Developing inclusive residential care for older lesbian, gay, bisexual and trans (LGBT) people: An evaluation of the Care Home Challenge action research project

Interventions addressing care staff views of older LGBTQ+ people in residential and homecare settings: a scoping review protocol

INTRODUCTION

Previous research has identified that lesbian, gay, bisexual, trans and queer (LGBTQ+) social care service users have concerns and/or negative experiences of their care due to staff views and attitudes about them/their sexual and gender identities. This has resulted in a number of barriers and challenges for the delivery of social care to this population. However, there is a little research relating to what types of evidence-based interventions can help overcome these barriers, enhance knowledge and promote positive attitude change in staff. The objective of this review was to systematically review current literature on interventions targeted at staff views and attitudes of LGBTQ+ older people in care and identify gaps in knowledge to inform a future theory of change and identify potential interventions to address these.

METHODS AND ANALYSIS

This scoping review will be conducted in line with the Joanna Briggs Institute methodology for scoping reviews. We will conduct a comprehensive search of electronic databases (ie, Social Services Abstracts, Social Care online, Sociological Abstracts, PsycINFO, Medline, CINAHL, Scopus, ASSIA and Web of Science) focused on both health and social care literature to identify peer-reviewed literature as well as targeted online searches of potentially relevant grey literature. We will include literature published in the past 20 years (2003-2023) that report interventions to address care staff attitudes of LGBTQ+ populations older than 50 years who are receiving adult social care in a broad range of healthcare, residential or home settings. Citations will be screened by two independent researchers for inclusion and relevant data extracted using a bespoke template. Data will be analysed narratively and summarised to identify gaps in knowledge and aid in developing a theory of change.

ETHICS AND DISSEMINATION

Ethics approval is not required. Findings will be disseminated via publication in a peer-reviewed journal.

REVIEW REGISTRATION

A priori registration on Open Science Framework: https://osf.io/v76ws.

Relationship between staff and quality of care in care homes: StaRQ mixed methods study

Background

Quality of life and care varies between and within the care homes in which almost half a million older people live and over half a million direct care staff (registered nurses and care assistants) work. The reasons are complex, understudied and sometimes oversimplified, but staff and their work are a significant influence.

Objective(s)

To explore variations in the care home nursing and support workforce; how resident and relatives' needs in care homes are linked to care home staffing; how different staffing models impact on care quality, outcomes and costs; how workforce numbers, skill mix and stability meet residents' needs; the contributions of the care home workforce to enhancing quality of care; staff relationships as a platform for implementation by providers.

Design

Mixed-method (QUAL-QUANT) parallel design with five work packages. WP1 - two evidence syntheses (one realist); WP2 - cross-sectional survey of routine staffing and rated quality from care home regulator; WP3 - analysis of longitudinal data from a corporate provider of staffing characteristics and quality indicators, including safety; WP4 - secondary analysis of care home regulator reports; WP5 - social network analysis of networks likely to influence quality innovation. We expressed our synthesised findings as a logic model.

Setting

English care homes, with and without nursing, with various ownership structures, size and location, with varying quality ratings.

Participants

Managers, residents, families and care home staff.

Findings

Staffing's contribution to quality and personalised care requires: managerial and staff stability and consistency; sufficient staff to develop 'familial' relationships between staff and residents, and staff-staff reciprocity, 'knowing' residents, and skills and competence training beyond induction; supported, well-led staff seeing modelled behaviours from supervisors; autonomy to act. Outcome measures that capture the relationship between staffing and quality include: the extent to which resident needs and preferences are met and culturally appropriate; resident and family satisfaction; extent of residents living with purpose; safe care (including clinical outcomes); staff well-being and job satisfaction were important, but underacknowledged.

Limitations

Many of our findings stem from self-reported and routine data with known biases - such as under reporting of adverse incidents; our analysis may reflect these biases. COVID-19 required adapting our original protocol to make it feasible. Consequently, the effects of the pandemic are reflected in our research methods and findings. Our findings are based on data from a single care home operator and so may not be generalised to the wider population of care homes.

Conclusions

Innovative and multiple methods and theory can successfully highlight the nuanced relationship between staffing and quality in care homes. Modifiable characteristics such as visible philosophies of care and high-quality training, reinforced by behavioural and relational role modelling by leaders can make the difference when sufficient amounts of consistent staff are employed. Greater staffing capacity alone is unlikely to enhance quality in a cost-effective manner. Social network analysis can help identify the right people to aid adoption and spread of quality and innovation. Future research should focus on richer, iterative, evaluative testing and development of our logic model using theoretically and empirically defensible - rather than available - inputs and outcomes.

Study registration

This study is registered as PROSPERO CRD42021241066 and Research Registry registration: 1062.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 15/144/29) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 8. See the NIHR Funding and Awards website for further award information.

LGBTQ+ Inclusivity Training and Education: A Toolkit for Skilled Nursing Facilities

OBJECTIVES

The objective of this study was to develop the LGBTQ+ Inclusivity Training and Education (LITE) toolkit and to examine the usability and acceptability of the LITE toolkit to health care workers and staff who work within skilled nursing facilities (SNFs).

DESIGN

A community-engaged approach using human-centered design to develop the LITE toolkit. To test the usability and acceptability of the LITE toolkit, we provided a posttest survey to users after a 9-week period.

SETTING AND PARTICIPANTS

The LITE toolkit was distributed to 25 SNFs throughout a 7-county area in North Carolina.

METHODS

Development processes included an LGBTQ+ community advisory board, development of resource topics and a list of best practices, and development of a website. The LITE toolkit comprised a website of LGBTQ+ resources, poster of 6 Best Practices to LGBTQ+ Care, rainbow lapel pins, and writing pens with the LITE logo. Online surveys were distributed to SNF administrators to share with health care workers and staff to collect data on the usability and acceptability of the LITE toolkit. Descriptive statistics were used for data analysis.

RESULTS

Fifteen participants completed the survey. Answering all survey questions was not a requirement. Seventy-nine percent (n = 14) of SNF health care workers indicated that the LITE toolkit was "easy to understand" and that they were satisfied with the contents. Fifty-three percent (n = 15) responded that the LITE toolkit would improve the way they care for patients. Sixty-six percent (n = 15) of health care workers and staff strongly agreed the LITE toolkit was applicable to their job role.

CONCLUSIONS AND IMPLICATIONS

Providing useful and acceptable LGBTQ+-focused training and education for members of the SNF community addresses the need for health care worker and staff training to foster equitable care and inclusive environments for the LGBTQ+ older adult community. Additional work focused on understanding the facilitators and barriers to using the LITE toolkit in the SNF setting is needed.

The complexity of leadership in coproduction practices: a guiding framework based on a systematic literature review

BACKGROUND

As coproduction in public services increases, understanding the role of leadership in this context is essential to the tasks of establishing relational partnerships and addressing power differentials among groups. The aims of this review are to explore models of coproduction leadership and the processes involved in leading coproduction as well as, based on that exploration, to develop a guiding framework for coproduction practices.

METHODS

A systematic review that synthesizes the evidence reported by 73 papers related to coproduction of health and welfare.

RESULTS

Despite the fact that models of coleadership and collective leadership exhibit a better fit with the relational character of coproduction, the majority of the articles included in this review employed a leader-centric underlying theory. The practice of coproduction leadership is a complex activity pertaining to interactions among people, encompassing nine essential practices: initiating, power-sharing, training, supporting, establishing trust, communicating, networking, orchestration, and implementation.

CONCLUSIONS

This paper proposes a novel framework for coproduction leadership practices based on a systematic review of the literature and a set of reflective questions. This framework aims to help coproduction leaders and participants understand the complexity, diversity, and flexibility of coproduction leadership and to challenge and enhance their capacity to collaborate effectively.

Intersecting sex and gender diversity with sexual rights for people living with dementia in later life: an example of developing a learning framework for policy and practice

The proliferation of literature on dementia over the last decade has begun to address the experience of LGBTQ+ people's experiences in later life. Changes in cognitive function can jeopardize the safety, wellbeing, and human rights of LGBTQ+ people if the social care workforce are not prepared or versed in responding to their unique needs. The intersection of age, cognitive function, sexual and gender diversity with the expression of intimacy and sexuality requires sensitive and respectful consideration. Yet, this is currently an under-researched and less understood area in social care practice. This paper highlights the main messages from the different bodies of contributory literature and introduces the national framework in England UK on LGBTQ+ aging and its potential for supporting workforce development to consider its flexibility in supporting services to becoming more nuanced and affirmative in these areas of practice.

Experiences and Attitudes of the LGBTQ+ Community on Care/Nursing Homes

Recent research has found that older lesbian, gay, bisexual, transgender and queer (LGBTQ+) people have a negative attitude toward long term care services. To build upon this, we conducted a systematic review analyzing current research into the LGBTQ+ communities' perspectives and experiences of care/nursing homes. Additionally, we sought to explore the attitudes of care/nursing home staff toward providing care for LGBTQ+ residents. To conduct this study, we used the databases Embase, Medline and Web of Science, which identified 19 articles for review. From this, we were able to draw several conclusions, including that LGBTQ+ participants were concerned that they would have to conceal their identity and experience abuse. Most staff had a positive attitude toward LGBTQ+ residents, but there were exceptions to this. Despite their positive attitude, staff often lacked awareness of LGBTQ+ issues. The results of this review suggest that care/nursing homes are not welcoming environments for sexual and gender minorities, and that staff require more training to support this community. We end with innovative suggestions to tackle these issues, such as designing coproduced services with the support of LGBTQ+ communities.

Prejudice against the older LGBTQIA+ population in Long-Term Care Facilities (LTC): a scoping review

Among older people, LGBTQIA+ persons represent one of the groups most likely to depend on formal care services because of socio-economic vulnerability. However, the prejudice rooted in society, including health and social care professionals, result in a cis-heteronormative model of care delivery in Long-Term Care Facilities for older persons (LTC). The aim of this article is to investigate, describe and analyse the scientific production on prejudice against the older LGBTQIA+ population in LTC. Scoping review based on searches in the following databases: AgeLine, Portal de Periódicos CAPES, SciELO, Portal USP and HeinOnline. No time limit was set. Of the initial 642 articles, 31 were selected to comprise the sample. Four categories and 11 subcategories were identified. These covered agents, causes, effects, and solutions found in the research. The lack of preparation of the LTC staff and the history of prejudice during life leads the LGBTQIA+ community to fear institutionalisation, when the desire is to have a friendly or exclusive environment. Training of LTC staff is essential, in addition to the need to create legislation to protect this population based on local surveys.

Queer(y)ing aging-potentialities and problems in applying Queer Theory to studies of aging and later life

Queer Theory is a radically deconstructionist perspective within the humanities and social sciences. Since its initial emergence in the late 1980s and early 1990s in the field of sexualities studies, Queer Theory has increasingly been used to challenges normative notions of self, identity, temporality and the nature of being, more broadly. Whilst Queer Theory has been utilized, to some extent, in gerontology and aging studies, this article makes an original contribution to this endeavor, assessing the potentiality and problems with queer(y)ing three aspects of aging: chronology; cognition; and frailty and vulnerability. To achieve this, the article draws on ideas from some key Queer theorical writers, existing studies of queer aging and illustrates theoretical points with qualitative data collected from two LGBTQ+ projects to illustrate. The article also considers problems with Queer Theory in challenging normativities associated with aging. It is concluded that despite problems, Queer Theory remains an important and valuable theoretical approach for disturbing and challenging many of the norms and understandings that shape and constrain older LGBTQ+ people's lives, in particular, and therefore have importance for how we think and understand aging and later life sociologically.

Standards of Care for the Health of Transgender and Gender Diverse People, Version 8

Background: Transgender healthcare is a rapidly evolving interdisciplinary field. In the last decade, there has been an unprecedented increase in the number and visibility of transgender and gender diverse (TGD) people seeking support and gender-affirming medical treatment in parallel with a significant rise in the scientific literature in this area. The World Professional Association for Transgender Health (WPATH) is an international, multidisciplinary, professional association whose mission is to promote evidence-based care, education, research, public policy, and respect in transgender health. One of the main functions of WPATH is to promote the highest standards of health care for TGD people through the Standards of Care (SOC). The SOC was initially developed in 1979 and the last version (SOC-7) was published in 2012. In view of the increasing scientific evidence, WPATH commissioned a new version of the Standards of Care, the SOC-8. Aim: The overall goal of SOC-8 is to provide health care professionals (HCPs) with clinical guidance to assist TGD people in accessing safe and effective pathways to achieving lasting personal comfort with their gendered selves with the aim of optimizing their overall physical health, psychological well-being, and self-fulfillment. Methods: The SOC-8 is based on the best available science and expert professional consensus in transgender health. International professionals and stakeholders were selected to serve on the SOC-8 committee. Recommendation statements were developed based on data derived from independent systematic literature reviews, where available, background reviews and expert opinions. Grading of recommendations was based on the available evidence supporting interventions, a discussion of risks and harms, as well as the feasibility and acceptability within different contexts and country settings. Results: A total of 18 chapters were developed as part of the SOC-8. They contain recommendations for health care professionals who provide care and treatment for TGD people. Each of the recommendations is followed by explanatory text with relevant references. General areas related to transgender health are covered in the chapters Terminology, Global Applicability, Population Estimates, and Education. The chapters developed for the diverse population of TGD people include Assessment of Adults, Adolescents, Children, Nonbinary, Eunuchs, and Intersex Individuals, and people living in Institutional Environments. Finally, the chapters related to gender-affirming treatment are Hormone Therapy, Surgery and Postoperative Care, Voice and Communication, Primary Care, Reproductive Health, Sexual Health, and Mental Health. Conclusions: The SOC-8 guidelines are intended to be flexible to meet the diverse health care needs of TGD people globally. While adaptable, they offer standards for promoting optimal health care and guidance for the treatment of people experiencing gender incongruence. As in all previous versions of the SOC, the criteria set forth in this document for gender-affirming medical interventions are clinical guidelines; individual health care professionals and programs may modify these in consultation with the TGD person.

Religious-based negative attitudes towards LGBTQ people among healthcare, social care and social work students and professionals: A review of the international literature

There is a dearth of research on how negative religious attitudes towards LGBTQ people inform professional practice. This paper reports on a scoping review of 70 selected studies from 25 different countries. It explores key issues and knowledge gaps regarding the delivery of services to LGBTQ adults by religious healthcare, social care and social work organisations and/or practitioners with faith-based objections to LGBTQ people and their lives. The review identified four main themes: (1) a close connection between religious affiliation and negative attitudes towards LGBTQ people, among both students and professionals; (2) a heightening effect of religiosity, particularly among Christian and Muslim practitioners/students; (3) educators' religious attitudes informing curriculum design and delivery, and some highly religious students resisting and/or feeling oppressed by LGBTQ-inclusivity, if present; (4) examples of practice concerns raised by professionals and lay LGBTQ people. The article considers the ethical, practical, educational and professional standards implications, highlighting the need for further research in this area.

Unheard voices: A qualitative study of LGBT+ older people experiences during the first wave of the COVID-19 pandemic in the UK

This paper reports findings from a qualitative study into the immediate impact of social distancing measures on the lives of lesbian, gay, bisexual and trans (LGBT+) older people (≥60 years) living in the UK during the first lockdown of the COVID-19 pandemic. It draws on in-depth interviews with 17 older people and 6 key informants from LGBT+ community-based organisations, exploring the strategies used to manage their situations, how they responded and adapted to key challenges. Five themes emerged related to: (1) risk factors for LGBT+ older people and organisations, including specific findings on trans experiences; (2) care practices in LGBT+ lives; (3) strengths and benefits of networking (4) politicisation of ageing issues and their relevance to LGBT+ communities and (5) learning from communication and provision in a virtual world. The findings illuminate adaptability and many strengths in relation to affective equality and reciprocal love, care and support among LGBT+ older people. It is vital UK that the government recognises and addresses the needs and concerns of LGBT+ older people during emergencies.

Investigating the lived experience of LGBT+ people with dementia and their care partners: a scoping review

Dementia, a global health priority, poses a disproportionately high risk to lesbian, gay, bisexual and trans plus (LGBT+)/gender and sexuality diverse people. Despite this, little research has explored the lived experience of LGBT+ people with dementia or their care partners. This scoping review aims to understand what the literature reveals about their experiences, the ways in which their lives have been investigated, to inform future research, policy and practice. Using an established scoping review methodology, we identified seven papers that reported empirical research on the lived experience of LGBT+ people with dementia and their care partners. Only a single study reported on in two of the papers included people who were trans. This in itself reveals how rarely LGBT+ people are asked to speak about how dementia has shaped their lives in academic research. Our reflexive thematic analysis indicates that LGBT+ people with dementia and their care partners endure overlapping forms of disadvantage. This results in heightened experiences of fear and discrimination, lack of services and compounded social isolation. Importantly, while dementia was embodied as interference and loss by LGBT+ people, it was their gender and sexuality differences that provided solace, even in the face of disadvantage. Importantly, people's relationships with LGBT+ identities were framed as fundamental for safety, resilience and wellbeing, rather than a complicating or confounding factor in living with dementia.

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.

A rapid review of end-of-life needs in the LGBTQ+ community and recommendations for clinicians

BACKGROUND

Lesbian, gay, bisexual, transgender, and queer plus (LGBTQ+) adults face challenges accessing end-of-life care. Understanding the experiences of LGBTQ+ persons within the end-of-life context is crucial in addressing their needs and supporting equity at end of life.

AIM

Review recent literature documenting the experiences of LGBTQ+ adults nearing end-of-life, identifying needs, barriers to care, and translating this into clinical recommendations.

DESIGN

A rapid review design was chosen for prompt results. The process was streamlined by limiting the literature search to peer-reviewed articles, dissertations, theses, by date and language. Data collection used a predetermined set of items based on Meyer's Minority Stress and Bronfenbrenner's Ecological Models including participants' voices, needs, and barriers. Thematic analysis of collected data was conducted and presented results in a narrative summary.

DATA SOURCES

We searched six electronic databases (PubMed, Medline, ProQuest Dissertations and Theses A&I, ProQuest Dissertations and Theses, Open Access Theses and Dissertations, CINAHL, and Google Scholar) for articles published from 2016 to 2020.

RESULTS

We included and appraised for quality 33 articles. We uncovered three latent themes: systemic barriers, a lack of lived experience within the literature, and treatment of LGBTQ+ as one homogeneous group.

CONCLUSIONS

The hybrid Meyer's Minority Stress and Bronfenbrenner Ecological model elucidated how stressors and social contexts may impact LGBTQ+ adults when accessing end-of-life care. Incorporating LGBTQ+ cultural competence training into continuing education and ensuring that LGBTQ+ individuals participate in the development of end-of-life care programming may better attend to the needs of this population.

Worry and Wisdom: A Qualitative Study of Transgender Elders' Perspectives on Aging

Purpose: While lesbian, gay, bisexual, transgender, and queer or questioning (LGBTQ) elders face a multitude of barriers to healthy aging, little is known about needs and concerns specific to transgender elders, except that they face many self-perceived challenges to healthy aging, which exist at the individual, community, and institutional levels. To further understand these needs, we explored the perspectives of transgender individuals aged 65 and older on health care, expectations of aging, concerns for the future, and advice for young transgender people. Methods: We performed 19 semistructured interviews with individuals who identify as transgender elders, 10 transgender women and 9 transgender men. Interviews were transcribed and coded by three investigators to generate salient themes via thematic analysis. Results: We identified 7 major themes that exemplify the concerns and experiences of this sample of the aging transgender community: fear of mistreatment in elder care, isolation and loneliness exacerbated by transgender identity, increased vulnerability to financial stressors, perceived lack of agency, health care system and provider inclusivity, giving back to one's community, and embracing self-truth as a path to fulfillment. Conclusion: While some of these concerns, such as fear of mistreatment, are common among elders, the concerns of transgender elders are heightened due to stigma compounded by being both transgender and elderly. Health care providers, nursing home staff, and social workers must be sensitized to these needs and fears to provide appropriate, affirming, and respectful care and support to transgender elders.

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.

Inclusive Practices toward LGBT Older Adults in Healthcare and Social Services: A Scoping Review of Quantitative and Qualitative Evidence

Objectives: To determine what constitutes inclusive practices toward LGBT older adults in healthcare and social services and the supportive competencies of these practices. Methods: A comprehensive scoping review of the existing literature was conducted.Results: To be competent when addressing LGBT elder needs, personnel must have knowledge on LGBT realities, openness and be able to put certain skills into practice.Conclusions: Given the limited powers conferred on them by their respective positions, institutions must also play a role in encouraging the inclusion of LGBT older adults. Beyond the importance of taking into account the three dimensions of competence in staff training, changes must be made at all levels of the organizational structures.Clinical implications: Inclusive practices require 1) Educating personnel on the diversity of the life journeys of LGBT older adults; 2) Promoting relational and communication skills and open, friendly attitudes toward the diversity of LGBT identities; 3) Developing policies and procedures to create and maintain inclusive and safe environments for LGBT older adults.

Action research improved general prerequisites for evidence-based practice

The present study was part of an action research project that was performed to implement a clinical pathway for patients on mechanical ventilation and simultaneously explore the implementation process in a Swedish intensive care unit. The aim of this questionnaire study was to evaluate whether an action research methodology could affect the general prerequisites for evidence-based practice (EBP). Informed by the Promoting Action on Research Implementation in Health Services (PARIHS) framework, the study included registered nurses, assistant nurses and anesthesiologists in the unit at start of the project (n = 50) and at follow-up (n = 44). Data was collected with the Evaluation Before Implementation Questionnaire and the Attitudes towards Guidelines Scale.

The results revealed that the general prerequisites for EBP in the setting improved. Compared to baseline measurements, the staff at follow-up conversed significantly more about the importance of the patients’ experiences, research utilization, context and facilitation, while changes with respect to clinical experiences were not significant. The attitudes towards guidelines were perceived as positive at baseline as well as at follow-up and did not significantly change.

Longer professional experience was associated with a slightly lower probability of perceiving that the importance of research utilization was discussed and reflected upon, while belonging to a profession with longer education was associated with a higher probability of this perception. Compared to registered nurses and assistant nurses, the anesthesiologists perceived, to a greater extent, that the importance of clinical experience was discussed and reflected upon in the setting, while there was no significant association with the length of professional experience and/or specific professions regarding the other components.

In conclusion, using action research to implement a clinical pathway methodology seems to set in motion various mechanisms that improve some but not all prerequisites that, according to the PARIHS framework, are advantageous for EBP.

Learning to deliver LGBT+ aged care: exploring and documenting best practices in professional and vocational education through the World Café method

Substantial evidence on the adverse impact of ageing on lesbian, gay, bisexual and transgender (LGBT+) populations through the lack of inclusive care services has highlighted the need for education and training of the health and social care workforce to enhance their skills, knowledge and capabilities in this area. We describe a cross-national collaboration across four European Union countries called BEING ME. This collaboration examined the current pedagogic environment within professional, vocational and community-based education to identify what is most valuable for addressing these needs. The World Café method enabled a process of structured learning and knowledge exchange between stakeholders resulting in: (a) identification of best practices in pedagogies, (b) generation of tailored co-produced educational resources, and (c) recommendations on how to improve the knowledge and capabilities of future care professionals in the area of LGBT+ affirmative practices. Combined with themes from the post-Café evaluation, our findings suggest that underpinning professional and vocational education with a person-in-environment perspective facilitates going some way to acknowledging the historical context of older LGBT+ people's lives. Addressing the unique needs of sub-populations within LGBT+ communities and setting these in the context of holistic and person-centred care may better enable the meeting of their unique diverse needs for ageing. Recommendations are made for learning and teaching strategies to support improved LGBT+ aged care.

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.

Health care for LGBTI+ elders living in Nursing Homes

OBJECTIVE

to describe and analyze the scientific production on health care for Lesbians, Gays, Bisexuals, Transvestites, Transsexuals, Transgenders, Intersex (LGBTI+) and other variations of gender or sexual orientation living in Nursing Homes (NHs).

METHODS

a scoping review, in which PubMed, Web of Science, Scopus and Virtual Health Library databases were analyzed and studies from other sources were added. After assessment by two independent reviewers, 19 publications were selected to compose the sample.

RESULTS

the studies were grouped into two categories.

FINAL CONSIDERATIONS

NHs are configured as spaces that are not very inclusive, where LGBTI+ elders' demands are not considered due to the cis-heteronormativity in force in these places. Training and awareness of health professionals on the LGBTI+ theme is a tool that can make such spaces more inclusive for this population.

Inequalities in older LGBT people's health and care needs in the United Kingdom: a systematic scoping review

The hostile environment that older lesbian, gay, bisexual and transgender (LGBT) people faced at younger ages in the United Kingdom (UK) may have a lasting negative impact on their health. This systematic scoping review adds to the current knowledge base through comprehensively synthesising evidence on what is known about the extent and nature of health and care inequalities, as well as highlighting gaps in the evidence which point the way towards future research priorities. We searched four databases, undertook manual searching, and included studies which presented empirical findings on LGBT people aged 50+ in the UK and their physical and mental health or social care status. From a total of 5,738 records, 48 papers from 42 studies were eligible and included for data extraction. The synthesis finds that inequities exist across physical and mental health, as well as in social care, exposure to violence and loneliness. Social care environments appeared as a focal point for inequities and formal care environments severely compromised the identity and relationships that older LGBT people developed over their lifecourse. Conversely, the literature demonstrated how some older LGBT people successfully negotiated age-related transitions, e.g. emphasising the important role of LGBT-focused social groups in offsetting social isolation and loneliness. While there exist clear policy implications around the requirement for formal care environments to change to accommodate an increasingly diverse older population, there is also a need to explore how to support older LGBT people to maintain their independence for longer, reducing the need for formal care.

Understanding the staff behaviours that promote quality for older people living in long term care facilities: A realist review

BACKGROUND

Little is known about how the workforce influences quality in long term care facilities for older people. Staff numbers are important but do not fully explain this relationship.

OBJECTIVES

To develop theoretical explanations for the relationship between long-term care facility staffing and quality of care as experienced by residents.

DESIGN

A realist evidence synthesis to understand staff behaviours that promote quality of care for older people living in long-term care facilities.

SETTING

Long-term residential care facilities PARTICIPANTS: Long-term care facility staff, residents, and relatives METHODS: The realist review, (i) was co-developed with stakeholders to determine initial programme theories, (ii) systematically searched the evidence to test and develop theoretical propositions, and (iii) validated and refined emergent theory with stakeholder groups.

RESULTS

66 research papers were included in the review. Three key findings explain the relationship between staffing and quality: (i) quality is influenced by staff behaviours; (ii) behaviours are contingent on relationships nurtured by long-term care facility environment and culture; and (iii) leadership has an important influence on how organisational resources (sufficient staff effectively deployed, with the knowledge, expertise and skills required to meet residents' needs) are used to generate and sustain quality-promoting relationships. Six theoretical propositions explain these findings.

CONCLUSION

Leaders (at all levels) through their role-modelling behaviours can use organisational resources to endorse and encourage relationships (at all levels) between staff, residents, co-workers and family (relationship centred care) that constitute learning opportunities for staff, and encourage quality as experienced by residents and families.

The Politics of LGBT+ Health Inequality: Conclusions from a UK Scoping Review

This scoping review of UK evidence aimed to describe what is known about Lesbian, Gay, Bisexual, and Trans (LGBT+) health inequalities in relation to cancer, mental health, and palliative care to inform research, policy and public health interventions. Using a scoping review methodology, we identified studies from database searches, citation tracking, and expert consultation. The in/exclusion criteria was based on the PICOS framework. The data were charted and then summarised to map the theoretical approaches and the main types of evidence and identify knowledge gaps. In total, 279 articles were screened and 83 were included in the final review. We found that there is limited UK research examining LGBT+ health inequality in cancer, mental health and palliative care. We would argue that this thin evidence base is partly due to national policy discussions of LGBT+ health inequality that are framed within a depoliticised 'it's getting better' narrative, and an unwillingness to adequately acknowledge the unjust social and economic relations that produce LGBT+ health inequality. In addition, LGBT+ health inequality is depoliticised by existing public health explanatory theories, models and frameworks that exclude sexual orientation and gender diversity as dimensions of power that interlock with those of socio-economic, race and ethnicity. This is a barrier to developing public health interventions that can successfully tackle LGBT+ health inequality.

The needs of LGBTI+ people within student nurse education programmes: A new conceptualisation

There is a growing body of international research evidence highlighting concerns around social exclusion and discrimination, significant health inequalities and health needs, and barriers to accessing effective healthcare for LGBTI + people. However, ways in which the healthcare needs of LGBTI + people can be addressed in student nurse education programmes have yet to be fully explored. The aim of this discussion paper is to present the evidence to support the inclusion of LGBTI + health throughout the nursing curriculum. A new conceptualisation of the full and effective integration of LGBTI + health content across and within the nursing curriculum is proposed. This can be achieved by further developing theory, skills simulation and practice learning opportunities. There is a need to ensure that nursing students are positioned and adequately prepared to effectively address concerns of social justice, reducing health inequalities, and providing responsive person-centred care for LGBTI + health service users.

Provider and LGBT Individuals' Perspectives on LGBT Issues in Long-Term Care: A Systematic Review

BACKGROUND AND OBJECTIVES

Discrimination toward the lesbian, gay, bisexual and transgender (LGBT) population has raised concerns about the type of long-term services and supports (LTSS) that will be available to them as they age. To understand the unique needs of aging LGBT populations, we sought to synthesize and critique the evidence related to LTSS providers and LGBT individuals' perspectives of LGBT issues in LTSS in the United States.

RESEARCH DESIGN AND METHODS

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses, a systematic review of the literature was conducted. The Crowe Critical Appraisal Tool was used to appraise the quality of the included studies.

RESULTS

Nineteen studies met inclusion criteria. Seven studies that examined the perspectives of LTSS providers identified two themes, including that they lack knowledge and training on LGBT health issues and generally report negative attitudes toward same-sex relations among older adults. In addition, 12 studies that examined the perspectives of LGBT individuals found that they (i) are concerned about LTSS planning, (ii) fear discrimination from providers in LTSS, and (iii) identify several strategies for improving care of LGBT older adults receiving LTSS.

DISCUSSION AND IMPLICATIONS

This systematic review highlights the importance for LTSS providers to receive training in LGBT health and be reflective of potential biases toward the LGBT population. LGBT individuals identified concerns related to LTSS planning and fear of discrimination from LTSS providers. LGBT individuals also identified a need for increased training of providers to improve the care of LGBT older adults in LTSS.

Older LGBT+ health inequalities in the UK: setting a research agenda

Lesbian, gay, bisexual and trans+ (LGBT+) people report poorer health than the general population and worse experiences of healthcare particularly cancer, palliative/end-of-life, dementia and mental health provision. This is attributable to: (a) social inequalities, including 'minority stress'; (b) associated health-risk behaviours (eg, smoking, excessive drug/alcohol use, obesity); (c) loneliness and isolation, affecting physical/mental health and mortality; (d) anticipated/experienced discrimination and (e) inadequate understandings of needs among healthcare providers. Older LGBT+ people are particularly affected, due to the effects of both cumulative disadvantage and ageing. There is a need for greater and more robust research data to support growing international and national government initiatives aimed at addressing these health inequalities. We identify seven key research strategies: (1) Production of large data sets; (2) Comparative data collection; (3) Addressing diversity and intersectionality among LGBT+ older people; (4) Investigation of healthcare services' capacity to deliver LGBT+ affirmative healthcare and associated education and training needs; (5) Identification of effective health promotion and/or treatment interventions for older LGBT+ people, and subgroups within this umbrella category; (6) Development of an (older) LGBT+ health equity model; (7) Utilisation of social justice concepts to ensure meaningful, change-orientated data production which will inform and support government policy, health promotion and healthcare interventions.

A Systematic Review of UK Educational and Training Materials Aimed at Health and Social Care Staff about Providing Appropriate Services for LGBT+ People

Background: There is greater dissatisfaction with health services by LGBT people compared to heterosexual and cisgender people and some of this is from lack of equality and diversity training for health professionals. Core training standards in sexual orientation for health professionals have been available since 2006. The purpose of this project is to systematically review educational materials for health and social care professionals in lesbian, gay, bisexual, and transgender (LGBT) issues. Methods: A protocol was developed and searches conducted in six databases. Selection criteria: any studies reporting delivery or evaluation of UK education of health and/or social care professionals in LGBT issues, with no language or setting restrictions. Inclusions and data extraction were conducted in duplicate. Narrative synthesis of educational evaluations was used. Educational materials were assessed using thematic synthesis. Results: From the searches, 165 full papers were evaluated and 19 studies were included in the narrative synthesis. Three were successful action-research projects in cancer services and in residential care. Sixteen sets of educational/training materials have been available since 2010. These varied in length, scope, target audience, and extent of development as classroom-ready materials. Conclusions: Despite the availability of appropriate training programmes for post-qualifying staff, recommendations to undertake training, best practice examples, and statements of good intent, LGBT people continue to report that they are experiencing discrimination or direct prejudice from health and/or social care services. Better training strategies using behaviour change techniques are needed.

Experiences and perceptions of residential and home care services among older lesbian women and gay men in Australia

The needs of older lesbian and gay people regarding access and use of aged-care services remain underresearched. This paper reports the findings of 33 qualitative interviews with older lesbian women and gay men about their perceptions and experiences of residential aged-care and home-based aged-care services in Australia. The focus of this paper is their preparedness for using aged-care services. The results highlight that participants had a number of concerns related to accessing residential-care services in particular, including perceptions of a lack of inclusivity and concerns of potential for discrimination and hostility, loss of access to community and partners, decreased autonomy and concerns relating to quality of care and the potential for elder abuse. Participants noted a number of strategies they employed in avoiding residential-care services, including the use of home-care services, renovating the home for increased mobility, moving to locations with greater access to outside home-care services, a preference for lesbian/gay-specific housing and residential-care options if available, and the option of voluntary euthanasia to ensure dignity and autonomy. Participants, on the whole, were hopeful that they would never require the use of residential-care services, with some believing that having current good health or the support of friends could prevent this from happening. The findings suggest that older lesbian and gay people have a variety of concerns with aged-care and may need additional support and education to improve their perceptions and experiences of services, whether these are needed presently or in the future.

"It's a nice country but it's not mine": Exploring the meanings attached to home, rurality and place for older lesbian, gay and bisexual adults

An ageing population across European nations, including the United Kingdom, brings with it new challenges for health and social care services and precipitates social policy initiatives targeted at meeting the care and support needs of a rapidly expanding number of older people. Ageing in place is one such policy driver-policy efforts that seek to promote the maintenance of older citizens residing in their own homes for as long as possible with minimal state intervention. Current generations of older lesbian, gay and bisexual (LGB) people have endured homophobia throughout their life histories, and sexual identity can shape perceptions and experiences of ageing, including experiences of home life, community and place. Our objective is to examine the meanings attached to home and place for older LGB adults living independently across three dimensions: rural places as "home," connections to LGB communities, and social care provision in the home. We present interview findings from a mixed-methods study on the social inclusion of older LGB adults in Wales. Twenty-nine LGB-identifying adults (50-76 years) self-selected to participate in semistructured interviews between 2012 and 2013. Thematic findings from interviews indicate varying and contradictory meanings attached to home life in rural places, the importance of connection to communities of identity across geographical and online localities, and a high degree of ambivalence towards the prospect of receiving social care services in the home. We argue that a more nuanced understanding of the subjective meanings attached to home, rurality and community for older LGB people is needed to fully support LGB citizens to continue to live independently in their homes.

Turning the Co-Production Corner: Methodological Reflections from an Action Research Project to Promote LGBT Inclusion in Care Homes for Older People

Background: Older lesbian, gay, bisexual and trans (LGBT) residents are often invisible in long-term care settings. This article presents findings from a community-based action research project, which attempted to address this invisibility through co-produced research with LGBT community members. Particular Question: What conditions enable co-produced research to emerge in long-term residential care settings for older people? Aims of Project: To analyse outcomes and challenges of action-oriented, co-produced research in the given context. In particular, we explore how co-production as a collaborative approach to action-orientated research can emerge during the research/fieldwork process; and reflect critically on the ethics and effectiveness of this approach in advancing inclusion in context. Methods: The project was implemented across six residential care homes in England. Reflections are based on qualitative evaluation data gathered pre- and post-project, which includes 37 interviews with care home staff, managers and community advisors (two of whom are co-authors). Results and Conclusions: We discuss how the co-production turn emerged during research and evaluate how the politics of this approach helped advance inclusion—itself crucial to well-being. We argue for the value of co-produced research in instigating organizational change in older people’s care environments and of non-didactic storytelling in LGBT awareness-raising amongst staff.