Commentary on Kong SKF, Wu LH & Loke AY (2009) Nursing students’ knowledge, attitude and readiness to work for clients with sexual health concerns Journal of Clinical Nursing 18, 2372–2382

The paper by Kong et al. (2009) is a welcome addition to the literature on nurses’ attitudes to sexual health and one that expands our understanding by providing a Chinese dimension to the literature on this topic – which is so often seen only from a Western perspective. However, the paper certainly reflects the Western literature by demonstrating that client sexuality is a problematic area for nurses, reinforcing that this is an ethically and attitudinally difficult aspect of practice (Hayter 1996, 1997). It also adds to other literature from Asia indicating that nurses often find intimate aspects of care difficult (Zang et al. 2008, 2009). The article reports some interesting contrasts between knowledge and attitudes, and it was refreshing to see relatively high levels of sexual health knowledge from the respondents, although it would have been helpful to know what elements of sexual health were included in their training. However, the attitudinal data seem to be where the problems lie. In this element of the study, respondents demonstrate that they agree that nurses have a role to play in the sexual concerns of their clients – but do not feel skilled or confident enough to initiate sexuality care or are concerned about clients’ reactions to raising this issue. Nurses often cite this last point as being a barrier to raising sexual health concerns – but is not one supported by the evidence. The literature is replete with example of clients expressing the wish that nurses would raise this issue with them (Burt et al. 2005, Mercer 2008, Thompson & Ryan 2009). All nurses need to do is initiate the issue with sensitivity and patients will talk. The other attitudinal issue relates to nurses’ concerns about their clinical skills in relation to sexuality, and the study by Kong et al. (2009) highlights this quite correctly and identifies elements that are required in nurse education to address this issue. Although I would disagree with the notion that sexuality care is in any way an ‘extended role’ of nursing – it is integral and core to basic nursing care. With regard to skills, the study identifies that counselling, communication and assessment skills are important – and I would agree. Where the problem may lie is with the type of sexual health knowledge we often provide in the nursing curriculum to underpin these skills. Most sexual concerns of clients are nothing to do with safer sex or contraception – although these issues are of vital concern to nurses working with adolescents and in sexual health clinics (Hayter 2005). The majority of clients are more likely to have concerns about the impact of their illness on their sexual function, the impact of bodily changes on their sexuality and self-esteem, the impact of treatments on sexual issues, the effect of illness on relationships, etc. (Ivarsson et al. 2008). Therefore, it is not surprising that, although nurses know how a condom works, they probably do not know what the evidence is for resuming sexual activity after a myocardial infarction or even that sexual intercourse puts less strain on the heart than taking one flight of stairs! I suggest that it is the latter type of information they are most likely to need in everyday clinical practice. This is not intended as a criticism of Kong et al. (2009) but is an issue raised in response to the type of knowledge we often assume is central to sexual health in nursing curricula. Therefore, one thing we could do is to address the sexual health knowledge base we provide for our students. There is now a growing literature on the impact of physical health problems such as diabetes, stroke and heart disease on sexuality and also a growing realisation that nurses should become involved in dealing with psychosexual and relationship problems encountered by clients too (Mercer 2008, Fitter et al. 2009). We need to integrate this literature more fully into nurse education. Secondly, as Kong et al. (2009) point out, the use of workshops and experiential learning to develop communication skills to address sexual concerns of clients will play a vital role in enhancing nurse’s skills. Indeed, the literature is now beginning to explore how nurses can practically do this (Ayaz & Kubilay 2008) – as sign that maybe the argument of whether client’s sexuality is a nursing concern has been won and replaced by how nurses can `address' the sexual concerns of their clients. However, Kong et al.’s (2009) study reinforces the fact that we still have some way to go towards meeting the sexual health needs of all our clients.