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Psychosexual awareness: an invaluable skill for nurses

Elizabeth Cort
RGN RMN DN MSc
Research Nurse
Association of Psychosexual Nursing
London
This article was written with ­reference to ­material prepared by members of the Executive Committee of the Association of Psychosexual Nursing
E:psychosexualnursing@btopenworld.com

Sexual adjustment is an important component of overall wellbeing and mental health, and is a building block of our self-esteem and self-image.(1) When sexual care is not acknowledged as part of every healthcare practitioner's concern and responsibility, the principle of holistic care is lost and there is potential for patients' needs to remain unmet.(2) Psychosexual awareness is a crucial component of nursing and healthcare (see Box 1).

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Although the nursing literature expounds the notion of sexuality as an integrated dimension of nursing care, difficulties persist as to how such theory translates into nursing practice.(4) Health professionals remain reticent and uncomfortable in actively broaching sexual matters and assessing patients' sexuality and intimacy needs.(5-9) A recent report by the Family Planning Association found that primary care nurses, including those with family planning qualifications, were less than equipped and lacking in the confidence to deal with sexual health issues.(10)
Primary care nurses are at the forefront of healthcare delivery, preventive healthcare and health education. The Department of Health document National Strategy for Sexual Health and HIV places emphasis on the role of nurses in relation to delivering good standards of practice in relation to sexual healthcare.(11) It highlights the extent to which sexual healthcare is and will be delivered by the primary care team and community services. Training programmes are under review with the proposed training strategy, emphasising a holistic, social model of sexual health.
Although nurses who work in specific sexual health settings may develop specific areas of knowledge and practice, it is important for all nurses to acknowledge sexuality as an intrinsic part of general healthcare. Healthcare professionals need to recognise and respond to the fact that the patients we meet are sexual beings in health and in illness. Continuing training and support are necessary to enable practitioners to develop the confidence needed to respond appropriately to sexuality issues that arise in the context of everyday clinical practice.
Primary care nurses encounter a range of patients who present with a myriad of healthcare needs. Some patients' requests for help are overt, while at other times nurses are required to look beyond the patient's direct communication and be sensitive to their underlying concerns. Many patients choose to share anxieties or broach sensitive issues with nurses. Such disclosures may arise in the context of a routine nursing encounter or procedure. Patients can arouse a range of feelings in the nurse, such as empathy, concern, anger or anxiety. Some feelings provoked are more easily dealt with than others. And yet how the nurse responds to each patient is crucial, as this interaction can be highly influential in terms of the therapeutic outcome of the encounter. When nurses are learning to develop their professional style, careful consideration is needed of how to manage the boundary between personal involvement and professional detachment. This is especially relevant when nurses are faced with people in distress.(2)
All nurses are expected to acquire skills that enable them to listen and respond to the sexual health needs of their patients in everyday clinical practice. Primary care nurses are under increasing pressure to develop their role in sexual health work.(10) Waterhouse, citing a number of references, states that nursing practice in relation to sexuality may include "assessing sexuality, providing anticipatory guidance about sexual development, validating normalcy, educating about sexual health and disease prevention, counselling clients who must adapt to changes in their usual form of sexual expression, providing intensive therapy for sexual problems, and referring clients to other healthcare providers".(12) Professional responsibility includes each nurse being aware that feelings about sexuality, often unspoken, can influence health, complicate responses to treatment, and even impair recovery.(2) Being "aware" of such issues can enable nurses to create a safe forum in which patients can share their feelings if they wish. This choice is vital, and no patient should ever feel under pressure to disclose sexual ­information.
A range of social, cultural and political factors serve to influence the degree of comfort with which health professionals discuss sexuality matters with patients.(13)
It is not unusual for nurses to feel uncertainty and even apprehension about addressing sexual anxieties with patients. Many nurses may remember a time when a patient's distress has left them feeling overwhelmed and unable to help. Sometimes we experience anxiety as we simply don't know what to do. This uncertainty can feel uncomfortable and may trigger defensive or avoidant behaviour. However, recognising this discomfort and reflecting on the area of distress can be a crucial step towards developing skills with which to meet those unmet needs.(2) The Association of Psychosexual Nursing acknowledges that without the appropriate learning it can be tempting for nurses to turn away and ignore patients' sexual anxieties. The Association aims to provide support and training that can enable nurses to develop the ­confidence and skills with which to address these needs.
The Association of Psychosexual Nursing was formed in 1998 (see Box 2). The group provides an active network for the support and training of nurses who wish to develop their psychosexual awareness and skills. As part of their commitment to ongoing professional development, the Association organises two study days each year. The study days provide a forum for nurses to meet and share ideas as well as an opportunity to experience being in a seminar group.

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The Association has a commitment to raising psychosexual awareness through the provision of Balint-style seminars. Members who attend seminar training have the opportunity to gain accreditation with the University of Greenwich. In addition, seminar training serves as a means of clinical supervision.

What is Balint seminar training?
The style of training utilised by the Association of Psychosexual Nursing was developed by Michael Balint, a Hungarian-born psychoanalyst. The initial training groups were developed with doctors at the Tavistock Clinic in the early 1950s. Balint considered the patient-practitioner relationship as a key element of the therapeutic process.(14) (For information on the background and an account of Balint's psychosocial and psychosexual care, see Wells.(2)) Balint seminar training underlines the ­importance of incorporating psychosexual care into everyday work with patients and is applicable to all levels of practice.(2)
The Association currently runs groups in London, Bedford and Bristol. The potential for setting up new groups is also constantly under review. The seminars are made up of no more than 12-15 coequal members. Each group is facilitated by a trained member of the Association. Members present examples of their clinical work for consideration by the group. The complexity of feeling that is aroused by each situation is explored empathetically, discussed and understood as a possible indicator of the patient's needs and feelings. Reflective practice has a number of potential benefits, including skill development, promotion of fresh thinking and making explicit the knowledge embedded in practice.(2) Seminar groups attract a range of nurses with varying levels of experience, the groups are often stimulating, and there is great potential for reward and personal benefit. The seminars serve as a form of clinical supervision and provide a forum for professional development.
The psychosexual seminar groups provide an opportunity for practitioners to develop their skills in relation to everyday practice (see illustrative case study). The focus is on the psychosexual needs of the patient/client in health or illness. The study is always the professional work of the nurse or healthcare workers and the relationship with their patients or clients and does not involve the personal lives of the professionals. Rather than providing a prescriptive list of "dos and don'ts", each person is considered individually. The nurse, rather than adopting an authoritarian expert role, is encouraged to collaborate with the client and facilitate dialogue and communication.
The Association aims to attract nurses from all spheres of clinical nursing rather than limit the experience only to those involved in specific psychosexual or sexual health work. Nurses are in a unique position to provide reassurance, advice and information on health matters that are not usually spoken about freely. Sexuality is one such matter that should be seen in context and approached with routine sensitivity.(15)

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References

  1. Chapman J, Sughrue J. A model for sexual assessment and intervention. Health Care for Women International 1987;8:87-99.
  2. Wells D, editor. Caring for sexuality in health and illness. Edinburgh: Churchill Livingstone; 2000.
  3. Clifford D. Psychosexual awareness in everyday nursing. Nursing Standard 1998;12(39):42-5.
  4. Cort E, Attenborough J, Watson JP. An initial exploration of community mental health nurses' attitudes to and experience of sexuality related issues in their work with people experiencing mental health problems. J Psychiatr Mental Health Nurs 2001;8:489-500.
  5. Park Dorsay J, Forchuk C. Assessment of the sexuality needs of individuals with psychiatric disability. J Psychiatr Mental Health Nurs 1994;1:93-7.
  6. Lewis S, Bor R. Nurses' knowledge of and attitudes towards sexuality and the relationship of these with nursing practice. J Adv Nurs 1994;20:251-9.
  7. Sharkey V. Sexuality, sexual abuse. Omissions in admissions? J Adv Nurs 1997;25:1025-32.
  8. Waterhouse J, Metcalfe M. Attitudes towards nurses discussing sexual concerns with patients. J Adv Nurs 1991;16:1048-54.
  9. Van Ooijen E. Learning to approach patients' sexuality as part of holistic care. Nurs Times 1996;92(36):44-5.
  10. Coombes R. Sexual healing. Nurs Times 2002;98(24):10-11.
  11. Department of Health. National strategy for sexual health and HIV: consultation document. London: HMSO; 2001.
  12. Waterhouse J. Nursing practice related to sexuality: a review and ­recommendations. NT Res 1996;1:412-8.
  13. Rafferty D. Putting sexuality on the agenda. Nurs Times 1995;91(17):28-31.
  14. Balint M. The doctor, his patient and the illness. Tunbridge Wells: Pitman Medical; 1957.
  15. Cort E. Nurses' attitudes to ­sexuality in caring for cancer patients. Nurs Times 1998;94(42):54-6.

Resources
If you are ­interested in being part of the network for the Association of Psychosexual Nursing and/or joining a seminar group, please write to:
The Association of Psychosexual Nursing
Registered Charity No. 1076225
PO Box 2762, London W1A 5HQ
W:www.psychosexualnursing.org.uk
Contains further information and details of study days. Trained members of the association can provide ­workshops and training days by arrangement