SEXUALITY AND OLDER ADULTS
This article is drawn from a larger study which explored professional caregivers' experiences of elderly nursing home residents' sexuality. The issue of the privacy needs and rights of elderly residents related to their ability to express and fulfill their sexual desires will be addressed. Participating caregivers shared an understanding that sexual expression in nursing homes was difficult and acknowledged residents' rights to privacy and their need for it, although the degree to which this actually was respected in practice varied considerably.
The current culture values young and beautiful individuals and sexuality, and older individuals usually are seen as incongruent. Although research during the past 40 years supports the view that older people are sexually capable, interested in sexual activity, and to varying degrees, sexually active (Bretschneider & McCoy, 1988; Kinsey, Pomeroy, & Martin, 1948, 1953; Masters & Johnson, 1966; Mulligan & Palguta, 1991; Pfeiffer & Davis, 1972; Starr & Weiner, 1981; Turner & Adams, 1988; Wiley & Bortz, 1996), the view that older people are beyond sexuality and without sexual interests, needs, or capabilities remains prevalent.
Nursing homes provide ongoing nursing and personal care to older people who are no longer able to live independently or with the level of support available to them in the community. Eligibility for nursing home care requires a significant degree of dependency because of either physical or cognitive impairment. The level of dependence is assessed by a multidisciplinary aged care assessment team. In 1994, 2.1 million people in Australia were age 65 or older, and 71,000 of them resided in nursing homes (Mathur, 1996). As the Australian population ages, a significant number of older people will find themselves living in some form of residential care. Some of these older people will maintain their sexual interest and ability, whereas others may find it necessary to adjust their sexual behaviors in response to the aging process itself or because of the prevailing social milieu. What is significant is that sexual expression can continue to play an important role in the maintenance of older people's well-being, even in public institutions such as nursing homes. If nursing home residents are to have control over their sexual lives, then the environment needs to be supportive of their needs for sexual fulfillment and provide them with opportunities for sexual intimacy.
THE NEED FOR PRIVACY
Privacy can be conceptualized in many ways, but for the purposes of this article, it is defined as having designated space and time which people can call their own and which does not have to be shared by others except by choice (Glen & Jownally, 1995). In other words, nursing home residents are free to choose how and where they spend their time within the confines of nursing homes and with whom they spend that time. Control over privacy is an important concern for older people living in nursing homes because they frequently are without it. As Fry, Slivinske, and Fitch (1989) note, "to be old is to be powerless.. .[and]. ..to be powerless is to be old" (p. 319). Notwithstanding the ethical arguments, there are compelling reasons to advocate choice for older people. There is ample evidence to suggest that nursing home residents who are allowed to make decisions generally are less withdrawn, more active, more motivated, happier, and have lower mortality rates (Fry et al., 1989; Langer & Rodin, 1976; Rodin, 1986; Rodin & Langer, 1977).
This study is based on a hermeneutic phenomenological method and does not claim to exemplify a pure form of phenomenological thinking. Those aspects of phenomenology which will assist in clarifying the area of enquiry have been adopted and incorporated into the discussion. It is hoped that the experiences described in this article may adopt new meanings for gerontological nurses and, as van Manen (1990) suggests, allow gerontological nurses to understand better the significance of an aspect of human experience in the context of the whole of human experience.
Selecting an appropriate sample for qualitative research is difficult because there is no single formula or criterion to use (Luborsky & Rubinstein, 1995). This also is true of phenomenological research where there are no advance criteria for locating and selecting research participants (Moustakas, 1994).
Considering the above criteria and given the social taboos surrounding the topic of sexuality, it was important that the initial informants were both articulate and prepared to talk freely about the subject matter. Initially, a list of potential participants was identified jointly by the author and the Directors of Nursing. Caregivers then were invited to have further informal discussions with the author. A mutually agreed on time was arranged to meet with those caregivers who had expressed an interest in participating in the research. At this meeting, the purpose of the study was discussed with all participants, and anonymity and confidentiality were assured. Interviews were conducted at the nursing homes 1 week later.
Five paid caregivers (e.g., as opposed to family) - two nursing assistants, one Level 2 nurse (LPN), and two RNs from two nursing homes in metropolitan Melbourne, Australia - participated in this study. The participating caregivers were all women age 25 to 55 who had worked in a nursing home for more than 1 year. To elicit caregivers' experiences of elderly nursing home residents' sexuality, conversational indepth interview techniques as described by Minichiello, Aroni, Timewell, and Alexander (1990) were used. The sample size was determined by time constraints because indepth interviewing is very time intensive and generates voluminous field notes and transcript data (Minichiello et al., 1990). All interviews were audiotaped and later transcribed. To facilitate the research process, field notes detailing personal reflections of the interviews and methodological issues pertinent to the research context also were kept. Although the study was based on the experiences of only five caregivers, the richness of the data suggests that the findings add to the understanding of aged care.
Data were analyzed in three stages as described by Miles and Huberman (1984). The first phase involved condensing the data set through a process of determining themes and then clustering the data. Themes were identified by using "...criteria internal to the discourse and to the speaker's own sense of significance" (Luborsky, 1994, p. 197). This approach is considered to be the most suitable for discovering experiences and meanings, and it is a more hermeneutic approach (Luborsky, 1994). The second phase involved grouping and clustering the reduced data set. This becomes the basis which allows researchers to think about the meaning of the data using a range of strategies. The final step in the analysis is to verify the authenticity of the data and to derive meaning and draw conclusions from the data. However, these phases were not separated by fixed and discrete boundaries because the processes of data collection and analysis are spread throughout a qualitative study (Huberman & Miles, 1994).
While researchers never can be sure they have understood all the possible meanings elicited in an interview (Minichiello et al., 1990), it is important in a phenomenological study that researchers are satisfied the experience and its meaning have been captured as the participants had intended. Reviewing the findings with participants to obtain the "phenomenological nod" as Munhall (1994, p. 189) refers to it, plays a crucial role in determining the merit and worth of the research findings.
The larger study from which this article is drawn identified a number of themes which depict how caregivers perceived older nursing home residents' sexuality and how caregivers behaved when confronted by it. This article will discuss the theme of "Their only privacy is between their sheets."
PARTICIPANTS' VIEWS ON PRIVACY AND SEXUALITY IN NURSING HOMES
Caregivers in this study were very aware of the lack of private spaces available to residents. Many of the caregivers revealed a sense of powerlessness and frustration because of their inability to provide residents with what they know is a right to personal space.
However, although the need to respect residents' privacy may be accepted in theory, privacy regarding residents' sexuality remains problematic for a number of reasons. First, the environment is constructed as public space so it is very difficult, if not impossible, for residents to physically distance themselves from other people. One resident said:
There's not many places that have the facilities to give people a single room...there's not a lot of places they can go to have some privacy, which is a big problem. I mean, where would they go here for instance?
Caregivers did their best to maintain privacy in an environment which can be antagonistic to personal space. A caregiver stated:
I tell other staff members, "Knock." I know there's not a door but say "Knock, knock," before you walk in there, because I don't know what they're doing, you know. It's just for some dignity. I mean you'd do it at home... why not do it here, there's no difference. Just because they're old. ..it's a four-bed room, and the only privacy they really get is if, you know, if someone will come and pull the curtain around them...and that's their own little private Idaho. As far as what they do, it's their business because the curtain is drawn.
The degree to which staff respect residents* privacy and adhere to privacy guidelines varies. Residents often are dependent on the attitudes of staff for the provision and maintenance of privacy, but not all staff comply with the appropriate protocol when it comes to showing respect for personal space. A resident remarked:
One of the nurses just walked in. She sort of, you know, against outcome standards... you're supposed to knock on the door. She did knock, but then she didn't wait for a reply.
Furthermore, sexuality is not considered to be part of the primary caregiving role in an environment which has been geared toward the demands of medical and basic body care. Because sexuality is not deemed to play a vital role in the maintenance of bodily functions, nursing homes are less likely to create an environment conducive to the fulfillment of sexual needs.
Very few rooms in a nursing home have doors, and although curtains can be drawn to screen a resident, this does not accord privacy every time. Bedroom walls in nursing homes remain public space, irrespective of where they are. The ways in which residents choose to decorate the space around their beds still is subject to the approval of nursing home staff and nursing home administrators. The creation of private space by drawing the curtains can be an illusion. A caregiver said:
We have someone else herc.he has Playboys [magazines] and things like that... and I put a picture up on his pinboard, which he requested, and was told to take that down. So I had an issue with that, but obviously as nursing home standards or rules go, I wasn't allowed to, even though he requested it.
Incidents such as this convinced one caregiver that it was the nursing home administrators who were the biggest obstacle to residents' intimacy. On another occasion, the caregiver became aware of a relationship that had developed between two residents, both of whom occupied different single-sex, multibed rooms. The caregiver felt it would be appropriate for them to share the one room so she approached the subject with her superiors. The outcome speaks for itself:
Researcher: Are they [the couple] in the same room?
Caregiver: No, no. That was one thing we were trying to push for. There were two of us trying to push for it, but it was just, "No! No way!".
Researcher: Why do you think that was?
Caregiver: Oh, I really don't know. It's just like, "Don't be stupid!".
PRIVACY AND CONFIDENTIALITY
Privacy also was compromised in another way in the nursing homes, although this was not recognized by the caregivers interviewed. Confidentiality of information is rare because staff frequently admitted sharing intimate information about residents' lives. This dissemination of knowledge about residents' day-to-day activities is accepted and taken for granted as part of the caregiving role. Detailed information regarding things residents had been doing or saying was verbally conveyed to other caregivers either informally or formally at staff "handovers" (i.e., reports). As this anecdote from a caregiver shows, there is little that escapes the attention of nursing home staff:
They'll say, "Oh Mr. Such-andSuch has just done this today" or "Mr. Such-and-Such asked me to play with him in the shower but not to tell his wife." There's that sort of communication that's going on.
However nursing home residents are aware of privacy issues, and they do lament the loss of personal space. Nursing home residents place great importance on having a space of their own, so much so that having to share a room with others is considered to adversely affect their quality of life (Bartlett, 1993).
Confidentiality of personal information is a less obvious issue for staff. While it may not impact residents' immediate well-being as dramatically as the loss of space or time, information privacy is nevertheless an essential ingrethent in the maintenance of people's dignity. Caregivers are privy to a large slice of residents' lives, and detailed information about things residents do or say is conveyed verbally to other caregivers either informally one to one or at a staff meeting at the beginning of a shift.
Litz, Fischer, and Arnold (1992) are skeptical about the value of much of this salient information. Residents' personal activities and discourses are noted and relayed to other caregivers, usually under the guise of the caregiving role. These authors assert that this information frequently has no bearing on staff's ability to provide care for the residents. Considering this, is such information mere gossip and does it serve any purpose?
PRIVACY, SEXUALITY, AND CAREGIVING IN NURSING HOMES
Although the right to privacy is one of the fundamental tenets of quality nursing home care, in practice, privacy in nursing homes is virtually nonexistent. Structurally and organizationally, nursing homes resemble health care institutions such as hospitals (Diamond, 1 986; Litz & Arnold, 1995). Multibed rooms typically without doors flanking long corridors with a centrally located nurses' station are a common design feature of nursing homes. Other spaces such as lounges and dining rooms remain designated communal areas. Room furnishings and accessories generally are uniform, and the segregation of beds is only possible by drawing curtains suspended from overhead rails. This typical layout is reminiscent of Foucault's "panopticon" (Foucault, 1977, p. 201), an architectural feature specifically designed to allow for easy observation.
This design feature of nursing homes is very useful for caregiving staff to monitor residents' behavior from hallways or at a distance. As one caregiver in this study commented:
He didn't actually get into any serious activity because of the surveillance of staff, you know. He was stopped before he could really get up to anything.
Single rooms, doors, and effective screening would render such observation more difficult.
The way the caregiving role of staff is constructed in nursing homes is based on the medical health care model. Good care still is defined frequently in terms of meeting medical needs (Litz et al., 1992). Therefore, physical health and safety become the primary standards by which the maintenance of residents' well-being are measured. Most of the staff's time is spent on the routine fulfillment of custodial tasks (Litz & Arnold, 1995) related to residents' hygiene, nutrition, and rest. The maintenance of residents' sexuality does not rate highly on this list of priorities.
The emphasis on physical care subordinates individuals to a daily routine. Established, predictable, and regimented routines in nursing homes can regulate the most mundane daily activities such as mealtimes, toileting, bathing, recreational pursuits, and sleeping. However, such scheduling of activities effectively limits the range of options available to residents on a daily basis. Voelkl (1986) notes that routines establish expectations for appropriate behavior to which residents are expected to adhere for no other reason than to facilitate the efficient and smooth running of the institution. Staff adopt the role of decision-makers who determine what constitutes appropriate behavior and care. Within this schema of care, the fulfillment of sexual needs is not an activity which is accorded great importance by staff. Nor is sexuality likely to be perceived as a function which is going to expedite the daily routines and caregiving tasks.
Generally staff do not feel uncomfortable with the low level of privacy accorded to residents in nursing homes because many residents are considered to be demented. Residents also are known to be reluctant to complain, which could suggest to staff that transgressions of privacy may not be that significant. According to Applegate and Morse (1994), nursing staff often find it necessary to redefine privacy norms in terms of the perceived caregiving relationship to affect their responsibilities. While staff may accept residents' right to privacy in theory, in practice this right may not be feasible given the tasks that need to be accomplished to maintain residents' immediate physical well-being. To fulfill their roles, caregivers come to accept that they must have unrestricted access to residents' personal space. If the physical health of residents can be enhanced, staff generally agree the loss of privacy is justified and appropriate (Litz et al., 1992).
Life in nursing homes is very public. Not only are all aspects of residents' Uves discussed openly by staff, but as was readily acknowledged by the informants in this study, nursing homes seldom have spaces where residents can be alone. Previous studies have indicated that nursing home residents are conscious of privacy issues and would like to have more private space and time made available to them. Moreover, research findings indicate that residents who are able to exereise choice and control over their environments see themselves as healthier and happier, and as having an improved quality of life.
Regrettably, research also would suggest that most staff are not uncomfortable with residents' low levels of privacy. Caregivers in this study, while acknowledging the difficulties for residents, also acceded to the need to have easy and uninhibited access to residents' spaces to accomplish their caregiving duties. While residents' rights to privacy have been given attention by government authorities, it is readily apparent that the degree to which staff adhere to these regulations varies greatly.
The cost of architecturally remodeling existing nursing homes is in many cases not feasible. However, staff can be made more aware of ways to enhance residents' privacy within the existing "home-like" environment. First and foremost, staff need to be alert to residents' need for private space and time in what are largely public institutions. Educating caregivers to respect residents' needs for space and time which they can call their own and providing them with strategies to achieve this is vital if caregivers are to plan care that is inclusive of residents' privacy requirements and considerate of sexual health.
Workshops that address the importance of sexuality should be offered to existing staff and to new staff as they are inducted into the work force. Although this in itself does not guarantee that caregivers will be free of negative attitudes toward older people's sexuality or will respect their right to privacy, having knowledge of the role of sexuality places caregivers in a better position to achieve a solution to residents' sexual needs in a way which is less confrontational and more dignified.
Until it is recognized and accepted that sexuality can play an important role in the maintenance of older people's well-being even in nursing homes, administrators and caregivers will continue to overlook residents' privacy needs. If the tenet of quality of life for older nursing home residents is to move a step closer to reality, then caregivers need to show greater understanding of residents' needs for sexual privacy, and nursing home structures need to support that understanding.
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