VOL: 98, ISSUE: 18, PAGE NO: 39
Sue Jolley, BA, CertEd, RGN, is gynaecology research sister, Queen’s Medical Centre, Nottingham
Research often generates as many questions as it answers and an investigation into the teenage sexual health service provided by gynaecology nurses at Queen’s Medical Centre in Nottingham (Jolley, 2001) found a lack of consistency in how they approached sexual health issues. The hospital had no policy or guidelines for taking a sexual history.
In the wake of these findings, a literature search on the subject was carried out. It revealed that support for patients’ sexual health needs was a recognised part of nursing practice (RCN, 2000), but that nurses often found it difficult to raise such issues. A survey was also carried out to determine what nurses in other gynaecology departments did. It revealed a similar picture across the country.
Gynaecology nurses also seemed to receive little or no training in assessing patients’ sexual health needs and did not have any guidelines or documentation. However, there was general agreement that effective sexual history-taking would improve patient care.
This article discusses some of the issues surrounding nursing assessment of sexual health needs. It also assesses the findings of the survey, which provided the rationale for the development of a policy for sexual health assessment by nurses in the hospital’s gynaecology department.
What is sexuality?
Sexuality used to be linked only to reproduction, but is now seen as an important part of general health and personal fulfilment. The definitions are very broad. Roper et al (1996) describe the expression of sexuality in terms of gender, appearance, behaviour, personality, pleasure, sexual intercourse and reproduction, while Lewis and Bor (1994) say it involves an individual’s physical, emotional, intellectual and social aspects. The RCN (2000) describes it as an individual’s self-concept, shaped by their personality and expressed as sexual feelings, attitudes, beliefs and behaviours through a heterosexual, homosexual, bisexual or transsexual orientation.
Ingram-Fogel (1990) suggests that sexuality has a range of benefits, including:
- It enables people to establish a link with the future through children;
- It provides a means of physical release and sexual pleasure;
- It binds people together;
- It allows people to communicate subtle, gentle or intense feelings;
- It provides feelings of self-worth when sexual experiences are positive;
- It is one of the factors that helps to build an individual’s identity.
There is general agreement that biological, psychological, emotional, cultural and sociological elements are involved in expressing sexuality (Weston, 1993). Nurses cannot ignore this if they want to provide holistic care (RCN, 2001). However, they need to be realistic about what can be achieved and must not attempt to tackle problems without adequate training.
It is helpful to distinguish between sexuality, sexual functioning and sexual health (Gregory, 2000). While sexuality refers to issues of gender, identity, self-esteem and self-expression (Masters et al, 1995), sexual functioning relates to whether the body is working normally or whether it is (or will be) impaired. Sexual health is an essential component of general health and includes the prevention of unplanned pregnancies and sexually transmitted diseases.
These areas are clearly mutually dependent, but nurses are usually most directly concerned with sexual functioning and sexual health (Lewis and Bor, 1994). They do not always have enough time or the appropriate training to deal with gender issues or psychological and relationship difficulties, and should refer the patient to other professionals.
Sexual health relates directly to the ability to recover from or adapt to medical conditions, and sexual problems can affect health and well-being. The physical causes of sexual problems include cancer, vascular or heart disease, neurological impairment, rheumatoid and arthritic conditions and, of direct concern to gynaecology nurses, hormonal dysfunctions, continence problems, difficulties with fertility and the consequences of early pregnancy or gynaecological conditions.
Treatments such as medication, surgery, radiation and chemotherapy can affect sexual functioning, while surgery such as mastectomy, hysterectomy, amputation or stoma creation can result in sexual problems. For example, one study of sexual activity after radical vulvectomy or hysterectomy found that 75% of women had sexual difficulties for more than six months postoperatively and 15% never resumed sexual intercourse (Marquiegui and Huish, 1999).
The purpose of assessment
Assessment aims to obtain physical, medical and psychological information so that appropriate nursing care can be planned. The nurse needs to identify the patient’s level of understanding about his or her own body and how it works, and the patient’s knowledge and awareness of his or her own sexuality and sexual health (RCN, 2000).
The aim should be to provide the best possible treatment and care for each patient. The factors to consider during assessment include the effects of the condition, disease or medication on sexual functioning, the prognosis in terms of sexual function and the options for treating sexual problems. Nurses are in a key position to provide information on sexual functioning and an effective assessment should result in patients gaining the following:
- An understanding of their situation or condition, and its effect on sexual function;
- Relief from fear and anxiety;
- An understanding of the treatment options.
The extent to which sexual issues should be considered depends on circumstances such as the nature of the medical problem, the physical setting, the skills of the staff and the needs of the patient. Matthews (1998) identifies five main areas directly associated with women’s health where a sexual history is relevant: social contact and relationships, contraception, pregnancy, genital-tract pathologies and sexual health promotion. These are all part of gynaecology nursing care.
Considerations when taking a sexual history
A general assessment often provides enough information, but sometimes a fuller and more structured sexual history is appropriate. Several factors should be considered before taking a sexual history. They include:
- There should always be a valid reason for taking a sexual history; each clinical area will have specific groups of patients who might have sexual difficulties;
- A sexual history should be taken only by a suitably qualified person, someone who has good communication skills and knowledge of the subject, and who is comfortable with sexual issues and knows when and to whom the patient should be referred (Pillaye, 1994);
- The permission, limited information, specific suggestions and intensive therapy (PLISSIT) model is still widely used to describe levels of nursing intervention in sexuality (Annon, 1976). The patient’s permission must be obtained before initiating a discussion on sexuality (Ross and Channon-Little, 1991) so that the individual is made aware that the issue can be discussed and that any concerns are normal. Nurses can then progress to a level at which they feel comfortable, after which specialist professionals should become involved;
- The timing and situation should be considered. A quiet, private environment is important and patients should not be expected to discuss personal or sensitive subjects when they are unduly anxious, unwell or feel rushed;
- It is important to avoid making assumptions, especially in relation to age and sexual orientation. Older people’s sexual needs are often ignored because of an assumption that sexual activity is no longer important to them. However, research shows a wide discrepancy between practitioners’ perceptions of sexual orientation and reported behaviour (Levy, 1998). It is sensible to establish sexual orientation before asking questions that might cause offence;
- A sexual history is useful when providing a patient with information on the effects of surgery because a practical focus will make it more relevant. It may also be necessary to ensure effective treatment (for sexually transmitted infections, for example);
- There are ethical considerations. Confidentiality is of paramount importance and this should always be made clear to the patient. Nurses should maintain professional boundaries and beware of probing too much. The code of professional conduct (UKCC, 1992) requires them to be aware of their limitations and always consider the patient’s best interests. The UKCC (1999) has published guidance on the prevention of exploitation and abuse of patients by nurses;
- There should be consistency in each clinical area, so the method for taking a sexual history should be agreed and supported by guidelines. Although questionnaires are not always reliable or useful (Gregory, 2000; Warner et al, 1999), some sort of format or agreed documentation is helpful. This should allow for flexibility and may vary depending on the clinical area and reason for taking the sexual history;
- Nurses may prefer to use a problem-solving approach, because once the information has been collected the main emphasis should be on providing information.
Reluctance to consider sexual problems
Most patients feel that nurses should discuss sexual concerns with them (Waterhouse and Metcalfe, 1991). However, although nurses accept that sexuality is relevant to their practice, they are often reluctant to carry out a sexual assessment or perform it inadequately (Lewis and Bor, 1994; Warner et al, 1999). This will affect the care given and is particularly relevant to gynaecology patients, when both the quality of advice and the level of sexual counselling may be inadequate (Cort, 1998; Jolley, 2001).
Merrill and Thornby (1990) identify four reasons why staff often avoid obtaining information on a patient’s sexuality:
- A feeling that the patient’s sexual history is not relevant;
- Inadequate training;
- Fear of offending.
Other authors also emphasise embarrassment and lack of both training and knowledge as important factors (Gregory, 2000; Lewis and Bor, 1994). The sexual health content on most nursing courses is inadequate. Pillaye (1994) suggests that it is necessary to recognise sexual problems to promote sexual health, but nurses do not always have sufficient knowledge to do this (Lewis and Bor, 1994). It has been suggested that sexual issues are seen as unimportant compared with the struggle to overcome disease and cope with its treatment (Gregory, 2000) or the acute care of patients (RCN, 2000). Barriers can also be created when people speak different languages or through the inappropriate use of jargon or slang (Levy, 1998).
All these issues can be addressed through discussion, research, training and support, and strategies are being developed to raise the profile of sexual health and include it in nursing education programmes (RCN, 2000; Department of Health, 2001). However, knowledge and training are not enough without a change in attitude (Hayter, 1996; Lewis and Bor, 1994).
The issues also need to be considered by qualified nurses. The use of reflection, facilitated by clinical supervision, has been suggested as a means by which nurses can explore their attitudes towards sexuality (Hayter, 1996). The development of policies supported by clear guidelines, documentation and in-house training can also guide best practice.
A survey on sexual history-taking
The gynaecology department at Queen’s Medical Centre in Nottingham conducted a survey to find out how gynaecology nurses took sexual histories in different hospitals. The main objectives were:
- To establish whether gynaecology nurses were trained to take a sexual history;
- To investigate the practice of taking sexual histories by looking at whether guidelines and documentation were used;
- To ascertain nurses’ views on whether the quality of sexual history-taking was important in providing good patient care.
The survey was confined to UK hospitals with more than 500 patients. Using a protocol to ensure consistency of approach, researchers conducted telephone interviews with the sister or nurse in charge of the gynaecology ward in each hospital. If any guidelines or documentation were in use, the researchers requested a copy. From 130 telephone calls made, 129 responses were received (one was too busy to answer queries). Box 1 shows the grades of the respondents.
Nurses in most hospitals had not had any training in how to take a sexual history (109 out of 129 hospitals, or 84%). In the remaining 20 (16%), some had had training. A total of 52 nurses (one to six per hospital) had received some training. Of these, 35 had done a family planning course, 11 had taken various gynaecology/degree courses with a sexual history component, and six had worked in genitourinary medicine clinics.
None of the hospitals had a protocol or guidelines for taking sexual histories, and none had any specific documentation for recording them. Most respondents felt that guidance on taking a sexual history was important in providing a good sexual health service (127; 98%) and that it would improve the care given (119; 92%). The rest said they did not know. Comments in response to questions on these issues are summarised in Box 2.
The survey confirmed that the lack of consistency and guidance at Queen’s Medical Centre was not an isolated problem and that gynaecology nurses need to look more closely at how they assess patients’ sexual health needs. This should be supported by education, training and the development of clear policies. Education and training for those who provide sexual health services, including gynaecology nurses, is an important element of the government’s sexual health strategy (Department of Health, 2001), but perhaps the best way to determine exact educational needs is by talking to individual members of staff (Jolley, 2001).
Since there were no existing guidelines to adapt, a new policy was written to help gynaecology nurses at Queen’s Medical Centre take sexual histories. This is supported by documentation, guidance and training. Study days have been organised to include a mixture of group work and presentations from different experts in sexual health assessment and gynaecology. We have decided to start using the policy in the preadmissions unit and with oncology patients. The practice will be evaluated after six months.