Changing the Culture of Long-term Care: Combating Heterosexism
Changing the Culture of Long-term Care: Combating Heterosexism
While there is limited literature on the experience of LGBTQ elders in LTC facilities, research indicates that there are several themes to be considered. Adding to this body of knowledge requires further discussion on sexuality, strategies for changing LTC culture, and educating elders on their roles, responsibilities, and rights for their future healthcare. Each of these themes will be discussed below.
While age is often used as the common denominator to explain behavior in the elderly, LTC facilities are mandated to provide culturally competent care based on a number of other parameters including spoken language, class, ability, gender, and race (Health and Human Services, n.d.; Meneses & Monroe, 2007; Somers & Mahadevan, 2010). Sexuality is a broad term that encompasses sex, gender, gender identity, gender roles, sexual orientation, pleasure and reproduction (World Health Organization [WHO], 2014).
When providing care for adults in LTC, staff must understand the distinctions among the complex aspects of sexuality. Sex refers to a person's biological status and is typically categorized as male, female, or intersex. Gender is culturally defined as attitudes, feelings, and behaviors that a given culture assigns to a person based on sex. Related to gender is gender identity, which refers to one's sense of self as male, female, or transgender. Sexual orientation refers to one's romantic and sexual attraction toward others and is fluid for some people. One's sexual orientation does not always result in sexual behavior or sexual acts (American Psychological Association [APA], 2011). Sexual expression in LTC involves a complex interaction between individual preferences, laws, policies, family values, beliefs and staff attitudes and knowledge (Hinrichs & Vacha-Haase, 2010). Additionally, sex, sexuality, and sexual identity are often used interchangeably, and many researchers and healthcare providers fail to clearly identify differences between the three terms (Solarz, 1999). In the above review of literature on perceptions of LTC staff toward LGBTQ residents, researchers made little distinction between sexual orientation and sexual expression, contact, or behavior. Unclear definitions can result in ambiguity for LTC staff who may be accepting of residents that identify as LGBTQ but not of sexual behavior between same-sex couples. It is evident that education of LTC staff regarding the complex nature of sexuality is essential to providing culturally competent care for residents.
Employees in LTC facilities are in a unique position to improve the lives of LGBTQ elders in their care by implementing a two-tiered approach to cultural change. The first tier consideration (assessment) begins by assessing both the fears of LGBTQ residents along with staff/resident attitudes toward, and knowledge about, LGBTQ residents under their care. This may include interviews, written questionnaires, and/or focus groups. It is important to assign these duties to professionals who are sensitive to the unique needs of the LGBTQ elder population. Assessment can potentially help to address two key issues: LGBTQ residents may voice their concerns and staff and residents with homosexual prejudice might have an opportunity to gain new perspectives. Just as the issue of heterosexism exists in the greater society and among LTC staff, so too, may it exist among heterosexual LTC residents. As such, it is the staff's responsibility to identify residents who might be hostile toward their LGBTQ peers and to make every effort to prevent verbal/physical abuse and forced or self-imposed isolation of LGBTQ residents. Many LGBTQ elders believe that the most significant impact a LTC facility can make in fighting LGBTQ isolation and invisibility is to combat heterosexism (Stein et al., 2010).
A second assessment consideration is that of the environment. For example, art work in the facility could reflect diverse people, and reading material in public areas could include journals and books that illustrate LGBTQ points of view or characters. Conversely, one must caution to avoid art, reading material, and television programs reflecting homophobia and heterosexism. Facilities that place pink triangles or rainbow-colored safezone signs in public areas will indicate to LGBTQ patients and their families that the facility is safe and accepting of sexual minorities (Gay and Lesbian Medical Association [GLMA], n.d.). Environmental assessment also includes a review of facility forms. Adding inclusive language options to the questions related to spouse, relationship, family, and sexual history will help remove barriers to self-disclosure for LGBTQ elders. Inclusive forms also aid in normalizing LGBTQ experiences (GLMA, n.d.).
Assessment of policies and procedures is the third assessment consideration. Patient non-discrimination policies could include sexual orientation and gender identity as protected classifications. Visitation policies could explicitly grant equal visitation to LGBTQ patients and their visitors. The facility's policy regarding couples sharing living quarters could be inclusive of same sex couples (Bluestein & Bach, n.d.; LLDEF, n.d.). To complement resident policies, employment non-discrimination policies could include the terms sexual orientation and gender identity. LGBTQ staff can informally educate co-workers and residents and provide guidance to facility leadership (HRC, 2013). LTC facilities may also find it helpful to recruit board members who have a professional understanding of the lives of LGBTQ elders. When necessary, facility leaders should enforce a zero tolerance policy on discrimination against LGBTQ residents and staff.
The second tier consideration (cultural change) calls for expert training in LGBTQ patient-centered care. Formal healthcare education provides only a limited amount of core LGBTQ curricular content (Brennan, Barnsteiner, Siantz, Cotter, & Everett, 2012); the limits of this formal education increase the importance of workplace education for LTC staff. Since LTC residents are in daily contact with a wide variety of service providers, such as housekeepers, dietary workers, therapy staff and maintenance personnel, all persons working in a LTC facility should receive LGBTQ training.
An educational curriculum could focus on several content areas, including: human sexuality and aging; homophobia and heterosexism; sexual diversity among LTC residents; fears and experiences of LGBTQ in LTC facilities; inclusive policies and procedures; Health Insurance Portability and Accountability Act (HIPAA) requirements; and best practice in caring for LGBTQ residents (Bluestein & Bach, n.d.; HRC, 2013). Care should be taken to allow for question-and-answer sessions in order to dispel myths and discuss personal nursing/work experiences (Low, Lui, Lee, Thompson, & Chau, 2005). For example, during group and individual activities with LTC staff and residents, activities staff could be encouraged to include current events topics about LGBTQ newsworthy events, thereby normalizing the lives and experiences of LGBTQ residents.
However, increased training and education does not always result in a change in attitudes and behaviors. Because some employees may find this type of education in conflict with their religious beliefs, placing LGBTQ education in the context of professional practice and workplace requirements is critical (Hinrichs & Vacha-Haase, 2010). It is important to note that in order for training to be most effective, it must be ongoing and complemented with routine mentoring and performance evaluation. Several professional organizations have called for a standardized diversity education program, one that is developed in collaboration with LGBTQ advocacy programs and that may be utilized by LTC leadership (U.S. Administration for Community Living, 2014; Bluestein & Bach, n.d.; GLMA, n.d.; HRC, 2013).
During a time of health crisis or significant change, it is challenging to consider the ramifications of long-term disability. Hence, prior to LTC placement, it is imperative that elders and their families understand their personal rights and responsibilities. This is of particular importance for LGBTQ elders who may not find anti-discrimination protection under state or federal laws and regulations. Designating a DPOA-HC and identifying preferences in an advanced directive are two important documents that should be considered (Bluestein & Bach, n.d.). Information about LTC planning is available from multiple national organizations, including the following: the American Association of Retired Persons (AARP, n.d.); the Center for Positive Aging, (n.d.); the LongTermCare.gov (n.d.); the National Long-Term Care Ombudsman Resource Center (NORC, n.d.); the National Resource Center on LGBT Aging (n.d.); and the U.S. Administration for Community Living (2014). Additionally, elders may want to locate a LTC facility that specifically markets to LGBTQ residents. While multiple resources exist, healthcare providers at every encounter share in the responsibility of educating elders. In all healthcare settings, there should be the obligation to educate LGBTQ elders on preparing for their future healthcare needs.
Changing the Culture of LTC Related to LGBTQ Elders
While there is limited literature on the experience of LGBTQ elders in LTC facilities, research indicates that there are several themes to be considered. Adding to this body of knowledge requires further discussion on sexuality, strategies for changing LTC culture, and educating elders on their roles, responsibilities, and rights for their future healthcare. Each of these themes will be discussed below.
Discussion of Sexuality
While age is often used as the common denominator to explain behavior in the elderly, LTC facilities are mandated to provide culturally competent care based on a number of other parameters including spoken language, class, ability, gender, and race (Health and Human Services, n.d.; Meneses & Monroe, 2007; Somers & Mahadevan, 2010). Sexuality is a broad term that encompasses sex, gender, gender identity, gender roles, sexual orientation, pleasure and reproduction (World Health Organization [WHO], 2014).
When providing care for adults in LTC, staff must understand the distinctions among the complex aspects of sexuality. Sex refers to a person's biological status and is typically categorized as male, female, or intersex. Gender is culturally defined as attitudes, feelings, and behaviors that a given culture assigns to a person based on sex. Related to gender is gender identity, which refers to one's sense of self as male, female, or transgender. Sexual orientation refers to one's romantic and sexual attraction toward others and is fluid for some people. One's sexual orientation does not always result in sexual behavior or sexual acts (American Psychological Association [APA], 2011). Sexual expression in LTC involves a complex interaction between individual preferences, laws, policies, family values, beliefs and staff attitudes and knowledge (Hinrichs & Vacha-Haase, 2010). Additionally, sex, sexuality, and sexual identity are often used interchangeably, and many researchers and healthcare providers fail to clearly identify differences between the three terms (Solarz, 1999). In the above review of literature on perceptions of LTC staff toward LGBTQ residents, researchers made little distinction between sexual orientation and sexual expression, contact, or behavior. Unclear definitions can result in ambiguity for LTC staff who may be accepting of residents that identify as LGBTQ but not of sexual behavior between same-sex couples. It is evident that education of LTC staff regarding the complex nature of sexuality is essential to providing culturally competent care for residents.
Approaches for Changing the Culture in LTC Facilities
Employees in LTC facilities are in a unique position to improve the lives of LGBTQ elders in their care by implementing a two-tiered approach to cultural change. The first tier consideration (assessment) begins by assessing both the fears of LGBTQ residents along with staff/resident attitudes toward, and knowledge about, LGBTQ residents under their care. This may include interviews, written questionnaires, and/or focus groups. It is important to assign these duties to professionals who are sensitive to the unique needs of the LGBTQ elder population. Assessment can potentially help to address two key issues: LGBTQ residents may voice their concerns and staff and residents with homosexual prejudice might have an opportunity to gain new perspectives. Just as the issue of heterosexism exists in the greater society and among LTC staff, so too, may it exist among heterosexual LTC residents. As such, it is the staff's responsibility to identify residents who might be hostile toward their LGBTQ peers and to make every effort to prevent verbal/physical abuse and forced or self-imposed isolation of LGBTQ residents. Many LGBTQ elders believe that the most significant impact a LTC facility can make in fighting LGBTQ isolation and invisibility is to combat heterosexism (Stein et al., 2010).
A second assessment consideration is that of the environment. For example, art work in the facility could reflect diverse people, and reading material in public areas could include journals and books that illustrate LGBTQ points of view or characters. Conversely, one must caution to avoid art, reading material, and television programs reflecting homophobia and heterosexism. Facilities that place pink triangles or rainbow-colored safezone signs in public areas will indicate to LGBTQ patients and their families that the facility is safe and accepting of sexual minorities (Gay and Lesbian Medical Association [GLMA], n.d.). Environmental assessment also includes a review of facility forms. Adding inclusive language options to the questions related to spouse, relationship, family, and sexual history will help remove barriers to self-disclosure for LGBTQ elders. Inclusive forms also aid in normalizing LGBTQ experiences (GLMA, n.d.).
Assessment of policies and procedures is the third assessment consideration. Patient non-discrimination policies could include sexual orientation and gender identity as protected classifications. Visitation policies could explicitly grant equal visitation to LGBTQ patients and their visitors. The facility's policy regarding couples sharing living quarters could be inclusive of same sex couples (Bluestein & Bach, n.d.; LLDEF, n.d.). To complement resident policies, employment non-discrimination policies could include the terms sexual orientation and gender identity. LGBTQ staff can informally educate co-workers and residents and provide guidance to facility leadership (HRC, 2013). LTC facilities may also find it helpful to recruit board members who have a professional understanding of the lives of LGBTQ elders. When necessary, facility leaders should enforce a zero tolerance policy on discrimination against LGBTQ residents and staff.
The second tier consideration (cultural change) calls for expert training in LGBTQ patient-centered care. Formal healthcare education provides only a limited amount of core LGBTQ curricular content (Brennan, Barnsteiner, Siantz, Cotter, & Everett, 2012); the limits of this formal education increase the importance of workplace education for LTC staff. Since LTC residents are in daily contact with a wide variety of service providers, such as housekeepers, dietary workers, therapy staff and maintenance personnel, all persons working in a LTC facility should receive LGBTQ training.
An educational curriculum could focus on several content areas, including: human sexuality and aging; homophobia and heterosexism; sexual diversity among LTC residents; fears and experiences of LGBTQ in LTC facilities; inclusive policies and procedures; Health Insurance Portability and Accountability Act (HIPAA) requirements; and best practice in caring for LGBTQ residents (Bluestein & Bach, n.d.; HRC, 2013). Care should be taken to allow for question-and-answer sessions in order to dispel myths and discuss personal nursing/work experiences (Low, Lui, Lee, Thompson, & Chau, 2005). For example, during group and individual activities with LTC staff and residents, activities staff could be encouraged to include current events topics about LGBTQ newsworthy events, thereby normalizing the lives and experiences of LGBTQ residents.
However, increased training and education does not always result in a change in attitudes and behaviors. Because some employees may find this type of education in conflict with their religious beliefs, placing LGBTQ education in the context of professional practice and workplace requirements is critical (Hinrichs & Vacha-Haase, 2010). It is important to note that in order for training to be most effective, it must be ongoing and complemented with routine mentoring and performance evaluation. Several professional organizations have called for a standardized diversity education program, one that is developed in collaboration with LGBTQ advocacy programs and that may be utilized by LTC leadership (U.S. Administration for Community Living, 2014; Bluestein & Bach, n.d.; GLMA, n.d.; HRC, 2013).
Educating Elders Regarding Their Rights and Responsibilities
During a time of health crisis or significant change, it is challenging to consider the ramifications of long-term disability. Hence, prior to LTC placement, it is imperative that elders and their families understand their personal rights and responsibilities. This is of particular importance for LGBTQ elders who may not find anti-discrimination protection under state or federal laws and regulations. Designating a DPOA-HC and identifying preferences in an advanced directive are two important documents that should be considered (Bluestein & Bach, n.d.). Information about LTC planning is available from multiple national organizations, including the following: the American Association of Retired Persons (AARP, n.d.); the Center for Positive Aging, (n.d.); the LongTermCare.gov (n.d.); the National Long-Term Care Ombudsman Resource Center (NORC, n.d.); the National Resource Center on LGBT Aging (n.d.); and the U.S. Administration for Community Living (2014). Additionally, elders may want to locate a LTC facility that specifically markets to LGBTQ residents. While multiple resources exist, healthcare providers at every encounter share in the responsibility of educating elders. In all healthcare settings, there should be the obligation to educate LGBTQ elders on preparing for their future healthcare needs.