Advanced Search Abstract Purpose: This study investigates sexual expression management in long-term care settings based on cases requiring intervention from ombudsmen. Although the literature frequently mentions a lack of policies governing sexual expression in these settings, there is little information available on management of situations when they occur. This study addresses these missing elements through the perspective of resident advocates. A thematic analysis was performed on the interview transcripts.
Ombudsmen intervened in cases based on dilemma or conflict due to risk, risk associated with dementing illness, limited knowledge, privacy, and values. The theoretical framework of the total institution was utilized to interpret the results.
This research also highlights the importance of workforce training and examination of the institutional impact on resident sexual expression. Formulation of standards of practice for ethically complex situations is also critically important.
Intimacy , Resident advocates , Nursing homes Older adults have long been considered asexual in American culture, particularly those individuals living within institutional care Langer, ; Walz, Contrary to this cultural belief, older adults have been found to be sexual throughout life wherever they are living Lindau et al.
Sexuality can be broadly defined as the quality or state of being sexual. Drench and Losee conceptualized sexuality as a combination of sex drive, sexual acts, and the psychological aspects of relationships, emotions, and attitudes. Seventy-five percent of those aged 70 and older reported engaging in these same activities AARP, In this study, increasing age predicted decreased sexual activity and was related to declining health and lack of partner AARP, People living in nursing home care have reported sexual desires in equal proportions to noninstitutionalized older adults Hubbard et al.
Though sexual intercourse is infrequent in nursing homes, intimate relationships and sexual feelings are often experienced. Residents with dementia have also continued to express sexual feelings and frustrations Hellen, ; Kuhn, There are a number of hindrances for older adults in long-term care who wish to express their sexuality.
However, behaviors may be encouraged by nursing home management when they are privately expressed, considered culturally safe, and are not difficult to manage. When these same behaviors are expressed in public or when caregivers are involved, they have been viewed as less acceptable and interpreted as problematic Archibald, Long-term care facilities, particularly nursing homes, have much in common with total institutions.
Goffman , p. Their whole lives, including their sexuality, are under observation Parkin, However, these facilities have been considered a part of both the private and public domains Parkin, Sexuality has been an issue within these settings because of the close proximity in which people live Parkin, Management of sexual expression may be further confounded by multifaceted resident needs.
There has been little guidance concerning decision-making capacity to enter into intimate relationships Tenenbaum, In the context of individuals with intellectual disability and cognitive impairment, Lyden , p.
This lack of uniformity in the definition of consent means the needs of sexually active cognitively impaired residents may not be addressed. The literature related to sexuality in nursing homes has several consistent messages. In addition, numerous articles recommended that facilities implement training programs to help sensitize staff members to this subject Ehrenfeld et al. Literature supported that sexuality training and policies for staff are not the norm in long-term care; thus, it is unclear how sexual expression is managed overall.
The purpose of this study was to initiate an in-depth investigation of the management of sexual expression in institutional care based on interviews with long-term care ombudsmen. Ombudsmen are an understudied group and provide unique perspectives on the issue of sexuality in care settings.
Unlike past research looking at the issue at the facility level, this study examines cases requiring ombudsman intervention. This study contributes to the discussion of person-centered care regarding the issue of resident sexual expression. Design and Methods Qualitative research methods were employed for this study to gain a complex, detailed understanding of the issue Creswell, In collecting the data, other themes became evident. Using qualitative research design allowed the researchers to develop detailed descriptions of sexual expression cases that required ombudsmen intervention.
Participants shared case details but intentionally omitted names of the resident s and facilities to maintain confidentiality. To protect the identity of those interviewed, the states will not be identified.
Long-term care ombudsmen are advocates for residents in nursing homes, board and care homes, and assisted living facilities and are trained to resolve problems and complaints NORC, Ombudsmen were selected because their viewpoints have seldom been studied and because the researchers were interested in the types of sexual expression requiring intervention.
It was assumed that these cases were more complex than those handled at the facility level due to the need for third party consultation. Studying ombudsmen also gave the researchers a unique opportunity to cover a broad range of facility types in multiple regions of the country using maximum variation sampling Patton, Selection of participants for this study was done deliberately in combination with a random selection process Patton, All states were asked to volunteer for the study through correspondence with state leaders.
Six states out of those expressing interest were then selected to represent different regions of the country: States were selected in terms of their willingness to participate in the project and to achieve a mix of both urban and rural populations.
The first part of the study involved a survey, not addressed in this article, of paid ombudsmen in the six participating states.
From the submitted surveys, individuals from each state were randomly selected for interviews. The ombudsmen completed informed consent to participate in the interviews.
The participation rate in interviewing was high: The few individuals who did not wish to participate in the interviews were dropped from the study and another participant from the same region was randomly selected from those remaining.
Refer to Supplementary Material for participant characteristics. All other interviews were done over the phone within a 6-month timeframe. Data Collection This qualitative study employed face-to-face and telephone interviewing as the primary data collection methods. All sessions were audiorecorded to allow the interviewer to engage in active listening. Telephone interviewing provided an opportunity to include a nationwide, diverse pool of interviewees.
An interview schedule was developed using knowledge found in literature and the professional experience of the researchers Weiss, To develop a rapport with participants, the interviewer started by asking ombudsmen about the nature of their work and a typical day. To conclude the interview, participants were asked to talk about their motivations for working in this field. The interviews lasted an average of an hour; the shortest was 35min and the longest was 2hr.
Data Analysis Strategies Audiotapes from these interviews were transcribed and initially sorted by the main content areas laid out in the interview schedule. NVivo software was used for data management.
The researchers took what Weiss called an issue-focused approach to data analysis, looking at the issue of resident sexuality in care facilities through specific cases described by long-term care ombudsmen. Following the initial sorting of the data, the primary investigator began coding by reading the data with the following questions in mind: Through reviewing the excerpt files, the open codes began to demonstrate patterns that yielded the final five themes.
Once the primary categories were in place, the co-researcher read through transcripts related to cases involving sexuality, asking the same questions the primary researcher had initially. The researchers met frequently to discuss the codes and establish agreement on the primary categories.
Integration to current theory was then formalized, and key quotes from the respondents were selected to exemplify the concepts found. To increase the trustworthiness of the data, the researchers employed member checking Creswell, by sending an initial draft of the findings to all the ombudsmen who participated in the interview process. Results The study revealed that cases involving the sexuality of residents and requiring ombudsmen intervention involved complex challenges such as moral and ethical dilemmas.
Of the 31 ombudsmen interviewed, only 2 reported that they had not been involved with a case related to resident sexual expression. One of these individuals was new to her position. A total of cases were noted in the transcripts.
Included in this report are data from cases that occurred in nursing homes. The initiator of cases was not noted in all instances; however, of those stated, staff members did a majority of the initiation followed by residents.
Although ombudsmen noted many other instances where they provided information and referral related to the sexual expression of residents, these situations did not turn into cases.
Thematic review of interview transcripts found that the cases requiring ombudsmen intervention involved conflict or dissatisfaction by the initiator. The source of the conflict or dissatisfaction brought to the ombudsmen clustered around five areas: Risk When risk, resident safety, or the safety of others was involved, ombudsmen intervened. Ombudsmen are key players in resolving ethically complicated situations as this example shows. Intimacy can be risky. It is a care planning issue to help people be safe in what they choose to do.
Protection from disease is another safety consideration. For instance, the potential for transmission of sexually transmitted disease in care settings is often overlooked. Ombudsmen assist in preparing facility staff to educate residents about sexually transmitted disease and safer sex practices.
In addition, ombudsmen may become involved when confidentiality of personal information is in conflict with the protection of others. In our inner city nursing homes this happens where two people are in an intimate relationship and one of them is HIV positive and will not tell the other. We have an obligation to protect the one who is not positive. So we sit that person down who is infected and encourage them to tell their partner so they can make an informed decision. We warn them that we have an obligation to inform their partner if they do not.
The actions of one resident may put other residents at risk. For example, a resident living in a nursing home began dating people she met on the internet. These individuals, who were under the influence of drugs and had criminal backgrounds, began visiting her in the nursing home.
This situation put other residents at risk. A final salient theme emerged regarding the challenges facilities face when residents have a criminal background as a sex offender.