesitate to conduct sexual health assessment in clinical practice [4] .

Sexual health following CADs has gained a great attention in nursing research. Despite increase attention, sexual health assessment still is challenging for the vast majority of nurses. There are several authors that studied barriers to sexual health assessment in nursing practice in different cultural background [34] . For purposes of this paper, authors classified barriers based on previous research work and reviewing the literature into four main categories: nurses-related barriers, patients-related barriers, organizational related barriers and values-related barriers. Barriers to sexual health assessment is viewed differently by different cultures, authors studied barriers taking cultural backgrounds in consideration. This classification organizes and integrates all possible barriers in a comprehensive and clear way that might help nurse clinicians, educators, administrators and re-

searchers where to focus to find the most appropriate interventions to facilitate sexual health assessment.

In order to find out the main barriers that constrain nurses from addressing patients’ sexual health in clinical practice, Ho and Fernández found that lack of education, embarrassment, cultural restrictions, lack of experience and religious prohibitions are the main barriers [47] . Saunamäki and Engström reported that some nurses thought that sexual health assessment is a taboo subject and therefore it should not be discussed and it is not within their job description and it is someone else’s responsibility [30] . Doherty et al. mentioned lack of proper training on how to discuss sexual health issues as a barrier [34] .

Other barriers include insufficient nurses’ knowledge and viewing sexual health as a private matter between adult partners that should not be discussed by nurses [27] , lack of time to prepare and feeling uncomfortable to provide patients with sexual education [24] . Some nurses view assessment of patients’ sexual health as at low priority [33] or make them upset, embarrassed or anxious [24] . Byrne and colleagues found that lack of enough time due to workload, feeling that patients are not ready to receive sexual information and lack of education and training are important barriers that nurses may encounter [48] .

Magnan and Reynolds [45] investigated the main barriers for sexual health assessment in five fields of specialization (N = 302) and found that nurses perceived that sexual health is not a part of their patient care have coalesced with their lack of comfort, confidence and time to discuss patient sexual health needs. Huang et al. found that nurses are uncomfortable when addressing patients’ sexual health matters [42] . Doherty et al. outlined a list of barriers including patients’ lack of readiness, knowledge deficit and lack of training programs for nurses [34] . Saunamäki, Andersson and Engström found that Sweden nurses are knowledgeable in sexual health field, feel comfortable and responsible and show readiness to do sexual health assessment, but the vast majority of them did not address patients’ sexual health as they feel unconfident and did not specify a time to do so [36] .

Finally, nurses’ beliefs and attitudes toward sexual health may prevent them from assessing patients’ sexual health. Most of nurses who never assess patients’ sexual health have a negative attitude toward sexual health discussion [48] . The main responses that affect health care providers’ attitudes are difficulties in answering to patients’ sexual problems, concerns, and questions and lack of confidence, skills and training [49] . Some nurses have personal beliefs and values that assessment of sexual issues is not ethical [50] . Therefore, understanding nurses’ attitudes towards addressing patients’ sexual health is an important consideration by encouraging nurses to attend to patients’ sexual concerns within the routine nursing care.

Additional barriers were found that were not related to the competency of health care providers. Patient related factors can also impede the addressing of sexual health needs. Many patients reported their interest to discuss sexual concerns with health care providers, but they did not do so because they are embarrassed [51] , or believe that they just have experienced a diminishing sexuality due to nor- mal ageing process [52] . Sometimes, nurses may be reluctant to start sexual assess- ment and teaching because they fear that discussion of sexual related issues can annoy the patient [51] or fear from any unexpected response from patients [53] . Buttaro et al reported that pateints’ age, culture, sexual orientation, comorbidity diseases, and limited time are main barriers to sexual health assessment [54] .

Some barriers are related to the academic and health care institutions. Doherty and colleges stated that cardiac nurses ignore sexual health assessment because health institutions lack guidelines regarding sexual assessment and management, specialized referral clinics and nurses do not have enough confidence, knowledge and training [34] . Hoekstra et al. [5] reported that lack of health policies about addressing sexual health was the main barrier. Furthermore, Quinn and colleagues found that healthcare organization view sexual health assessment is not a priority [33] . In China, nurses reported that nurses’ shortage and lack of resources are significant barriers to address patients’ sexual health [55] . Furthermore, lack of support from the institutions [56] , lack of privacy [57] , work overload and a sense that addressing sexual health is non-nursing job [29] are cited as organizational barriers.

Academic nursing curricula in Jordan often ignore discussing of sexual health issues for nursing students. Despite that, several studies reported that addressing sexual health issues during undergraduate education is vital to increase nurses’ knowledge [33] [58] .

Finally, culture, society, and religion are external barriers that are related to values of persons or community preventing assessment of sexual health with patients during their hospitalization. Many cultures including Arab Islamic culture considering sexual related topics are sensitive. Goossens et al examined the impact of culture in five Europe countries and found that nurses’ beliefs and attitudes about sexual health are influenced by both culture and country [30] . In some cultures, there is a common belief that sexual health is not a matter for older adults or those who with chronic conditions [59] . Turkish nursing students’ did not offer sexual health assessment and education to patients due to effects of cultural and religious beliefs [60] . In the Turkish culture, open communications about sexual matters between different sexes is prohibited, then preventing nurses from sexual health assessment [61] .

Societal restrictions can interfere with providing sexual health care [29] . Purabuli, Azizzade and Alizadeh found that most nurses in Iran (96%) highlight the necessity for nurse educators to be same sex as the patient [40] . Social interpretation of sexual issues is another barrier, for example, sex means pleasure and enjoyment and it is not logical to address it during illness. Based on this interpretation, Chinese nurses pay more attention to physical health condition rather than sexual concerns [55] .

In summary, to gain more depth insight, all possible barriers to sexual health assessment in nursing practice based on reviewed studies are outlined below in Table 2.

As sexual health-related needs are sensitive issues and often challenging task for nurses. Special considerations are required to help nurses conducting patients’ sexual health assessment in clinical practice. In attempts to overcome barriers, we suggest a multidisplinary team to develop standardized guidelines to sexual health assessment. Strategies to facilitate sexual health assessment are outlined below.

First: Integrate sexual health assessment topics in nursing curriculum during undergraduate studies. Jaarsma et al. found that nurses have knowledge deficit

*Means that barrier is related to two or more categories.

and lack of confidence to talk about sexual matters [24] . Well-prepared nurses in term of knowledge and skills make them more confident in providing sexual health assessment and information.

Second: Conduct training sessions and workshops on sexual health assessment for nurses in clinical setting (sexual health competency). Training programs about sexual health improve nurses’ comfort and attitude toward bringing sexual health assessment into practice [35] [36] . Clinical training workshops with simulation role-play case scenarios by nurse specialist in sexuality matters is highly recommended to help nurses addressing patients’ sexual health [24] .

Third: Teach effective communication skills to nurses and build rapport and therapeutic relationship between nurse and patients to make nurses more able to translate their acquired sexual knowledge into practice [55] . The close relationship between nurses and patients gives both a great chance to discuss sexual con- cerns [62] . Nurses could use their art to address patients’ sexual health in a way that fit with patients’ values, beliefs, culture and religion. As many cultures view sexual matters as secret and private, nurses need to take cultural perceptions in the process of sexual health assessment [37] . To achieve a successful addressing of sensitive information, Waltz, Strickland and Lenz recommended ensuring privacy and confidentiality of patients’ responses; seeking only relevant data starting from less to more sensitive and allowing more time for participants to express their needs [63] .

Fourth: Use written educational material such as brochures and leaflets that are developed by experts about sexual health. These materials play an important role in improving patients’ knowledge and encourage patients to express their sexual health concerns [19] .

Fifth: Select appropriate time is an important factor for effective assessment and teaching of patients’ sexual health. For example, nurses viewed that time is not suitable for discussing sexual concerns as patients are ill and they may have anxiety and fear due to their conditions [59] . As existence of third party is a barrier, before or after visiting hours is more appropriate for both nurse and patient to address sexual health needs. Discharge period is a suitable time where patients become stable and ready for assessment and to receive information. Three quarters of nurses recommended that the best time to assess patients’ sexual health is during their follow-up visits or during medications review [5] .

Sixth: Create, adopt and implement sexual health policies and procedures for sexual health assessment in clinical settings to facilitate nurses’ roles in conducting this important nursing task [34] . For example, integrating sexual assessment as a part to the nurses’ charts enable nurses to address the sexual health during history taking and discharge planing. Annon developed the PLISSIT model as a tool to facilitate the assessment and treatment of sexual related problems. PLISSIT letters are abbreviations for sequent interventions where P means Permission; LI means Limited Information; SS mean Specific Suggestions and IT means Intensive Therapy [64] . The PLISSIT model is a framework that helps nurses to conduct sexual health assessment [42] .

Seventh: Invite partners during sexual health assessment and counseling. Partners may complain of distress and anxiety that may affect patient’s sexual health [65] . Partners play significant roles in patient support and facilitating successful resuming of sexual activities.

Eighth: Break down external barriers, Media can play a vital role in discussing the sexual health and related concerns publicly. Nurses can present a television shows about sexual health and instructions for patients and their partners.

Ninth: Nurses need to understand patients and partners’ sexual health experiences and needs for sexual health information, nurses’ knowledge, attitudes, beliefs, barriers and best teaching methods. Conducting more research in sexual health nursing field is recommended to improve sexual health assessment [44] .

Tenth: Create an appropriate work environment through establishing specialized rooms in health institutions to help both nurses and patients to address sexual health related issues in a more comfortable manner [37] .