3.4 Organisational systems and care practices
Organisational systems that do not take residents’ sexuality or intimate relationships seriously will not acknowledge their real needs and can cause deep unhappiness. Staff should aim to work inclusively with people from all cultures, types of relationships and sexual orientations. Care home residents will have different lifestyles – single, celibate, married, in a partnership or seeking a relationship. Organisational systems should promote non-judgmental, non- discriminatory approaches, whatever the personal beliefs of individual staff.
Acknowledgement of individual cultural backgrounds and beliefs is essential in care homes. These can be fundamental – such as how different cultures view what is regarded as normal or abnormal, acceptable or unacceptable in terms of sexuality, relationships, sexual behaviour or intimate care (for example accepting care only from a caregiver of the same gender) – or subtle, for example in what is deemed to be appropriate humour.
Homes should offer education to help enhance staff understanding in relation to culture, and learning resources and support should be readily available.
Documentation is central to facilitating the acknowledgement of lifestyle, sexuality and relationship issues for residents. Biographical details can give clues on whether these are issues for individuals and how best they might be approached in the most sensitive and appropriate manner. Significant relationships can be recorded, along with the resident’s priorities for relationships – for example, that a couple want to spend uninterrupted time together or that a resident does not want his/her children to become aware of the desire for anintimaterelationship.Well-designeddocumentation can also assist the preservation of confidentiality, and this is particularly important when working with individuals who have a disability which necessitates assistance with intimate personal activities of daily living.
Documentation can also make explicit a resident’s priorities in terms of next of kin, who should be informed in problem situations and legal provision the resident wishes to make, for example a Lasting Power of Attorney.
Organisational systems can make explicit the boundaries, contained in policies, which promote safe practice and protect both residents and staff. Negotiating these in everyday practice requires judgment, skill and full support from senior staff.
Organisational systems should:
G value individuality and uniqueness
G view individual residents within the context of their lives and biographies
G be open to learning about significant experiences and relationships
G promote individual choice and control
G promote clear boundaries which protect and
support residents and staff.
In everyday care home practice, balancing the need for care and observation with an individual resident’s right to privacy can be delicate. For example:
G are residents free to remain in their rooms undisturbed?
G if they choose to lock their door, is this wish respected?
G do staff knock and wait to be invited into a resident’s room before entering?
Supporting sexual activity alongside other activities of daily living can also be delicate. For example, while you
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ROYAL COLLEGE OF NURSING
OLDER PEOPLE IN CARE HOMES
assist residents who need help with hygiene before and after meals, using the lavatory or episodes of incontinence, do you help the resident with hygiene before and after sexual activity? In your everyday work do you follow infection control procedures in order to protect yourself and others from infections which can be related to sexual activity, such as HIV?
3.5 Broaching issues of sexuality
Discussing personal or intimate topics requires skill and sensitivity. Nurses can build on their understanding of what is likely to be acceptable to a resident or family and what might be their priorities.
Nurses can help reduce the discomfort felt by older people in discussions about sexual concerns by adopting a professional demeanour, showing comfort with the topic, being kind, understanding and empathic. It is important to try to time sensitive conversations for when the person might be most ready to speak. Nurses should also aim to create an atmosphere conducive to uninterrupted discussion, initiating the conversation, using open-ended questions, being non-judgmental, avoiding abbreviations or jargon and being receptive to clues, however subtle, that the person may offer in terms of what is really important to him or her.
Opportunities to discuss sexuality issues can arise during conversations about physical health issues and starting from general topics and progressing to more specific and sensitive topics can be helpful. Two routes into discussing sexual issues (suggested by White and Heath, 2005) may be worth exploring:
G the direct impact of illness or its treatment on expression of sexuality or on intimate relationships
G the relationship context through such questions as ‘who is around for you?’,‘who are you close to?’ or ‘who is important in your life?’
It is essential to be respectful of the person’s response. Although an initial reaction could be something like ‘that’s not important’ or ‘what, at my age?’, and further disclosure is unlikely at that time, such responses can indicate a willingness to discuss the subject and further opportunities for discussion should be sought.
If individual staff feel they are unable to support a resident’s right to sexual expression, managerial
support, supervision or education can be offered. In the meantime, the resident’s care can be referred to another member of staff who is comfortable dealing with sexuality issues.