CPD
4 Page 60
Sexual health multiple choice questionnaire
CONTINUING PROFESSIONAL DEVELOPMENT
4 Page 61
Brenda Chivima’s practice profile on bone disease
4 Page 62
Guidelines on how to write a practice profile
Promoting sexual health and wellbeing: the role of the nurse NS718 Evans DT (2013) Promoting sexual health and wellbeing: the role of the nurse. Nursing Standard. 28, 10, 53-57. Date of submission: March 4 2013; date of acceptance: June 10 2013.
Abstract Anecdotal evidence from clinical practice, classroom learning and research studies suggests most aspects of sexual health and wellbeing are addressed inadequately or not at all. Some nurses may feel ill-equipped or underprepared to explore private or intimate aspects of a patient’s sexual health or relationships, or may be too embarrassed to talk to the individual about the personal side effects of medical conditions or treatment regimens. This article identifies strategies to assist healthcare professionals in addressing patients’ sexual health needs as part of holistic care.
Author David Thomas Evans Senior lecturer in sexual health, School of Health and Social Care, University of Greenwich, London. Correspondence to: [email protected]
4Identify some of the ways in which sexual health and wellbeing are hidden or inadequately addressed in nurse education and clinical practice. 4Reflect on elements of your own learning in relation to meeting patients’ sexual health needs. 4Discuss a triptych or threefold approach in which sexual wellbeing is integral to holistic care, is associated with other health conditions and includes specific sexual problems traditionally referred to as sexual health. 4Consider implementing sexual health interventions in your practice setting.
Introduction
Keywords Holistic care, sexual health and wellbeing, sexuality, stigma
Review All articles are subject to external double-blind peer review and checked for plagiarism using automated software.
Online Guidelines on writing for publication are available at www.nursing-standard.co.uk. For related articles visit the archive and search using the keywords above.
Serrant-Green (2005), a sexual health researcher, stated that ‘sexual health nursing as a distinct area of practice does not really exist’. This reinforces the difficulties in categorising sexual health, particularly in the presence of the many and varied meanings and interpretations worldwide (World Health Organization 2006). However, sexual health is important to patients (Serrant-Green 2011), and sexual wellbeing is considered as being on par with physical and psychological wellbeing (Royal College of Nursing (RCN) 2001).
Aims and intended learning outcomes
Lack of educational preparedness
This article aims to raise awareness of the importance of meeting patients’ sexual health needs across all fields of nursing practice. After reading this article and completing the time out activities you should be able to:
Research by Astbury-Ward (2011) and Evans (2011) suggests that many nurses share similar learning experiences, with limited formal pre-registration nurse education in sexual health. Evans (2011) found that nurses were
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CPD sexual health
1 Recall your own pre-registration education or a more recent course and make a list of the sexual health topics covered. This may include sexual infections, or different sexual activities or aspects of sexuality. Do you feel this learning prepared you to address and meet patients’ sexual health needs? 2 Think back to your early nursing career. What learning about different aspects of sex, sexualities or sexual health took place in your various clinical placements? Have you been able to apply this knowledge to your practice?
not adequately prepared to address the sexual health needs of patients, and when confronted by sexual health issues in clinical practice during their early career, most nurses found that their learning potential was restricted or thwarted. Lawler (1991) stated that ‘there is sometimes considerable dislocation between classroom/textbook knowledge and what is learned in clinical practice.’ This is significant because nurses are called on to be reflective practitioners (Cole 2005) and part of the experiential learning potential from reflection on or in practice comes from how clinical peers and the environment, and mentors and educators, help nurses to process this learning. Lack of educational preparedness to deal with matters relating to sexual health is problematic and ‘it is unsatisfactory that many nurses are not afforded the opportunities to achieve a level of learning commensurate with their clients’ needs, and their own skills and professional developments’ (RCN 2001). For example, Evans (2011) found that few nurses were given the opportunity to work in abortion services, with even less being given the emotional, psychological and educational support to cope with clinical dilemmas such as caring for a woman having an abortion in a bed on a gynaecology ward, and a woman experiencing a miscarriage in a bed nearby. Complete time out activities 1 and 2
Sexual health and wellbeing: a triptych approach Lawler (1991) highlighted nurses’ reluctance to instigate therapeutic sex talk, history taking
or safer sex advice-giving, as well as difficulty talking about certain sexual acts, body parts or intimate relationships. Sexual health and wellbeing continue to be seen as taboo subjects, despite increasing media coverage and more open discussion in the UK (French 2009). It is essential that nurses have the confidence to identify and meet patients’ sexual health needs. Evans (2011) identified three main domains for sexual health and wellbeing that nurses need to address during care provision (Table 1): 4Sexual wellbeing integral to holistic care. 4Sexual wellbeing associated with other health conditions. 4Sexual wellbeing including specific sexual problems and infections traditionally referred to as sexual health. Evans (2011) described sexual wellbeing as starting with the foundations, in other words, the holistic areas of sexual health and wellbeing as they relate to the person (Dattilo and Brewer 2005). These foundations include matters of enjoyment and performance of sex, as well as the individual’s sexual identity and relationships. The second domain includes sexual performance or lack of it, which may be secondary to or affected by the patient’s illness or injury, surgery, conditions or treatment regimen. Finally, the third domain includes the narrow definitions of sexual health specialties or fields of practice, which are routinely found in government strategies and statistics on matters such as reproductive health, unplanned conceptions and teenage pregnancies, abortion, psychosexual counselling, sexual infections and human immunodeficiency virus.
TABLE 1 Three domains of health and sexual wellbeing Foundations of sexual wellbeing (integral to holistic care)
Associated aspects of sexual wellbeing (secondary to other healthcare conditions, treatments or therapeutic interventions)
Specifics of sexual health: illnesses and problems (across sexual health specialties or fields of practice)
4Implications of an individual’s gender and sexual orientation on his or her health and wellbeing. 4Sexual desire and performance. 4Sexual relationships. 4Reproductive health. 4Safer sexual practices – awareness and resources for the client, irrespective of his or her sexuality. 4Freedom from discrimination. 4Ability to express sexuality consistent with self-actualisation and fulfilment.
4Post-menopausal vaginal dryness. 4Erectile dysfunction pertaining to diabetes, hypertension, high alcohol consumption and obesity. 4Loss of libido associated with certain mental health conditions such as depression, or as a consequence of treatments and medications. 4Poor self-image as a result of disfiguring injury, body-altering surgery, disabilities or chronic pain.
4Sexually transmitted infections. 4Reproductive health, including unplanned, unwanted and teenage conceptions. 4Abortion and repeat abortions. 4Human immunodeficiency virus. 4Psychosexual issues, including various sexual dysfunctions, intimate partner violence, rape, and sexual and domestic abuse.
(Evans 2011)
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Each of the domains in Evans’ (2011) sexual health and wellbeing triptych approach are routinely surrounded by what the National Assembly for Wales (2000) and the Department of Health (DH) (2001) termed sexual health stigmas. The French philosopher Michel Foucault (1984) coined the phrase: ‘triple edict’ of ‘taboo, non-existence and silence’ to describe such stigmas, which Evans (2011) suggested made sexual wellbeing somewhat invisible in nursing care. To ignore or deny individuals’ sexual health needs suggests they are not sexual beings with particular feelings and desires, and may result in stigmatising such individuals (RCN 2001). It should be noted, however, that not all aspects of sexuality and sexual health are hidden or ignored. In the UK, for example, there is a plethora of images and messages about sexual health and wellbeing, including public debates about the sexualisation of youth, and regular announcements of teenage pregnancy, sexual infections and repeat abortion rates. There are also important equality issues for lesbian, gay, bisexual and transgender people that need to be considered when providing health care (DH 2007, Burrows 2011a, Lomas 2013). Therefore, it is difficult to understand why many nurses are still reluctant to address the sexual health dimensions of their patients’ care. Many sexual health issues continue to be surrounded by stigma, for example matters concerning abortion. Some people still prefer not to discuss abortion, despite it being a legally permitted act in the UK since 1967, with the exception of Northern Ireland, and with around one in three women undergoing abortion at least once by the age of 40 (Astbury-Ward 2012). Some individuals prefer to use the phrase termination of pregnancy. However, some women and healthcare professionals are reclaiming the term abortion in an attempt to address any taboo associations (French 2009). Similarly, some nurses and/or patients find it difficult to use certain words, especially those relating to sexuality or sexual health, in front of others, whether healthcare professionals or patients. Lawler (1991) advised that ‘if nurses are not embarrassed, it gives permission also for the patient to feel no embarrassment, but nurses must first learn to manage their own embarrassment and to convey the impression that they are not feeling uncomfortable’. The use of euphemisms to describe sexual organs, non-procreative acts, non-heterosexual identities and transgender people is also common
(Burrows 2011b), particularly if the individual associates particular words with vulgarity (Lawler 1991). Eadie (2004) suggested that ‘abject’ refers to what people may find vulgar or dirty, or ‘the messy, biological components of our body’. However, Eadie (2004) also stated that ‘sexual health education must therefore take account of irrational fears in enabling people to feel comfortable with their own bodily processes’. Complete time out activity 3
ABC of sexual health learning To enhance sexual health learning and provide optimum patient care, healthcare professionals should adopt the ABC (Attitudes, Beliefs, Clinical practice) approach (RCN 2001). This will not only enhance professional development, but also personal development by encouraging healthcare professionals to identify any attitudes and beliefs that may hinder delivery of effective patient care.
Attitudes
Honest reflection and acknowledgement of nurses’ personal attitudes towards an individual or aspect of his or her sexual health and wellbeing is essential to provide optimum care. For example, some attitudes may result in healthcare professionals prejudging or stigmatising patients, making it difficult to provide best care (RCN 2001).
Beliefs
Attitudes and associated underlying feelings are frequently related to individuals’ belief systems, whether these beliefs are formally acknowledged such as in a professed faith or religious creed, or are a hunch or intuition when there is a sense that something feels right or wrong. As with attitudes, particular beliefs can affect healthcare professionals’ ability to provide non-judgemental and non-discriminatory care (RCN 2001).
Clinical practice
Nurses’ attitudes and beliefs can affect their professional practice. Many nurses are not adequately prepared for a number of the difficult and often complex situations they face in clinical practice, and may not be given adequate opportunities to critically reflect on their practice. To provide care that meets patients’ sexual health needs and to inform nursing practice, nurses need to examine and work through their attitudes and beliefs (RCN 2001). Complete time out activity 4
3 ‘Inside, I felt quite angry at this young woman coming in for her fourth termination of pregnancy in two years. Why the hell didn’t she use contraception?!’ With contraception and condoms freely available, why might a woman choose to have four abortions in two years? How might you relate or respond to this woman? Would your attitude and beliefs change if you knew this woman had been to four different abortion providers, so as not to be negatively judged by one provider? 4 Revisit the scenario above. On critical reflection, the nurse said that her opinions of the young woman and her situation changed when she found out that the 18-year-old was in a forced marriage to a man more than 40 years her senior. The patient said she could not bring herself to have a baby with her husband, and that she could not take the contraceptive pill because she feared that her husband would harm her if he found out. She knew of no other way to deal with her dilemma. Compare your feelings toward the patient in time out 3 and time out 4. Has your attitude changed? If so, how might this affect the care and support you would offer the patient?
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CPD sexual health Improving practice using the Ex-PLISSIT model Each of the three domains of sexual health and wellbeing identified by Evans (2011) can be approached using the PLISSIT model (Annon 1976) or the extended Ex-PLISSIT version developed by Taylor and Davis (2006, 2007) (Figure 1). The original PLISSIT model includes: 4Permission-giving. 4Limited Information. 4Specific Suggestions. 4Intensive Therapy. Taylor and Davis (2006, 2007) enhanced the PLISSIT model in a number of ways. They included permission-giving not as a one-off first step to open up a discussion on sexual health, but at the centre of every other step and, crucially, repeated for all encounters with the patient to ensure sexual wellbeing is maintained. This may involve repeating permission-giving to the client and/or requesting permission to revisit the topic again by saying, for example: ‘Last time you were here for your travel vaccinations, we briefly discussed how you can protect yourself from sexual infections when on holiday. As
5 List some of the sexual health issues that you have come across in clinical practice. Select one sexual health issue that you find challenging to deal with and use the Ex-PLISSIT model in conjunction with the ABC of sexual health learning to plan how you would best approach a discussion with a patient on this topic. You may want to discuss this process with a colleague.
FIGURE 1 Ex-PLISSIT model Review
fl Re
K n ow
le d
ge
t ec Ch
a ll en
ne ss
tio n s
Self-aware
t
um p
IT
LI
Reflect
Re vie w
flec
ass
Re
ct
ge
Refl e
vi e Re
P
w
iew
SS
Rev
ec Refl
t
Review
Key P = Permission-giving; LI = Limited Information; SS = Specific Suggestions; IT = Intensive Therapy (Taylor and Davis 2006, 2007)
56 november 6 :: vol 28 no 10 :: 2013
you requested, there is more time for us to discuss this today and for me to signpost you to free condoms if you wish’. Taylor and Davis (2006, 2007) also surrounded each element of the original PLISSIT model with two new interrelating activities: reflect and review, requiring the practitioner to demonstrate self-awareness, similar to the requirements of the ABC approach (RCN 2001). Reflection of this nature is aimed at helping the practitioner see beyond the performance of clinical tasks and to explore and analyse any biases or preconceptions that may hinder the delivery of effective care and prevent the development of a therapeutic relationship with the patient. Taylor and Davis (2006, 2007) argued that reflection and review need to be continuous because sexual wellbeing may alter throughout the individual’s life. Reflection and review are essential to ensure that healthcare professionals gain an insight into their own and/or patients’ attitudes, beliefs and feelings about particular sexual issues, to better understand how to provide appropriate care and what might hinder such care. Reflection and review may also involve colleagues and mentors, therefore enhancing clinical practice through shared learning. Taylor and Davis’ (2006, 2007) extended aspects of self-awareness, reflection, review, knowledge and challenge assumptions can be used to address all three domains of sexual health and wellbeing (Evans 2011). For example, permission-giving needs to be repeated often and with all new areas of discussion. An effective way to introduce talking about sexual issues is to say something like: ‘Many people with your condition have concerns related to sexual intimacy’. This should not be followed by a closed question such as: ‘Have you got any worries or problems in this regard?’ because if the patient responds with ‘No’, then it might be difficult to raise the issue with this patient again. Instead, an open question should be used such as: ‘Many men with diabetes experience problems with erections. How does diabetes affect you in this regard?’ (Roberts and Evans 2007, Evans and Stapley 2010a, 2010b). Although nurses may have limited information, the ability to make specific suggestions and refer the patient to appropriate resources or services can instil confidence in the patient. As Matthews (2009) stated ‘Open discussion using evidence-based information together with practical advice will reduce the patient’s immediate anxieties’. Complete time out activity 5
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By using personal reflection throughout the various stages of the Ex-PLISSIT model, the healthcare professional is able to explore the ABC of sexual health learning and identify any negative attitudes and beliefs and moderate these to ensure that care provision is not
BOX 1 Education and training resources for sexual health
affected. As well as using the Ex-PLISSIT model to improve practice, sexual health education and training should address patient needs in a wide range of settings, to ensure that healthcare professionals are adequately prepared to address these issues during health encounters. Training is available from a number of sources, some of which are shown in Box 1.
Conclusion
4Genito-urinary Nurses Association (www.guna.org.uk) – promotes sexual health nurses’ skills and development through education, training and encouraging networking between professionals. 4Society of Sexual Health Advisers (www.ssha.info) – a UK organisation providing an opportunity for members to meet and work towards further professional development. 4British Association for Sexual Health and HIV (www.bashh.org) – provides information on general and specialist education and courses that reflect the multidisciplinary nature of sexual health.
Sexuality and sexual health are challenging areas in nursing and should be approached in a way that respects patients’ confidentiality while sensitively exploring individuals’ needs. Sexual health and wellbeing are a component of holistic care, and healthcare professionals have a responsibility to ensure that patients’ sexual health needs are met or that individuals are referred to appropriate services. Self-awareness and reflection are essential to ensure that healthcare professionals’ attitudes and beliefs do not hinder the delivery of effective care NS Complete time out activity 6
6 Now that you have completed the article, you might like to write a practice profile. Guidelines to help you are on page 62.
References Annon J (1976) The PLISSIT model: a proposed conceptual scheme for the behavioural treatment of sexual problems. Journal of Sex Education Therapy. 2, 1, 1-15. Astbury-Ward E (2011) A questionnaire survey of the provision of training in human sexuality in schools of nursing in the United Kingdom. Sexual and Relationship Therapy. 26, 3, 254-270. Astbury-Ward E (2012) Stigma, abortion, and disclosure: findings from a qualitative study. Journal of Sexual Medicine. 9, 12, 3137-3147. Burrows G (2011a) Lesbian, gay, bisexual and transgender health, part 1: sexual orientation. Practice Nurse. 41, 3, 23-25. Burrows G (2011b) Lesbian, gay, bisexual and transgender health, part 2: gender identity. Practice Nurse. 41, 4, 22-25. Cole M (2005) Reflection in healthcare practice: why is it useful and how might it be done? Work Based Learning in Primary Care. 3, 1, 13-22.
Dattilo J, Brewer MK (2005) Assessing clients’ sexual health as a component of holistic nursing practice: senior nursing students share their experiences. Journal of Holistic Nursing. 23, 2, 208-219. Department of Health (2001) The National Strategy for Sexual Health and HIV. The Stationery Office, London. Department of Health (2007) Reducing Health Inequalities for Lesbian, Gay, Bisexual and Trans People: Briefings for Health and Social Care Staff. The Stationery Office, London. Eadie J (Ed) (2004) Sexuality: The Essential Glossary. Arnold, London. Evans DT (2011) Sexual Health Matters! Learning for Life: Mapping Client Need and Professional Education for Nurses in England. University of Greenwich, London. Evans DT, Stapley L (2010a) Sexual health issues in men – part 1. Practice Nurse. 40, 5, 30-34. Evans DT, Stapley L (2010b) Sexual health issues in men – part 2.
Practice Nurse. 40, 6, 33-36. Foucault M (1984) The History of Sexuality. Volume 1: An Introduction. Penguin Books, London. French K (Ed) (2009) Sexual Health. Wiley-Blackwell, Oxford. Lawler J (1991) Behind the Screens: Nursing, Somology and the Problems of the Body. Churchill Livingstone, Edinburgh. Lomas C (2013) Health care with dignity, courtesy and respect. Nursing Standard. 27, 23, 16-18. Matthews V (2009) Sexual dysfunction in people with long-term neurological conditions. Nursing Standard. 23, 50, 48-56. National Assembly for Wales (2000) A Strategic Framework for Promoting Sexual Health in Wales. National Assembly for Wales Cardiff. Roberts C, Evans DT (2007) Male Health. In Cross S, Rimmer M (Eds) Nurse Practitioner Manual of Clinical Skills. Second edition. Saunders Elsevier, Edinburgh, 253-270.
Royal College of Nursing (2001) Sexual Health Strategy: Guidance for Nursing Staff. RCN, London. Serrant-Green L (2005) Breaking traditions: sexual health and ethnicity in nursing research: a literature review. Journal of Advanced Nursing. 51, 5, 511-519. Serrant-Green L (2011) The sound of ‘silence’: a framework for researching sensitive issues or marginalised perspectives in health. Journal of Research in Nursing. 16, 4, 347-360. Taylor B, Davis S (2006) Using the Extended PLISSIT model to address sexual healthcare needs. Nursing Standard. 21, 11, 35-40. Taylor B, Davis S (2007) The Extended PLISSIT model for addressing the sexual wellbeing of individuals with an acquired disability or chronic illness. Sexuality and Disability. 25, 3, 135-139. World Health Organization (2006) Defining Sexual Health. Report of A Technical Consultation on Sexual Health. WHO, Geneva.
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4 Page 60
Sexual health multiple choice questionnaire
CONTINUING PROFESSIONAL DEVELOPMENT
4 Page 61
Brenda Chivima’s practice profile on bone disease
4 Page 62
Guidelines on how to write a practice profile
Promoting sexual health and wellbeing: the role of the nurse NS718 Evans DT (2013) Promoting sexual health and wellbeing: the role of the nurse. Nursing Standard. 28, 10, 53-57. Date of submission: March 4 2013; date of acceptance: June 10 2013.
Abstract Anecdotal evidence from clinical practice, classroom learning and research studies suggests most aspects of sexual health and wellbeing are addressed inadequately or not at all. Some nurses may feel ill-equipped or underprepared to explore private or intimate aspects of a patient’s sexual health or relationships, or may be too embarrassed to talk to the individual about the personal side effects of medical conditions or treatment regimens. This article identifies strategies to assist healthcare professionals in addressing patients’ sexual health needs as part of holistic care.
Author David Thomas Evans Senior lecturer in sexual health, School of Health and Social Care, University of Greenwich, London. Correspondence to: [email protected]
4Identify some of the ways in which sexual health and wellbeing are hidden or inadequately addressed in nurse education and clinical practice. 4Reflect on elements of your own learning in relation to meeting patients’ sexual health needs. 4Discuss a triptych or threefold approach in which sexual wellbeing is integral to holistic care, is associated with other health conditions and includes specific sexual problems traditionally referred to as sexual health. 4Consider implementing sexual health interventions in your practice setting.
Introduction
Keywords Holistic care, sexual health and wellbeing, sexuality, stigma
Review All articles are subject to external double-blind peer review and checked for plagiarism using automated software.
Online Guidelines on writing for publication are available at www.nursing-standard.co.uk. For related articles visit the archive and search using the keywords above.
Serrant-Green (2005), a sexual health researcher, stated that ‘sexual health nursing as a distinct area of practice does not really exist’. This reinforces the difficulties in categorising sexual health, particularly in the presence of the many and varied meanings and interpretations worldwide (World Health Organization 2006). However, sexual health is important to patients (Serrant-Green 2011), and sexual wellbeing is considered as being on par with physical and psychological wellbeing (Royal College of Nursing (RCN) 2001).
Aims and intended learning outcomes
Lack of educational preparedness
This article aims to raise awareness of the importance of meeting patients’ sexual health needs across all fields of nursing practice. After reading this article and completing the time out activities you should be able to:
Research by Astbury-Ward (2011) and Evans (2011) suggests that many nurses share similar learning experiences, with limited formal pre-registration nurse education in sexual health. Evans (2011) found that nurses were
©Downloaded NURSINGfrom STANDARD / RCN PUBLISHING november 6 :: vol 28 no 10 :: 2013 53 RCNi.com by ${individualUser.displayName} on May 14, 2015. For personal use only. No other uses without permission. Copyright © 2015 RCN Publishing Ltd. All rights reserved.
CPD sexual health
1 Recall your own pre-registration education or a more recent course and make a list of the sexual health topics covered. This may include sexual infections, or different sexual activities or aspects of sexuality. Do you feel this learning prepared you to address and meet patients’ sexual health needs? 2 Think back to your early nursing career. What learning about different aspects of sex, sexualities or sexual health took place in your various clinical placements? Have you been able to apply this knowledge to your practice?
not adequately prepared to address the sexual health needs of patients, and when confronted by sexual health issues in clinical practice during their early career, most nurses found that their learning potential was restricted or thwarted. Lawler (1991) stated that ‘there is sometimes considerable dislocation between classroom/textbook knowledge and what is learned in clinical practice.’ This is significant because nurses are called on to be reflective practitioners (Cole 2005) and part of the experiential learning potential from reflection on or in practice comes from how clinical peers and the environment, and mentors and educators, help nurses to process this learning. Lack of educational preparedness to deal with matters relating to sexual health is problematic and ‘it is unsatisfactory that many nurses are not afforded the opportunities to achieve a level of learning commensurate with their clients’ needs, and their own skills and professional developments’ (RCN 2001). For example, Evans (2011) found that few nurses were given the opportunity to work in abortion services, with even less being given the emotional, psychological and educational support to cope with clinical dilemmas such as caring for a woman having an abortion in a bed on a gynaecology ward, and a woman experiencing a miscarriage in a bed nearby. Complete time out activities 1 and 2
Sexual health and wellbeing: a triptych approach Lawler (1991) highlighted nurses’ reluctance to instigate therapeutic sex talk, history taking
or safer sex advice-giving, as well as difficulty talking about certain sexual acts, body parts or intimate relationships. Sexual health and wellbeing continue to be seen as taboo subjects, despite increasing media coverage and more open discussion in the UK (French 2009). It is essential that nurses have the confidence to identify and meet patients’ sexual health needs. Evans (2011) identified three main domains for sexual health and wellbeing that nurses need to address during care provision (Table 1): 4Sexual wellbeing integral to holistic care. 4Sexual wellbeing associated with other health conditions. 4Sexual wellbeing including specific sexual problems and infections traditionally referred to as sexual health. Evans (2011) described sexual wellbeing as starting with the foundations, in other words, the holistic areas of sexual health and wellbeing as they relate to the person (Dattilo and Brewer 2005). These foundations include matters of enjoyment and performance of sex, as well as the individual’s sexual identity and relationships. The second domain includes sexual performance or lack of it, which may be secondary to or affected by the patient’s illness or injury, surgery, conditions or treatment regimen. Finally, the third domain includes the narrow definitions of sexual health specialties or fields of practice, which are routinely found in government strategies and statistics on matters such as reproductive health, unplanned conceptions and teenage pregnancies, abortion, psychosexual counselling, sexual infections and human immunodeficiency virus.
TABLE 1 Three domains of health and sexual wellbeing Foundations of sexual wellbeing (integral to holistic care)
Associated aspects of sexual wellbeing (secondary to other healthcare conditions, treatments or therapeutic interventions)
Specifics of sexual health: illnesses and problems (across sexual health specialties or fields of practice)
4Implications of an individual’s gender and sexual orientation on his or her health and wellbeing. 4Sexual desire and performance. 4Sexual relationships. 4Reproductive health. 4Safer sexual practices – awareness and resources for the client, irrespective of his or her sexuality. 4Freedom from discrimination. 4Ability to express sexuality consistent with self-actualisation and fulfilment.
4Post-menopausal vaginal dryness. 4Erectile dysfunction pertaining to diabetes, hypertension, high alcohol consumption and obesity. 4Loss of libido associated with certain mental health conditions such as depression, or as a consequence of treatments and medications. 4Poor self-image as a result of disfiguring injury, body-altering surgery, disabilities or chronic pain.
4Sexually transmitted infections. 4Reproductive health, including unplanned, unwanted and teenage conceptions. 4Abortion and repeat abortions. 4Human immunodeficiency virus. 4Psychosexual issues, including various sexual dysfunctions, intimate partner violence, rape, and sexual and domestic abuse.
(Evans 2011)
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Each of the domains in Evans’ (2011) sexual health and wellbeing triptych approach are routinely surrounded by what the National Assembly for Wales (2000) and the Department of Health (DH) (2001) termed sexual health stigmas. The French philosopher Michel Foucault (1984) coined the phrase: ‘triple edict’ of ‘taboo, non-existence and silence’ to describe such stigmas, which Evans (2011) suggested made sexual wellbeing somewhat invisible in nursing care. To ignore or deny individuals’ sexual health needs suggests they are not sexual beings with particular feelings and desires, and may result in stigmatising such individuals (RCN 2001). It should be noted, however, that not all aspects of sexuality and sexual health are hidden or ignored. In the UK, for example, there is a plethora of images and messages about sexual health and wellbeing, including public debates about the sexualisation of youth, and regular announcements of teenage pregnancy, sexual infections and repeat abortion rates. There are also important equality issues for lesbian, gay, bisexual and transgender people that need to be considered when providing health care (DH 2007, Burrows 2011a, Lomas 2013). Therefore, it is difficult to understand why many nurses are still reluctant to address the sexual health dimensions of their patients’ care. Many sexual health issues continue to be surrounded by stigma, for example matters concerning abortion. Some people still prefer not to discuss abortion, despite it being a legally permitted act in the UK since 1967, with the exception of Northern Ireland, and with around one in three women undergoing abortion at least once by the age of 40 (Astbury-Ward 2012). Some individuals prefer to use the phrase termination of pregnancy. However, some women and healthcare professionals are reclaiming the term abortion in an attempt to address any taboo associations (French 2009). Similarly, some nurses and/or patients find it difficult to use certain words, especially those relating to sexuality or sexual health, in front of others, whether healthcare professionals or patients. Lawler (1991) advised that ‘if nurses are not embarrassed, it gives permission also for the patient to feel no embarrassment, but nurses must first learn to manage their own embarrassment and to convey the impression that they are not feeling uncomfortable’. The use of euphemisms to describe sexual organs, non-procreative acts, non-heterosexual identities and transgender people is also common
(Burrows 2011b), particularly if the individual associates particular words with vulgarity (Lawler 1991). Eadie (2004) suggested that ‘abject’ refers to what people may find vulgar or dirty, or ‘the messy, biological components of our body’. However, Eadie (2004) also stated that ‘sexual health education must therefore take account of irrational fears in enabling people to feel comfortable with their own bodily processes’. Complete time out activity 3
ABC of sexual health learning To enhance sexual health learning and provide optimum patient care, healthcare professionals should adopt the ABC (Attitudes, Beliefs, Clinical practice) approach (RCN 2001). This will not only enhance professional development, but also personal development by encouraging healthcare professionals to identify any attitudes and beliefs that may hinder delivery of effective patient care.
Attitudes
Honest reflection and acknowledgement of nurses’ personal attitudes towards an individual or aspect of his or her sexual health and wellbeing is essential to provide optimum care. For example, some attitudes may result in healthcare professionals prejudging or stigmatising patients, making it difficult to provide best care (RCN 2001).
Beliefs
Attitudes and associated underlying feelings are frequently related to individuals’ belief systems, whether these beliefs are formally acknowledged such as in a professed faith or religious creed, or are a hunch or intuition when there is a sense that something feels right or wrong. As with attitudes, particular beliefs can affect healthcare professionals’ ability to provide non-judgemental and non-discriminatory care (RCN 2001).
Clinical practice
Nurses’ attitudes and beliefs can affect their professional practice. Many nurses are not adequately prepared for a number of the difficult and often complex situations they face in clinical practice, and may not be given adequate opportunities to critically reflect on their practice. To provide care that meets patients’ sexual health needs and to inform nursing practice, nurses need to examine and work through their attitudes and beliefs (RCN 2001). Complete time out activity 4
3 ‘Inside, I felt quite angry at this young woman coming in for her fourth termination of pregnancy in two years. Why the hell didn’t she use contraception?!’ With contraception and condoms freely available, why might a woman choose to have four abortions in two years? How might you relate or respond to this woman? Would your attitude and beliefs change if you knew this woman had been to four different abortion providers, so as not to be negatively judged by one provider? 4 Revisit the scenario above. On critical reflection, the nurse said that her opinions of the young woman and her situation changed when she found out that the 18-year-old was in a forced marriage to a man more than 40 years her senior. The patient said she could not bring herself to have a baby with her husband, and that she could not take the contraceptive pill because she feared that her husband would harm her if he found out. She knew of no other way to deal with her dilemma. Compare your feelings toward the patient in time out 3 and time out 4. Has your attitude changed? If so, how might this affect the care and support you would offer the patient?
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CPD sexual health Improving practice using the Ex-PLISSIT model Each of the three domains of sexual health and wellbeing identified by Evans (2011) can be approached using the PLISSIT model (Annon 1976) or the extended Ex-PLISSIT version developed by Taylor and Davis (2006, 2007) (Figure 1). The original PLISSIT model includes: 4Permission-giving. 4Limited Information. 4Specific Suggestions. 4Intensive Therapy. Taylor and Davis (2006, 2007) enhanced the PLISSIT model in a number of ways. They included permission-giving not as a one-off first step to open up a discussion on sexual health, but at the centre of every other step and, crucially, repeated for all encounters with the patient to ensure sexual wellbeing is maintained. This may involve repeating permission-giving to the client and/or requesting permission to revisit the topic again by saying, for example: ‘Last time you were here for your travel vaccinations, we briefly discussed how you can protect yourself from sexual infections when on holiday. As
5 List some of the sexual health issues that you have come across in clinical practice. Select one sexual health issue that you find challenging to deal with and use the Ex-PLISSIT model in conjunction with the ABC of sexual health learning to plan how you would best approach a discussion with a patient on this topic. You may want to discuss this process with a colleague.
FIGURE 1 Ex-PLISSIT model Review
fl Re
K n ow
le d
ge
t ec Ch
a ll en
ne ss
tio n s
Self-aware
t
um p
IT
LI
Reflect
Re vie w
flec
ass
Re
ct
ge
Refl e
vi e Re
P
w
iew
SS
Rev
ec Refl
t
Review
Key P = Permission-giving; LI = Limited Information; SS = Specific Suggestions; IT = Intensive Therapy (Taylor and Davis 2006, 2007)
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you requested, there is more time for us to discuss this today and for me to signpost you to free condoms if you wish’. Taylor and Davis (2006, 2007) also surrounded each element of the original PLISSIT model with two new interrelating activities: reflect and review, requiring the practitioner to demonstrate self-awareness, similar to the requirements of the ABC approach (RCN 2001). Reflection of this nature is aimed at helping the practitioner see beyond the performance of clinical tasks and to explore and analyse any biases or preconceptions that may hinder the delivery of effective care and prevent the development of a therapeutic relationship with the patient. Taylor and Davis (2006, 2007) argued that reflection and review need to be continuous because sexual wellbeing may alter throughout the individual’s life. Reflection and review are essential to ensure that healthcare professionals gain an insight into their own and/or patients’ attitudes, beliefs and feelings about particular sexual issues, to better understand how to provide appropriate care and what might hinder such care. Reflection and review may also involve colleagues and mentors, therefore enhancing clinical practice through shared learning. Taylor and Davis’ (2006, 2007) extended aspects of self-awareness, reflection, review, knowledge and challenge assumptions can be used to address all three domains of sexual health and wellbeing (Evans 2011). For example, permission-giving needs to be repeated often and with all new areas of discussion. An effective way to introduce talking about sexual issues is to say something like: ‘Many people with your condition have concerns related to sexual intimacy’. This should not be followed by a closed question such as: ‘Have you got any worries or problems in this regard?’ because if the patient responds with ‘No’, then it might be difficult to raise the issue with this patient again. Instead, an open question should be used such as: ‘Many men with diabetes experience problems with erections. How does diabetes affect you in this regard?’ (Roberts and Evans 2007, Evans and Stapley 2010a, 2010b). Although nurses may have limited information, the ability to make specific suggestions and refer the patient to appropriate resources or services can instil confidence in the patient. As Matthews (2009) stated ‘Open discussion using evidence-based information together with practical advice will reduce the patient’s immediate anxieties’. Complete time out activity 5
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By using personal reflection throughout the various stages of the Ex-PLISSIT model, the healthcare professional is able to explore the ABC of sexual health learning and identify any negative attitudes and beliefs and moderate these to ensure that care provision is not
BOX 1 Education and training resources for sexual health
affected. As well as using the Ex-PLISSIT model to improve practice, sexual health education and training should address patient needs in a wide range of settings, to ensure that healthcare professionals are adequately prepared to address these issues during health encounters. Training is available from a number of sources, some of which are shown in Box 1.
Conclusion
4Genito-urinary Nurses Association (www.guna.org.uk) – promotes sexual health nurses’ skills and development through education, training and encouraging networking between professionals. 4Society of Sexual Health Advisers (www.ssha.info) – a UK organisation providing an opportunity for members to meet and work towards further professional development. 4British Association for Sexual Health and HIV (www.bashh.org) – provides information on general and specialist education and courses that reflect the multidisciplinary nature of sexual health.
Sexuality and sexual health are challenging areas in nursing and should be approached in a way that respects patients’ confidentiality while sensitively exploring individuals’ needs. Sexual health and wellbeing are a component of holistic care, and healthcare professionals have a responsibility to ensure that patients’ sexual health needs are met or that individuals are referred to appropriate services. Self-awareness and reflection are essential to ensure that healthcare professionals’ attitudes and beliefs do not hinder the delivery of effective care NS Complete time out activity 6
6 Now that you have completed the article, you might like to write a practice profile. Guidelines to help you are on page 62.
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Royal College of Nursing (2001) Sexual Health Strategy: Guidance for Nursing Staff. RCN, London. Serrant-Green L (2005) Breaking traditions: sexual health and ethnicity in nursing research: a literature review. Journal of Advanced Nursing. 51, 5, 511-519. Serrant-Green L (2011) The sound of ‘silence’: a framework for researching sensitive issues or marginalised perspectives in health. Journal of Research in Nursing. 16, 4, 347-360. Taylor B, Davis S (2006) Using the Extended PLISSIT model to address sexual healthcare needs. Nursing Standard. 21, 11, 35-40. Taylor B, Davis S (2007) The Extended PLISSIT model for addressing the sexual wellbeing of individuals with an acquired disability or chronic illness. Sexuality and Disability. 25, 3, 135-139. World Health Organization (2006) Defining Sexual Health. Report of A Technical Consultation on Sexual Health. WHO, Geneva.
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