Value pluralism about sexual intimacy in residential care.

BACKGROUND: The existing literature on sexuality and intimacy in residential care tends to focus on either the question of rights, or the value of autonomy. Where the literature does reference values other than autonomy, such values are considered in the context of being a guide to whether or not a resident is autonomous, rather than being important values in their own right. OBJECTIVE: This paper draws on qualitative data gathered as part of a larger study in order to inform practice on how care workers respond to intimacy issues that arise with residents with dementia and to inform a general ethics of sex and sexuality, demonstrating that an approach which permits value pluralism can be appropriate in certain contexts. RESEARCH DESIGN: The qualitative data referred to in this paper was gathered from semi-structured interviews undertaken as part of a larger mixed-method research project. The interview text was analysed using Thorne's methodological approach, interpretive description. PARTICIPANTS AND RESEARCH CONTEXT: The qualitative arm of the project consisted of semi-structured interviews conducted between October 2018 and October 2019 with participants (staff, residents and family members) recruited from 35 residential care homes in Aotearoa New Zealand. ETHICAL CONSIDERATIONS: Participation was informed, voluntary and written consent was gained before interviews. The project was approved by the Massey University Human Ethics Committee (Northern), number NOR 18/25. FINDINGS: Analysis of the scenarios presented in this paper shows that decision-making around sexual intimacy involving people with dementia in a residential care setting is complex and requires recognizing and weighing the different values that may be a in play. CONCLUSION: A focus on safety and consent to the exclusion of other values which matter morally in this context is a mistake which prevents care workers from providing appropriately person-centred care to residents, as policies which focus on the goal of care allow space for critical examination of issues which are likely to be highly context-sensitive.

Palliative Care, Intimacy, and Sexual Expression in the Older Adult Residential Care Context: "Living until You Don't".

Commonly, frail older adults move to residential care, a liminal space that is their home, sometimes a place of death, and a workplace. Residential facilities typically espouse person-centred values, which are variably interpreted. A critical approach to person-centred care that focuses on social citizenship begins to address issues endemic in diminishing opportunities for intimacy in the end-of-life residential context: risk-averse policies; limited education; ageism; and environments designed for staff convenience. A person-centred approach to residents' expressions of intimacy and sexuality can be supported throughout end-of-life care. The present study utilised a constructionist methodology to investigate meanings associated with intimacy in the palliative and end-of-life care context. There were 77 participants, including residents, family members and staff, from 35 residential facilities. Analysis identified four key themes: care home ethos and intimacy; everyday touch as intimacy; ephemeral intimacy; and intimacy mediated by the built environment. Residents' expressions of intimacy and sexuality are supported in facilities where clinical leaders provide a role-model for a commitment to social citizenship. Ageism, restrictive policies, care-rationing, functional care, and environmental hindrances contribute to limited intimacy and social death. Clinical leaders have a pivotal role in ensuring person-centred care through policies and practice that support residents' intimate reciprocity.

Culture clash: responses to sexual diversity in residential aged care.

This paper explores attitudes of staff, residents and family members towards sexually diverse persons based on data from the first national study of its kind in Aotearoa New Zealand. The study was a two-arm mixed-method cross-sectional study using a concurrent triangulation design. The quantitative arm included the results of 433 staff surveys related to knowledge, attitudes, behaviours and beliefs about sexuality, intimacy and ageing. The qualitative arm included interviews with 77 participants including staff, residents and family members. This paper focuses only on sexual diversity. A generational cultural effect was noted among all respondents; younger participants expressed the most open and accepting views of diversity. Residents were aware that they mostly held the views of their generation; nonetheless they also looked to staff to set the tone. Staff held varying views and felt that residents would be less accepting; some staff felt the issue of intimate relationships was not something they were willing to discuss at intake. Facilities will want to establish policies about sexuality and intimacy and communicate those policies and practices to staff, residents and family members. Facilities may also wish to consider specific educational events about sexual diversity for residents.

Not in the Brochure: Porneia and Residential Aged Care.

Introduction: Sexuality and intimacy in residential aged care (RAC) are receiving increased research attention. In this article, porneia refers to access to sex workers, as well as online pornography, and masturbation by residents in RAC. Sex work is legal and regulated in Aotearoa New Zealand. Methods: The present study was a two-arm mixed-method cross-sectional study using a concurrent triangulation design. A validated survey tool was developed. Data were collected in 2018-2019: 433 staff surveys were collected from 35 RAC across the country; 61 interviews were carried out with 77 staff, residents, and family members. Results: Staff opinions about sex work and pornography were inconclusive. Nevertheless, access to sex workers occurs in many RAC facilities across the country. Interviews demonstrated a diversity of responses among the three groups; staff attitudes are paramount. Conclusions: Some staff are prepared for resident requests for sex workers; others continue to look to policies and management for guidance, but such policies are often lacking. Most staff have adopted the language of needs vs. rights which dominates the literature. Policy Implications: Staff education on sexuality and facility policy is essential; education for residents and their families is also desirable. Facilities often over-notify third parties. Discourse about sexuality needs to move towards a person-centred, salutogenic approach.

Sexual harassment or disinhibition? Residential care staff responses to older adults' unwanted behaviours.

BACKGROUND: The ethical complexity of residential care is especially apparent for staff responding to residents' inappropriate sexual expression, particularly when directed towards care workers as these residents are typically frail, often cognitively impaired, and require ongoing care. OBJECTIVES: To explore staff accounts of how they made meaning of and responded to residents' unwanted sexual behaviours directed towards staff. This exploration includes whether staff appeared to accept harassment as a workplace hazard to be managed, or an unacceptable workplace violation, or something else. METHODS: These qualitative data are drawn from a national two-arm mixed method study in Aotearoa New Zealand undertaken in 35 residential care facilities. Semi-structured interviews were conducted with 77 staff, residents and family members. Interpretive description was used to analyse the data. RESULTS: Staff had numerous ways they used to respond to behaviours: (1) minimisation, deflection and de-escalation, where staff used strategies to minimise behaviours without requiring any accountability from residents; (2) holding residents accountable, where staff to some degree addressed the behaviour directly with residents; (3) blurred boundaries and complexities in intimate long-term care, where staff noted that in a context where touch is common-place, cognitive function was diminished and relationships were long-term, boundaries were easily breached; (4) dehumanising and infantilising residents' behaviours, where staff appeared to assert control through diminishing the residents' identity as an older person. It was evident that staff had developed considerable practice wisdom focused on preserving the care relationship although few referred to policy and education guiding practice. CONCLUSIONS: Staff appeared to be navigating a complex ethical terrain with thoughtfulness and skill. Care workers seemed reluctant to label resident behaviour as sexual harassment, and the term may not fit for staff where they perceive residents are frail and cognitively impaired. IMPLICATIONS FOR PRACTICE: Policy, education and clinical leadership are recommended to augment practice wisdom and ensure staff and resident safety and dignity and to determine how best to intervene with residents' unwanted sexual behaviours.

Intimacy for older adults in long-term care: a need, a right, a privilege-or a kind of care?

BACKGROUND: To investigate attitudes of staff, residents and family members in long-term care towards sex and intimacy among older adults, specifically the extent to which they conceptualise sex and intimacy as a need, a right, a privilege or as a component of overall well-being. METHODS: The present study was a part of a two-arm mixed-methods cross-sectional study using a concurrent triangulation design. A validated survey tool was developed; 433 staff surveys were collected from 35 facilities across the country. Interviews were conducted with 75 staff, residents and family members. RESULTS: It was common for staff, residents and family members to talk about intimacy and sexuality in terms of rights and needs. As well as using the language of needs and rights, it was common for participants to use terms related to well-being, such as fun, happiness or being miserable. One participant in particular (a staff member) described receiving intimate touch as a 'kind of care'-a particularly useful way of framing the conversation. CONCLUSION: While staff, residents and family frequently used the familiar language of needs and rights to discuss access to intimate touch, they also used the language of well-being and care. Reframing the conversation in this way serves a useful purpose: it shifts the focus from simply meeting minimum obligations to a salutogenic approach-one that focuses on caring for the whole person in order to improve overall well-being and quality of life.

Iatrogenic loneliness and loss of intimacy in residential care.

BACKGROUND: There is an international trend for frail older adults to move to residential care homes, rather than ageing at home. Residential facilities typically espouse a person-centred philosophy, yet evidence points to restrictive policies and surveillance resulting in increased loneliness and diminished opportunities for intimacy and sexual expression. Residents may experience what has been termed social death, rather than perceive they are related to by others as socially alive. AIM: To consider how the loss of intimacy and sexuality in residents' lives contributes to iatrogenic loneliness experienced in residential care, and the importance of considering these issues together. RESEARCH DESIGN: The study utilised a constructionist methodology, investigating the meanings associated with intimacy, loneliness, and ageing. PARTICIPANTS AND RESEARCH CONTEXT: Qualitative data used in this study are drawn from a larger dataset of a mixed-methods study. Interviews were completed as follows: staff, 21 individual interviews, and two groups with a total of 13 additional people; residents, 26 interviews with 28 people; and family members, 12 interviews with 13 people. FINDINGS: Five key themes were identified in the data analysis: loneliness and relational identity, loneliness and functional relationships, loneliness and disrupted intimacy, loneliness and liminality, and loneliness and the built environment. ETHICAL CONSIDERATIONS: The study was approved by a University Human Ethics Committee. Participation was voluntary. Consent was gained and confidentiality upheld. DISCUSSION: Residents' expression of intimacy and sexuality can be compromised through paternalism, ageism, restrictive policies, care-rationing and functional care, alienating residents from sustaining and developing significant relationships. Attitudes and cultural beliefs of staff and family members about ageing and intimacy, compounded by architectural design, may intensify loneliness. CONCLUSIONS: Nurses have a pivotal role in ensuring policies and practice enhance social citizenship.

Ethics, intimacy and sexuality in aged care.

AIM: To analyse the accounts of staff, family and residents to advance ethical insights into intimacy and sexuality in residential care. BACKGROUND: Discourses of ageing readily construct people in residential aged care as postsexual, vulnerable and at risk of sexual exploitation, and therefore, expressions of intimacy and sexuality may be responded to as deviant and inherently risky. Staff may manage decision-making tacitly, without recourse to policies and education. DESIGN: The proof-of-concept study used a discursive methodology, identifying discourses that shape diverse meanings of intimacy, sexuality and ageing. Data analysis involved thematic analysis. METHODS: Semi-structured interviews were conducted with four participants in 2015 as part of a mixed-methods study. This article reports on the qualitative data. RESULTS: Four themes were identified in the data analysis: mediated intimate relationships and everyday ethics; self-referential morality; knowing the person then and now; and juggling ethical priorities. Data indicated that participants used their personal moral compass to inform their decision-making, without any related policies and applied ethics and communication education. As a result, staff described moral uncertainty and moral distress. Staff indicated that there were tensions in terms of the role of proxy decision-makers, as there were situations where staff believed they were more aware of residents' current wishes and cognitive capabilities than family members. CONCLUSIONS: Staff, families and residents routinely address intimacy and sexuality in aged care. Ethically informed education and policies may enhance the role of staff as advocates, ensuring older people living in RAC are as at home and autonomous as possible.