There is a dearth of research on the care of gay and lesbian people in nursing and care homes. A questionnaire-based study has explored how it is perceived by nurses
In Ireland, the sexuality of older people living in nursing homes is often overlooked, particularly that of gay or lesbian residents. Research in this area is scant, and there has also been very little research on the attitudes of nurses towards caring for nursing home residents of sexual minority status. This article reports on a study exploring the views of 143 nurses working in nursing homes in Ireland about caring for older gay and lesbian people. It looks at heteronormativity, barriers to holistic care, the needs of older lesbian, gay, bisexual and transgender people, and the role of nurses in ensuring unbiased care for all.
Citation: MacGabhann P (2106) Nurses’ views on the care of gay and lesbian nursing home residents. Nursing Times [online]; 113: 3, 49-52.
Author: Patricia MacGabhann is clinical and operational director at Nightingale Nursing Home in Ballinasloe, County Galway, Ireland.
- This article has been double-blind peer reviewed
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The sexuality of older people is often ignored or negated and, if an older person is rarely thought of as a sexual being, for some, the idea of someone being old, sexual and gay is arguably even more difficult to contemplate. When seeking to offer older people holistic, person-centred care, the question of their sexuality should not be ignored, whatever their sexual identity.
In Ireland, the sexuality of older people in nursing homes continues to be overlooked, and this is particularly the case for residents of sexual minority status. Given that, in 2015, the Irish people voted in favour of same-sex marriage in a landmark referendum, it is time to look more closely at the attitudes of nurses towards gay and lesbian older nursing home residents.
This article presents and discusses the findings of a survey conducted in 2013 with nurses from 89 nursing homes in Ireland’s West Region, which aimed to explore their views on caring for gay and lesbian residents. Although the study focuses on Ireland, many of the issues raised will apply to nursing and care homes in other countries.
Survey and study design
Given the potential sensitivity of the topic, face-to-face interviews such as those used in qualitative research were not deemed appropriate, as they could have deterred participation. Self-reporting data collection methods such as questionnaires can be useful in nursing research, particularly when seeking information on variables that “cannot be directly observed or measured by physiological instruments”, such as attitudes (LoBiondo-Wood and Haber, 2010).
A questionnaire-based, quantitative, cross-sectional, descriptive research design was chosen, using the original version of Herek’s (1994) Attitudes Towards Lesbians and Gay Men (ATLG) scale, which comprises 20 statements – 10 about lesbians and 10 about gay men (Bit.ly/UCD_ATLGScale). Ethical approval was obtained from the National University of Ireland Galway Research Ethics Committee.
At the start of the research, 92 nursing homes were listed for the West Region on the website of the Health Information and Quality Authority (HIQA) – the inspecting body for nursing homes in Ireland. Using random research-generator software, one nursing home was chosen for a pilot study to check the questionnaire’s suitability.
After obtaining agreement from the director of nursing, all 10 nurses working in that home received the questionnaire by post. The return rate was 80% and there was no missing data on the completed surveys. One respondent commented that completing the survey was straightforward but more time-consuming than expected, as some questions prompted new reflection on personal attitudes. The respondent information sheet was therefore amended to include an estimation of how long completion might take (10-20 minutes).
Study sample and questionnaire
All nursing homes except the one involved in the pilot were approached via their director of nursing or other person in charge. In total, 89 of the 91 agreed to participate; one chose not to participate on religious grounds and one for unspecified reasons.
Information sheets, posters and letters explaining the study and that respondents would not be required to identify themselves or their places of employment were sent to the contact person by email. Two weeks later the questionnaires were sent by post with stamped, self-addressed envelopes. Participating nurses consented by ticking a box informing them that completing and returning the survey indicated consent to the data being used for the purpose of the research. Responses were anonymous and no homes were identified.
Respondents completed two different sections:
- Section 1: 20 questions on demographic information such as the nurse’s level of training, location, public versus private sector, and on points arising from the literature, such as their views, perceptions, experiences and attitudes affecting care;
- Section 2: 20 statements from the ATLG scale, which participants were asked to rate on a Likert scale.
A total of 350 questionnaires were distributed (based on the size of each nursing home and likely number of nurses); 143 were returned completed, giving a response rate of 40.9%. The results are shown in Box 1 and Table 1.
Box 1. Section 1: responses
- Sexual needs: 57.3% thought the sexual needs of older people living in nursing homes are not met; 24.5% were unsure
- Sexual expression: 83.2% felt this is integral to quality of life; 81.1% knew that sexual expression is a lifelong need
- Discussing sexuality: 67.8% said they felt comfortable discussing sexuality with residents in their care; 13.3% did not and 18.9% were unsure about how comfortable they would be to do so
- Impact of own attitudes/beliefs: 25.9% did not feel their own thoughts on sexuality affect the care they deliver
- Experience: 46.2% thought they had never cared for a lesbian, gay, bisexual or transgender person before, 32.9% thought they had done so and 21.0% were unsure
- Differences in care: 81.8% felt there was no difference between caring for an LGBT resident and caring for a heterosexual resident
- Assessment documentation: 43.4% indicated that nursing assessment documentation used at their workplace does not have any questions on sexuality; 9.8% were unsure
To date, there has been little research – if any – on nurses’ attitudes about caring for nursing home residents of sexual minority status, either in Ireland or more widely. There has also been little research on the sexual needs of older lesbian, gay, bisexual and transgender (LGBT) people; McCann et al (2013) acknowledge that research on this group is scant and rarely discussed in the Irish context. This may be due to cultural norms: historically, in Ireland, homosexuality was considered a deviance, a psychiatric illness and/or a criminal activity, and it was only decriminalised in 1993 (Box 2).
Box 2. Landmark dates of societal changes in Ireland
- 1993: homosexuality is decriminalised
- 2000: Equal Status Act
- 2013: civil partnership is introduced
- 2015: 62% vote in favour of same-sex marriage in referendum
Gay and lesbian care home residents
Increasing life expectancy means there are more older people who potentially need nursing home care, and therefore more older gay and lesbian people potentially requiring such care. According to a report on the inclusion of older LGBT people in residential care in Northern Ireland (Rainbow Project and Age NI, 2011), people of sexual minority status are 2.5 times more likely to live alone, twice as likely to be single, and 4.5 times as likely to have no children. They will, therefore, have less support from informal care networks and be more reliant on formal health and social care services.
Lack of sexual recognition
The HIQA (2009) standards for residential care settings for older people in force at the time stated that, when developing a comprehensive care plan, we need to ensure “all aspects of the health, personal and social care needs of the resident are met” and that “each resident has a lifestyle […] that is consistent with their previous routines, expectations and preferences, and satisfies their social, cultural, language, religious and recreational interests and needs”.
Although sexuality and its expression are not explicitly mentioned, the HIQA standards stress the importance of a truly holistic approach.
Expressing one’s sexuality contributes to wellbeing and overall quality of life, and is a fundamental, lifelong need (Gilmer et al, 2010). However, Harrison (2001) contends that, because sexuality is seen as private, it is often not discussed in healthcare. Anecdotal evidence and the absence of research on the topic indicate that the sexual needs of older people living in residential care are often overlooked, ignored or brushed aside. This is confirmed by the outcomes of the present study, in which 57.3% of respondents thought the sexual needs of older people in nursing homes are not met.
Assumption of heterosexuality
The widespread assumption of heterosexuality, in healthcare and society in general, reflects cultural norms. It creates a barrier to equal access to health services (Irwin, 2004) and contributes to the delivery of substandard care (Neville and Henrickson, 2006). It can also result in a reluctance of LGBT people to disclose their sexual identity, which may negatively affect their care (Beagan et al, 2012): inappropriate questions may be asked, irrelevant health information sought and perhaps even incorrect diagnoses given – the issue is the same in nursing and care homes.
If the assumption of heterosexuality was dropped, LGBT people seeking healthcare would be able to engage in a much more open, free dialogue, rather than constantly having to correct wrong assumptions or hide their sexuality (Fish and Bewley, 2010).
Orel (2004) asserted that the lack of research in gerontology on the topic of sexuality meant the “unique needs and realities” of older LGBT people are largely unknown, ignored and unaddressed. Stein et al (2010) emphasised this point, noting that older people of sexual minority status living in residential care are “generally invisible to staff and other residents, assuming closeted lives in their later years”. This can result in:
- Unaddressed needs for emotional, social and cultural support;
- A failure of nursing and care homes to provide adequate services;
- A failure of staff to acknowledge and respect residents’ partners and friends;
- A resident’s isolation both from the wider residential community and social support networks.
McCann et al (2013) note that cultural norms have resulted in LGBT people being invisible to policy makers and service providers, while the Health Service Executive (2009) stated that the failure to recognise the needs of older gay and lesbian people makes them an invisible minority within a minority; this has been described as “a double invisibility”.
Staff’s attitudes and beliefs
Reygan and D’Alton (2013) note that, despite significant changes in Irish society in the past 20 years, challenges for sexual minorities in healthcare persist, and that many of these challenges arise from staff’s attitudes and beliefs. They suggest the onus is on staff to tackle bias and discriminatory attitudes. In research dating from 2002, Cahill and South found that homophobia and heterosexism remained prevalent in nursing and healthcare. According to Matharu et al (2012), attitudes affect care, and inadequate care provision is often the result of healthcare providers’ negative attitudes towards same-sex behaviour.
In the present study, 25.9% of respondents did not think their own attitudes and beliefs had an impact on the care they delivered. The majority had positive attitudes towards the expression of sexuality but, interestingly, 21.0% were not sure whether they had ever cared for an LGBT person and 46.2% thought they had never done so; this is statistically unlikely.
Brennan et al (2012) acknowledge that nurses care for individuals who are as diverse as society itself, and that this diversity enriches both nursing practice and the wider society. To be truly effective and unbiased, nurses must embrace that diversity and accept each person’s individual needs. By recognising diversity and cultivating open-mindedness, nurses can truly provide “respectful caring for all people” (Brennan et al, 2012).
Specific needs and concerns
Röndahl et al (2004) suggested nurses may believe they are delivering care in a neutral manner and their personal attitudes do not affect care. However, neutral care may not be the standard to which we should aspire; indeed it may well be, in effect, a type of sexual identity blindness that contributes to the invisibility felt by LGBT people.
In the present study, most respondents (81.8%) felt there was no difference between caring for an LGBT resident and a heterosexual one; this seems to ignore the fact that older LGBT people in Ireland have experienced very different social circumstances than their younger counterparts. They were labelled as mentally ill, criminal, deviant and sinful, and will have faced, for most of their lives, “the complex realities of a heteronormative society” (Brennan et al, 2012). Many will have experienced shame, fear, self-loathing, discrimination, even violence and hate, and will have had to hide or repress their true selves to avoid stigmatisation and preserve their safety – often at the cost of their own psychosocial health, and/or will have lived isolated lives and avoided seeking care for fear of rejection or discrimination (Stein et al, 2010). Nursing and care home staff and care providers need to be aware of these particular circumstances and concerns so they can deliver care that fully responds to all their residents’ needs.
Almost half of all respondents in this study (43.4%) indicated that the nursing assessment documentation used in their workplace does not include any questions pertaining to sexuality. A 2012 study by Horner et al explored the attitudes of retirement and residential aged care providers in Western Australia on accommodating older people of minority sexual status. It found 83% of participants reported that the patient data collection forms in use in their practice area made no provision for individuals to identify as being of sexual minority status. As noted by Röndahl et al (2006), there is a heteronormative assumption in documentation: for example, people are often asked about marital status, as opposed to relationship status. This limits the opportunity for non-heterosexual people to express who they are without having to refute the dominant assumption of heterosexuality.
Gaps in education and training
In the present study, 18.9% of respondents felt unsure how comfortable they would be discussing sexuality with residents. Haboubi and Lincoln (2003) suggested that improving nurse training and education in this area would raise their comfort levels in discussing sexuality with patients.
The literature more generally reveals gaps in nurse education relating to sexuality and older people, as well as to sexuality and non-heterosexual older people. Nurse educators are ideally placed to tackle these gaps in education. Workshops and seminars addressing the sexuality of residents should be an essential element of nurse training. However, we could go much further and include in nursing curricula a module dedicated to sexuality throughout the lifespan.
The findings of this study echo other findings about sexuality in later life and the care of people from sexual minorities in later life. They indicate that the sexual needs of older people in nursing homes in Ireland are not adequately addressed, and that nursing education and practice need to improve so truly holistic care is provided to all. The literature suggests the same is true in other countries.
The nursing profession is a dynamic one and nurse education and practice need to reflect societal changes to ensure care is delivered to all, including older LGBT nursing home residents, in an unbiased and unprejudiced manner.
- Expressing one’s sexuality is a lifelong need; people do not cease to be sexual beings when they grow old
- Historically, in Ireland, homosexuality was considered a deviance, a psychiatric illness and/or a criminal activity; it was only decriminalised in 1993
- The assumption of residents’ heterosexuality can have a negative impact on care
- Nursing and care home residents’ sexuality is often negated, particularly if they are gay or lesbian
- By recognising diversity and cultivating open-mindedness, nurses can provide truly holistic and respectful care to all
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