Assessing Student Need for Human Sexuality Nursing
Teaching nursing students psychiatric nursing and practicing in the area of sexual counseling has increased my awareness of the importance of the nurse's comfort with various sexual values, feelings, attitudes, and behaviors. This awareness challenged me to design an innovative method for teaching human sexuality to baccalaureate nursing students. The primary goal of such a course was to increase the students' comfort levels when giving care to patients who were experiencing threat to their sexual integrity. With this challenge at hand, I turned to the professional literature for assistance.
The literature search offered scant information. Although three nursing course models for teaching human sexuality were described in the literature, their focus was primarily on content, methodology, and evaluation (Mandetta & Woods, 1974; Mims, Yeaworth & Horstein, 1974; Walker, 1971). However, the need for students to clarify their sexual attitudes and values and develop an ease with sexuality was repeatedly acknowledged. Results of these course models revealed that students' sexual knowledge increased significantly, but attitudes were not significantly altered.
Considering the results of the literature review, I turned to psychosocial theories and my knowledge and experiences as a psychiatric nurse and sexual counselor. Thus, the framework, techniques and methods for teaching human sexuality, with the primary goal of increasing students' comfort levels with sexuality, were borrowed from the behavioral and dynamic therapies used in psychotherapy and counseling.
Planning the Elective
A two-hour one semester nursing elective was developed utilizing a small group framework. The small group approach was selected because it potentially provided a structure in which students could enhance their self-awareness, increase personal and interpersonal comfort with sexual material, and integrate sexuality knowledge. In addition, the small group offered students a sanctioned environment in which they would be permitted to be open about sexuality, a subject still avoided and viewed negatively by many nurses and other professionals. Openness in a group setting has been identified as a prerequisite to behavior change and comfort with one's inner self (Gibb, 1972).
To parallel the concept of small group therapy, a comfortable setting was selected. Although a classroom was used, it was a small room located in a private area, with a semi-intimate atmosphere. Physical rearrangement of the furniture helped to foster interpersonal communication and comfort. Coffee and cookies were provided to promote relaxation and enhance positive associations with sexuality, a subject known to evoke negative feelings, such as anxiety.
Once the framework was established, course objectives and content were delineated. In addition to the general course goal of increasing students' comfort levels when giving care to patients who were experiencing threat to their sexual integrity, nine behavioral objectives were denned, and corresponding content topics were identified. These topics included sexual value systems, psychosocial-sexual development, human sexual response systems, sexuality assessment, organic illness and sexuality, chemicals and sexuality, trauma (emotional and physical) and sexuality, emotional problems and sexuality, male/female sexual dysfunctions, nursing functions in sexuality counseling, legal, ethical and moral issues in sexuality counseling, and variations of sexual behavior.
Implementing the Course
The dynamic and behavioral therapies of psychotherapy and counseling provided unique concepts, techniques and methods for implementing this human sexuality course. Selection of particular concepts, techniques and methods were subsequent to the delineation of the following assumptions:
1. Sexuality material carries the potential for increasing anxiety levels of students.
2. Clarifying one's sexual attitudes, feelings and values is a prerequisite to comfort with one's sexuality.
3. A warm, accepting non-threatening atmosphere encourages openness and facilitates clarification of sexual attitudes, values and feeling responses.
4. A small group framework is an appropriate structure for cognitive learning, emotional awareness, exploration and change.
5. The instructor has the potential for affecting students' sexual attitudes, values, feelings and knowledge.
6. Negative responses (i.e., anxiety) to sexuality material can be replaced with positive responses (i.e., comfort).
7. Individual comfort with sexuality is a prerequisite to effective sexuality counseling.
Techniques and concepts from Behavior and Transactional Analysis Theory were heavily utilized in this course. Specific concepts and techniques included: contracting, ego-states, modeling, role-playing, instruction and encouragement, differential reinforcement, social approval and systematic desensitization. Additionally, values clarification methods and simulated exercises were integral components of the course.
The initial class was designed to decrease students' anxiety by providing structure in the form of a contract. Contracting, according to psychotherapy literature has been defined as the mutual exploration and acceptance of treatment goals and methods by the therapist and client (Sulzer, 1962). It is widely accepted in psychotherapy that without a contract, the effectiveness of treatment is greatly diminished (Steiner & Cassidy, 1969).
Applying the concept of contracting to the human sexuality course, students and the instructor contracted for the following: 1) participation - the verbal sharing of thoughts and feelings in response to class topics, films, and individuals in class; 2) confidentiality - an agreement among students and the instructor not to discuss group material outside the regular class time; 3) topics students wished to present in class; 4) course content topics; and 5) individual grades. Opportunity was provided for the students to contract for anything else they deemed important.
An attitude of acceptance was also demonstrated in the first class and maintained throughout the course to build trust. Acceptance was defined as non-evaluative high regard for another person, communicated through the expression of warmth. The therapeutic literature has long recognized acceptance as the key to reducing fears and anxiety about vulnerability and building trust. The discussion of sexuality has been known to evoke fears, anxieties and feelings of vulnerability, like no other topic.
Recognizing that a course in human sexuality could elicit fears and anxieties, small group exercises were used to help student identify and dissipate their fears. An exercise developed by Morrison and Price (1974) was implemented for this purpose. In the exercise, students were asked to respond in writing to the question, "What makes it difficult to talk about sexual issues in a group like this?" After writing their responses, they were asked to share them with other students. The overwhelming fear of all students was rejection. Students feared being rejected for their individual attitudes, values, feelings or thoughts they held toward sexuality. It was believed that sharing this fear would help dissipate its intensity.
To further enhance students' awareness of their thoughts, feelings, opinions, and values, a Transactional Analysis exercise was employed. This exercise consisted of the group breaking into threes and discussing the topic of sex from each of the three ego states, Parent-Adult-Child, and rotating until each student discussed sex from the three ego states. This exercise had potential for giving students the following information about themselves: 1) sexual prejudices, opinions and/or values demonstrated by the Parent ego state, 2) facts they had about sexuality in their Adult ego state, and 3> feelings evoked in the Child ego state by discussing sex. Information learned from the exercise was shared with the group.
Rath's Value Clarification Process was utilized in assisting students to identify and clarify their sexual values and to increase their awareness of different sexual value systems within the class (Simon & Kirschenbaum, 1972). The seven-step process offered an objective and structured avenue for approaching highly emotionally charged topics, such as homosexuality, abortion, incest and rape.
In the preceding exercises, I participated in sharing with the class. Strategically speaking, the primary purpose of my participation was to build trust through selfdisclosure. Psychotherapy research has indicated that helper disclosure in the helping relationship was essential to building and maintaining trust with the client (Johnson & Matross, 1975). Trust was considered a prerequisite for students becoming open and risking to share their thoughts, attitudes, feelings and values in the group.
A second purpose of my participation in the previously described exercises and other classes was modeling. According to Bandura (1979), modeling is the exemplification of a desired behavior that could be learned by an observer. In the classroom situation, I modeled responsible communication, sexual history taking skills, and intervention techniques used with clients experiencing sexual concerns and/or problems.
Initially, the modeling techniques helped to demonstrate responsible verbal communication of emotionally charged thoughts and feelings evoked by discussing sexual material. The concept of responsible communication meant taking personal responsibility for knowing and expressing one's thoughts, feelings and sense data in response to another person or a class topic. The pronouns - I, me, mine - were to precede the expression of thoughts, feelings or sense data, i.e., I think this course is interesting, I feel anxious, and my skin is cold. Responsible communication was utilized to maintain open communication, decrease defensiveness, and to facilitate identification of differing student responses.
Modeling counseling skills was also important in teaching students to take sexual histories and intervene with patients who had sexual concerns or problems, in simulated role-play situations. Role-playing, a behavioral technique, has been defined by Storrow (1967) as a situation which approximates the real situation with attendant aversive stimulation reduced. Through the role-plays, students were to apply modeled counseling skills necessary to obtain intimate sexual information. The role-play situations provided the students as opportunity to gain awareness of thenfeelings as a nurse counselor while discussing emotionally charged material. In addition, simulated role reversal situations offered a unique avenue for students becoming more sensitive to the clients feelings.
Specific counterconditioning techniques were adapted to help students change their recognized avoidance patterns evoked by the role-play situations. Avoidance was interpreted as unwillingness to volunteer role-playing the nurse in role-plays, procrastinating by asking irrelevant questions, joking and laughing to release anxiety, and open admission of avoidance by students. Avoidance patterns were deemed incongruent, with the role of the nurse, and self-reinforcing, because they relieved anxiety. Counterconditioning has been successful in therapy when symptoms are maintained by mechanisms that are selfreinforcing, self-deceptive, and/or intermittently reinforced (Storrow, 1967).
To encourage new and more appropriate nurse role behaviors in the role-play situations, the behavioral principles of instruction and encouragement, differential reinforcement, and social approval were implemented. Instruction and encouragement were accomplished by modeling and explaining desired nurse role behaviors in role-play situations. Then, the advantages of the new behaviors were stated, and students were verbally encouraged to try out the specific behaviors.
The principle of differential reinforcement coupled with social approval was utilized to promote students' learning desired behavior appropriate to the nursing role. Differential reinforcement has been defined as a technique used to shape verbal responses by differentially rewarding desired responses with social approval and interest, while withholding reinforcement from non-desired responses (Storrow, 1967). For instance, during a role-play situation in which a student was implementing sexual counseling skills, I made positive statements when desired behaviors appeared and attention was withheld from nondesired responses.
Systematic desensitization, developed by Joseph Wolpe (1967) was adapted in order to determine the sequence of films, containing sexual material, to be presented to students. Wolpe's approach employs methods to deal with maladaptive emotional responses, such as guilt, anxiety and hostility First, aversive stimuli are identified, then arranged in a hierarchy from the weakest to strongest. The stimuli are then presented visually in an attenuated form until they are viewed without anxiety, or the new voluntary response displaces the maladaptive emotional response.
All of the films were assumed to contain aversive stimuli, having the potential to produce anxiety, guilt and other maladaptive emotional responses in the students. Hierarchial arrangement of the films was determined by the amount of cognitive content in the film, and whether sexual behaviors were considered socially acceptable or unacceptable. Films having high cognitive content and socially sanctioned sexual behaviors were presented first. Those films with little cognitive material and socially unsanctioned behaviors were shown last. For example, the first film viewed was, 'The Sexological Examination.'' In this film, a physician explained and demonstrated a sexological examination on a male and female. "Reflections," the last film shown, graphically depicted several individuals participating in group sex, a variation of human sexual behavior. In this film, the cognitive content was considered minimal.
Multiple films were shown to implode the students with anxiety producing stimuli, such as sexual material, in order to extinguish anxiety responses. According to Stampfl, learned avoidance responses that produce neurotic behaviors operate to help the individual reduce anxiety (Harper, 1975). Stampfl hypothesized that the neurotic behaviors would disappear and the anxiety extinguished if the stimuli that produced the anxiety were presented in strong force in the absence of primary reinforcement. The aforementioned principles and hypothesis were borrowed from Stampile Implosive Therapy. Repressed material, evoked by the stimuli, (i.e., films), also a part of Implosive Therapy, was not attended to in the class situation. However, conscious responses were encouraged to be shared.
Evaluating the Course
Evaluating the newly designed sexuality course, which had as its primary goal to increase students' comfort with sexual material, seemed imperative and difficult. A literature review revealed a distinct deficit of an appropriate evaluation tool to accomplish the task, so I developed a tool to gather data of both a cognitive and emotive nature.
Results from the evaluation form revealed that cognitive and emotive changes occurred in a majority of the students enrolled in the human sexuality classes. The following changes were identified:
1. Increased familiarity with biologic, psychologic, and social forces that affect human sexuality.
2. Increased awareness of my sexual values, feelings and attitudes and how these may affect client interactions.
3. Increased comfort in talking with clients about their sexual concerns.
4. Increased comfort with my own sexuality.
5. Increased sensitivity toward the client who is experiencing threatened sexual integrity.
In addition to the above information, many comments were written by the students. Some of the comments included the following: "One class I think is essential in nursing," "I thought the safety of confidentiality was important to freedom in group discussion," "The films increased my comfort level when dealing with sexuality for me," and "I felt not only myself but others in our group were uninhibited and free to express and share feelings, thoughts, opinions, attitudes, and even values."
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