Main Points
• Graduate nurses are expected to be able to provide essential sexual and reproductive health education and nursing care for sexual dysfunctions and reproductive health problems.
• The curriculum of undergraduate nursing programs in Turkey does not include enough sexual and reproductive health courses.
• There are differences in the name, type, semester, evaluation criteria, learning methods, national and European Credit Transfer System credits, theoretical course hours, and course contents of the sexual and reproductive health courses carried out in their programs.
Introduction
Sexuality is an intrinsic part of the human experience and influences our actions, thoughts, and day-to-day lives (1-3). While sexual health is defined as “positive enrichment and strengthening of personality, communication, and love by considering sexual life as a whole in terms of physical, spiritual, mental and social aspects” (4); reproductive health is defined as “not only the absence of disease but also a state of complete physical, mental and social well-being and the ability to use one’s sexuality without health risk” (5). About 50 years ago, the World Health Organization (WHO) recognized sexuality as an essential and integral aspect of human development and maturation throughout the life cycle, emphasized the necessity of integrating the subject of sexual health into the undergraduate education of health professionals and the importance of graduating by gaining competence in sexual health (6).
Nurses are uniquely positioned to meet the sexual and reproductive health (SRH) needs of individuals at all stages of life (childhood, adolescence, adulthood, and old age) (1,7-9). For this reason, nursing students should learn to provide holistic care, including SRH), throughout their education (1,7,8). However, in the literature, many research results state that nurses are not prepared enough to counsel healthy/sick individuals about sexuality (8,10-12). Blakey and Aveyard (2) highlighted that nurses graduate with a lack of knowledge that limits their ability to provide counseling, including the biological, psychological, and social aspects of sexuality. In a study conducted in Taiwan, stated that there is a need for an effective curriculum to increase student nurses’ ability and willingness to assess their patients’ sexual health (12). In the literature, the lack of focus on sexuality in the undergraduate nursing program curriculum is the main reason that nurses do not address sexuality with the healthy/sick individuals they care for (2,3,10-12). Despite WHO’s strong recommendation nearly 50 years ago (6), it shows that universities did not design curricula to provide this critical knowledge.
The literature has limited research on the content of SRH subjects taught in undergraduate nursing programs (8,9,13-15). It is known that the curricula of some nursing programs do not include sexuality and sexual health at all or that critical areas of human sexuality (for example, vulnerable groups such as lesbian, gay, bisexual, transgender, intersex communities, disabled people, the elderly, immigrants) are ignored in curricula that focus only on heterosexual orientation (2,8,16). Educators attribute these shortcomings in SRH education to a lack of time and the priority of other content (2,9). To provide adequate and quality care to healthy/sick individuals, nurses must receive primary SRH content that enables them to acquire sufficient information during their undergraduate education (1,8,9).
Studies examining the extent to which the United States of America includes SRH content in the curriculum of nursing programs, human sexuality, pregnancy, and prenatal health, nursing care in the postpartum and postpartum period, family and women’s health, family planning, nursing care in sexually transmitted diseases and chronic diseases that may affect SRH, socio-cultural, economic, political or ethical factors that affect the delivery of sexual health services are stated as actual contents (9,13,14). In the curricula of nursing programs in Europe, the content of SRH is traditionally structured in two areas. One of these areas is reproductive health, which includes the care of women during pregnancy, childbirth, and puerperium, and the other is sexual health, which focuses on sexuality and sexual relations (7,17). In other countries, such as China (18), Ethiopia (19), or Argentina (20) the SRH content of the curriculum of nursing programs is mainly focused on reproductive health.
In Turkey, on the other hand, no comprehensive research has been encountered on the courses and contents of SRH in the curriculum of nursing programs. However, it was emphasized in the National Nursing Core Education Program, which was held in 2014 to determine the minimum standards of the nursing undergraduate education program in the national framework and to ensure country standardization that the subject of “sexual health/reproductive health” should be included in the essential components of the education programs of institutions providing undergraduate education in nursing. It is expected that a nurse who graduated from an undergraduate nursing program will be able to provide basic level SRH education specific to age/development periods and to provide nursing care in sexual dysfunctions and reproductive health problems (21). This research will contribute to the literature revealing the current status of SRH education in nursing undergraduate programs in Turkey.
Research Aim and Questions
This study aimed to examine the characteristics of the SRH course in nursing undergraduate program curricula in Turkey. For this purpose, answers to the following questions were sought. In undergraduate nursing programs;
(i) What are the characteristics of universities offering SRH courses?
(ii) What are the features of SRH courses?
(iii) What are the contents of SRH courses?
Material and Methods
Study Design and Sample
This study used a descriptive and cross-sectional design using a scanning model to examine the characteristics of the SRH course in nursing undergraduate program curricula in Turkey. The screening model is a research model that aims to detect and show an existing situation (22).
The research universe consisted of all universities with nursing undergraduate programs in Turkey. According to the 2023 data from the Council of Higher Education, there are 154 undergraduate nursing programs, 103 of which are at state universities and 51 at private universities (23). The study sample consisted of 95 undergraduate nursing programs with SRH courses in their curriculum. This number represents 61.69% of the universe. Programs that do not have a SRH course in their curriculum (n=59) were excluded from the study. The data were gathered between 1-31 January 2023.
Data Collection Instrument
The data collection form created by the researchers in line with the literature (1,7,9,14) was used to collect the data. To determine the suitability of the research form, expert opinion was obtained from three lecturers with doctorate degrees in obstetrics and gynecology nursing. The form was finalized based on expert opinions. In the form, there are 14 questions about the nursing program’s SRH course inclusion status, university ownership, course name, the year the course was given, learning methods, the theoretical hour of the course, etc.
Data Collection
The data were collected by examining the web pages of the universities included in the scope of the study in line with the questions stated in the questionnaire between 1-31 January 2023. In the first stage, universities with undergraduate nursing programs were determined in the 2022-2023 academic year, and then the education/course programs published on the websites of undergraduate nursing programs and the Bologna course information packages, if any, were examined, and the presence of SRH courses in their curricula was determined. Secondly, the data of the research were transferred to the data collection form by examining the education/course programs of the nursing programs with SRH courses and the Bologna course information packages, if any. Thirdly, similar titles were combined in the course contents and grouped under three headings: “sexual health”, “reproductive health”, and “SRH”, Expert opinion was taken from three lecturers with doctorate degrees in obstetrics and gynecology nursing in the merging and categorization of the course contents in line with their similarity, and the grouping of the course contents was finalized by taking into account the suggestions of the experts. It took approximately 30-40 minutes to fill out each data collection form.
Statistical Analysis
The data was analyzed using Statistical Package for the Social Sciences (SPSS) 22.0, and numbers and percentages were used to present the data.
Ethical Considerations
Since the Higher Education Information Management System and the web pages of universities are accessible and the research does not include human participants, ethics committee and institutional permission approval was not required for this study.
Results
Table 1 shows the distribution of SRH courses according to their presence in the nursing undergraduate program curriculum. In Turkey, 61.69% of 154 state (n=103) and foundation (n=51) universities with undergraduate nursing programs have SRH courses. Most universities with SRH courses in their curriculum are state universities (73.7%), and the academic unit of 88.4% is the faculty of health sciences.
Table 2 shows information about SRH courses. It was determined that 90.5% of the courses had the Bologna information package. In the research, it was determined that SRH courses were carried out under different names, and they were primarily included in the curriculum with the names “sexual health” (34.7%), “sexual health and reproductive health” (31.5%), and “reproductive health” (9.4%). It was determined that 94.6% of the courses were elective courses, mainly in the 4th (24.1%) and 5th (24.1%) semesters. Final (100%) and midterm exams (97.3%) are the most common evaluation criteria of the course, and learning methods include homework/individual study (60%), presentation/seminar preparation (40%), and discussion/brainstorming/six hats (40%). The national credit of 93.5% of the courses is 2, 36.6% of them have European Credit Transfer System (ECTS) credits of 3, and 94.7% have 2 theoretical course hours.
Table 3 shows the data obtained from 77 undergraduate nursing programs whose SRH course content is shared and the distribution of the analyzed course content. In the research, content analysis was carried out to determine the essential topics in the content of the SRH course, and 27 topics directly related to SRH was created. The most common topics in sexual health curricula were determined as “sexuality and sexual health concept” (89.6%), “risky sexual behaviors” (85.7%), and “sexually transmitted diseases” (74.0%), respectively. The most common topics in reproductive health curricula are “formation of pregnancy” (28.6%), “reproductive health services in the world and Turkey” (27.3%), and “safe motherhood” (15.6%). The most common topics in the curricula of SRH are, respectively “factors affecting sexual health and reproductive health (media, internet, religion, culture, family, values, myths, etc.)” (83.1%), “SRH rights and legal dimension” (75.3%) and “development periods and sexual and reproductive health” (55.8%) (Table 3).
Discussion
This study analyzed the characteristics of the SRH course in nursing undergraduate program curricula in Turkey. The research findings showed that the SRH course needs to be sufficiently included in the curriculum of the undergraduate nursing program, and there are differences between the programs in the functioning and content of the SRH course.
In the research, it was determined that 61.69% of the undergraduate nursing programs had SRH courses. Saus-Ortega et al. (7) reported that 96.3% of nursing undergraduate programs in Spain have SRH courses in their curriculum. In the study by Aaberg (1) conducted with the educators of nursing undergraduate programs in the USA, he stated that 27% of the nursing programs do not include sexuality education. In the same study, all of the trainers who gave sexuality education in their curriculum stated that they placed SRH in the content of other courses in the nursing curriculum, not as a separate course (1). Our research finding shows that despite the strong recommendations of both WHO and National Nursing Core Education Program (NNCEP), the SRH course is limited in undergraduate nursing curricula. It is recommended that universities that do not have SRH courses in their curricula should evaluate their nursing undergraduate program curricula, considering the current situation.
SRH courses can be included in the undergraduate nursing curriculum with different methods. McLemore and Levi (13) emphasize that the SRH course is mainly included in the curriculum in a limited way, and if it is included as a separate course, it is left to the student’s choice as an elective course. The research determined that almost all SRH courses are included in the curriculum as elective courses. In addition, it was determined that the SRH course mostly took place in the 4th and 5th semesters of the curriculum and had 2 national credits and 3 ECTS credits. In some nursing undergraduate programs in the USA, the SRH course is given as a compulsory course, 3 national credits in the 5th or 6th semester (24,25). In comparison, in some of them, it is included in the curriculum as 3 national credits and can be taken in any semester (26). Saus-Ortega et al. (7) reported that the SRH course is predominantly in the third year of nursing undergraduate programs in Spain, and the course has 6 ECTS credits. Similar to our research results, it is seen that there are differences between universities in the ECTS credits of the SRH course. For example, the SRH course has 4.5 ECTS credits at the University of Valencia (27), while its credits at the Autonomous University of Barcelona are 3 ECTS (28). These differences in the semester in which the SRH course is given, especially in the national credit or ECTS credit of the course, may affect the content of the course and cause the basic SRH subjects not to be adequately covered in the course content. However, these results obtained from the study confirm the suggestions of previous researchers (3,10,11) that insufficient attention to SRH content in nursing programs contributes to nurses’ inability to provide SRH services to healthy/sick individuals.
It is seen that SRH courses are offered under different names in the undergraduate nursing programs included in the research, and most of them call the course “sexual health” and “sexual health and reproductive health”. When the curricula of nursing undergraduate programs in different countries are examined, it is seen that the SRH course is named with different names such as “Reproductive and sexual health nursing” (24), “reproductive and sexuality concepts” (25), “human sexuality” (26), and and “sexual education” (28).
The findings regarding the evaluation criteria and learning methods of the SRH course are limited since some of the universities examined in the study need to include the syllabus content on their web pages. Within the scope of the examination, the evaluation criteria of the course were reached on the web pages of 74 universities, and it was determined that the final exam was used as the evaluation method in all of them and the midterm exam in 97.3% of them. The learning methods of the course were accessed from the web pages of only 20 universities, and most of them were homework/individual study, presentation/seminar preparation, and discussion/brainstorming/six hat methods. This situation reveals that sharing information about the course evaluation criteria and learning methods on the web pages of universities needs to be improved.
When the NNCEP, which was created to ensure the standardization of nursing education at the national level, is examined, the content for SRH is quite limited (21). This situation may cause the content to be formed in line with the decision of the nursing programs and the instructors who teach SRH courses in these programs. In addition, it can lead to content differences between the curricula and cause inequalities in the education that students receive depending on the university they study (7). In the research, it was determined that the course contents of the programs with SRH courses in their curricula were different from each other. Similarly, it is emphasized in the literature that the contents of SRH courses in nursing programs are different from each other (1,7,9). Most educators decide on the topics that should be included in the course content, mainly by considering which ones will benefit the students the most (9). For nursing students to receive a homogeneous and desired level of SRH content, educators should evaluate the content of the SRH course. This evaluation should not include a certain number of topics but should aim to present critical content to all nursing students (29). Knowing the subjects included in the SRH course content examined in this research is very important to carry out the education improvement process in this field. Research findings can be an essential tool for educators to review the curriculum of their programs and reflect on the content they teach on SRH issues. However, it can serve as a basis for updating the teaching guides of undergraduate nursing programs in Turkey.
It has been determined that most of the 27 SRH course content topics determined in the research are in the field of sexual health. In addition, it has been determined that the subjects of “sexuality and sexual health”, “risky sexual behaviors”, “sexually transmitted diseases”, “family planning”, and “sexual dysfunctions” have a moderate prevalence in the course content. This finding is consistent with the results of previous studies (9,14). The main subjects identified in our research were accepted as the subjects that should be included in the undergraduate nursing program curriculum to develop SRH competencies in students in the USA (1) and Europe (7). Aaberg (1) stated that SRH courses do not have authoritative content and are mostly limited to general topics such as anatomy and physiology, formation of pregnancy, birth control, normal sexual function, sexual dysfunction, and sexually transmitted infections. The study’s findings show that the SRH content in most curricula may not be sufficient for students to acquire the basic information that will enable them to increase their knowledge level on sexual health. To determine the current situation, it is recommended to research to evaluate the sexual health knowledge levels of nursing students.
Study Limitations
The main limitation of this research is that the content of Bologna course information packages may have yet to be published or presented in a general way on the web pages of some nursing programs. However, this research, which was conducted for the first time to examine the SRH courses offered in the undergraduate nursing programs of universities in Turkey, made it possible to map the current status of the SRH course, which contents are included, and which ones are the most common.
In addition, in this study, only the SRH course was focused on. The courses such as obstetrics and gynecology nursing, oncology nursing, ınternal medicine nursing, geriatric nursing, etc., in the curriculum of the nursing undergraduate program, also include the content of the SRH course.
Conclusion
In this research, it has been determined that SRH courses need to be sufficiently included in the curriculum of nursing undergraduate programs in Turkey. In addition, although most of the programs with SRH courses have a Bologna course information package, it has been observed that the components (the semester in which it is given, evaluation criteria, learning methods, etc.) are either not shared at all or are shared superficially. It has been determined that there are differences in the name, type, semester, evaluation criteria, learning methods, national and ECTS credits, theoretical course hours, and course contents of the SRH courses conducted in the undergraduate nursing programs of the universities within the scope of the research.
In line with the research results, it is recommended to minimize the differences in SRH courses, provide standardization by reviewing the course contents, and integrate the SRH course into the curriculum of nursing undergraduate programs throughout the country. It is predicted that the research results will contribute to the development of SRH education in nursing undergraduate programs and to the graduation of nursing students who will take responsibility for the care of healthy/sick individuals in the future as having competence in SRH.
Ethics Committee Approval: Since the Higher Education Information Management System and the web pages of universities are accessible and the research does not include human participants, ethics committee and institutional permission approval was not required for this study.
Informed Consent: Not required.
Peer-review: Externally peer-reviewed.
Author Contributions: Conception – F.U.Ş, S.Y.H.; Design – F.U.Ş, S.Y.H.; Data Collection and/or Processing – F.U.Ş, S.Y.H.; Analysis and/or Interpretation – F.U.Ş, S.Y.H.; Literature Review – F.U.Ş, S.Y.H.; Writing – F.U.Ş, S.Y.H.
Declaration of Interests: No conflict of interest was declared by the authors.
Funding: The authors declared that this study received no financial support.