Research in Gerontological Nursing

State of the Science 

The Silence of Our Science: Nursing Research on LGBT Older Adult Health

Kristin G. Cloyes, PhD, RN

Abstract

Lesbian, gay, bisexual, and transgender (LGBT) older adults have been largely invisible within health and aging services research, despite being disproportionately burdened by poor health and aging outcomes. The current study examines the prevalence of LGBT aging and older adult health-related studies in the 2010–2014 nursing literature, and how this topic is being addressed. Systematic CINAHL and PubMed searches were conducted and compared to (a) quantify the prevalence of LGBT older adult–related scholarship in nursing research; (b) document the appearance of relevant publications in top nursing journals; (c) identify the focus of articles with a substantive focus on LGBT older adult health or aging; and (d) compare the prevalence of LGBT older adult–related literature in nursing, gerontology, medicine, and social work. Findings indicate that research explicitly including LGBT older adults is lacking across the health sciences, particularly in nursing (where it has been largely absent). Implications for nursing research, practice, and education are discussed.

[Res Gerontol Nurs. 2016; 9(2):92–104.]

Abstract

Lesbian, gay, bisexual, and transgender (LGBT) older adults have been largely invisible within health and aging services research, despite being disproportionately burdened by poor health and aging outcomes. The current study examines the prevalence of LGBT aging and older adult health-related studies in the 2010–2014 nursing literature, and how this topic is being addressed. Systematic CINAHL and PubMed searches were conducted and compared to (a) quantify the prevalence of LGBT older adult–related scholarship in nursing research; (b) document the appearance of relevant publications in top nursing journals; (c) identify the focus of articles with a substantive focus on LGBT older adult health or aging; and (d) compare the prevalence of LGBT older adult–related literature in nursing, gerontology, medicine, and social work. Findings indicate that research explicitly including LGBT older adults is lacking across the health sciences, particularly in nursing (where it has been largely absent). Implications for nursing research, practice, and education are discussed.

[Res Gerontol Nurs. 2016; 9(2):92–104.]

Nurses are among the health care professionals who interface most directly with the well-documented shift in U.S. demographics toward an increasingly aging population (Grady, 2011). Licensed practical nurses, RNs, and advance practice nurses are all frequently on the frontlines of providing care and services for an aging population of patients across numerous practice settings. Estimates placed the number of adults older than 65 at approximately 40 million in 2009, which is to increase to 72 million by 2030 (Administration on Aging, 2015). With this shift, there has been an emphasis in recent years on a discourse of healthy aging, the possibility of entering older adulthood and later life stages in optimal health with limited disability or dysfunction, and opportunities and challenges for health care professionals to support these goals (Hansen-Kyle, 2006).

Within this general trend toward an older population, the diversity of older adults is also increasing. By 2050, there will be a significant shift toward a reduction in the number of older adults categorized as White and non-Hispanic, and a corresponding increase in older adults identifying as Latino/Latina, Hispanic, Asian American, and African American (Centers for Disease Control and Prevention, 2013). This trend has crucial implications not only for issues of socially and contextually competent practice, but also for delivering effective health care and aging services. Intersecting evidence arising within the fields of health disparities and gerontological research demonstrates that health inequities associated with race, ethnicity, gender, and lower income established in earlier life continue to exert influence on (and in many cases even worsen) aging and health outcomes (Feng, Fennell, Tyler, Clark, & Mor, 2011; House, Lantz, & Herd, 2005; Hurst et al., 2013).

Nursing scholars have stressed a need to ensure that such systematic health disparities, as well as the structural and cultural conditions that enable them to persist and continue as individuals age, should be an explicit target of research and intervention (Flaskerud et al., 2002; Giger et al., 2007). These scholars have emphasized that nursing research in all areas must recognize and account for diversity of history, experience, risk, and response among racial and ethnic minority groups, as well as gender differences, to develop theories and practice guidelines that are empirically sound and effective. With the parallel growth of the concepts of evidence-based practice and cultural competency during the past decade, it is no longer sound practice to ignore the influence of historical, cultural, and social contexts of patients (and our health care systems), as these impinge on aging, health outcomes, and intervention.

However, two important sources of diversity remain relatively underexplored in the nursing research literature: (a) sexual orientation and (b) gender identity. Health issues concerning individuals who identify as lesbian, gay, bisexual, and transgender (LGBT) have not been well-addressed in the nursing literature in general; this situation becomes even more acute when considering the health status of LGBT older adults. Eliason, Dibble, and DeJoseph (2010) conducted a search of nursing research articles published from 2005–2009 in the top 10 nursing journals by a 5-year impact factor that included any reference to the terms “lesbian,” “gay,” “bisexual,” “transgender,” or “homosexual.” Only 19 articles in this sample contained one or more of these terms; seven mentioned one or more of the terms but did not focus on LGBT health issues, whereas eight met the criterion of central focus, amounting to only 0.16% of all articles in the sample. These eight articles were neither published by U.S. nurse researchers nor focused on or included LGBT older adults.

Although recent and much-needed developments in LGBT aging research have exponentially increased awareness and knowledge regarding issues affecting the health and well-being of LGBT older adults (e.g., the work of Fredriksen-Goldsen, Kim, Muraco, and Mincer [2009], Fredriksen-Goldsen, Emlet, et al. [2013], Fredriksen-Goldsen et al. [2015], and Witten [2014]), this research has generally been undertaken by scholars in fields other than nursing. Nursing as a whole, and gerontological and geriatric nursing in particular, continue to remain relatively silent on LGBT health and aging (Eliason et al., 2010; Lim, Brown, & Justin Kim, 2014; Lim & Levitt, 2011).

Health and Aging Issues Among LGBT Older Adults

Recently, research in gerontology, geriatric medicine, and social work has painted an emerging picture of the health status and aging issues of LGBT adults. Older adults who self-identify as LGBT are more likely than heterosexual older adults to (a) have poor health outcomes related to chronic illness and (b) experience multiple chronic comorbidities (Addis, Davies, Greene, Macbride-Stewart, & Shepherd, 2009; Fredriksen-Goldsen, Kim, Barkan, Muraco, & Hoy-Ellis, 2013; Fredriksen-Goldsen et al., 2009; Fredriksen-Goldsen, Emlet, et al., 2013; Institute of Medicine, 2011). LGBT older adults are also more likely to have low incomes or be in poverty (Albelda, Badgett, Schneebaum, & Gates, 2009) and require financial assistance to pay for health care (Fredriksen-Goldsen, Kim, et al., 2013; Lick, Durso, & Johnson, 2013). LGBT older adults are less likely to receive nonprofessional caregiving from biological relatives (Brennan-Ing, Seidel, Larson, & Karpiak, 2014; Croghan, Moone, & Olson, 2014; Fredriksen-Goldsen et al., 2009; Muraco & Fredriksen-Goldsen, 2011), although they are more likely than their heterosexual counterparts to have provided care for an adult relative, neighbor, or friend during the previous 6 months (Family Caregiver Alliance, 2012). Retirement and later life are significant times for a number of transgender older adults who choose to actively transition at this stage. Departure from the daily workplace and changing family dynamics, such as children leaving home, are cited by transgender older adults as events associated with decisions to transition (Fredriksen-Goldsen et al., 2014; Fredriksen-Goldsen, Kim, Barkan, Muraco, & Hoy-Ellis, 2015).

LGBT older adults have also reported experiencing isolation, marginality, invisibility, and ageism in relation to the larger, more youth-oriented LGBT community (Addis et al., 2009; Jönson & Larsson, 2009; Meisner & Hynie, 2009; Woody, 2014). Concerns related to invisibility are complicated by fears of exposure and mistreatment if health care or aging service providers were to discover their identity or orientation (Fredriksen-Goldsen et al., 2014; Fredriksen-Goldsen et al., 2015; McCabe, Bostwick, Hughes, West, & Boyd, 2010; Van Wagenen, Driskell, & Bradford, 2013). Several studies have reported that LGBT older adults express anxiety about transitions from community-dwelling to assisted living or long-term care because they fear being mistreated by caregivers and staff, and reports persist of individuals going “back in the closet” in later life to avoid these problems and to keep themselves safe (Addis et al., 2009). Overall, despite recent legal and social advances, such as the June 26, 2015, U.S. Supreme Court ruling on same-sex marriage equality, LGBT older adults also still face discriminatory state and federal legal, financial, and health care decision policies that disenfranchise relationships and families comprising same-sex spouses and nonbiological relationships (Buchmueller & Carpenter, 2010; Cronin & King, 2010).

Purpose

The purpose of the current study, which builds on the work of Eliason et al. (2010), was to examine the extent to which current nursing research has addressed health and aging issues among LGBT older adults. Of particular interest was (a) documenting whether nursing literature published in the past 5 years demonstrates an emerging focus on LGBT aging and LGBT older adult health-related studies; (b) examining how nursing stands in comparison to other fields, including geriatric medicine, gerontology, and social work, on this topic; and (c) exploring in greater detail how this topic is being addressed by nurse scholars.

Method

Study methods initially followed those described by Eliason et al. (2010). Several modifications and extensions updated the original literature search and review criteria and methods while adding a focus on publications specific to LGBT older adults and generating comparisons between studies published in nursing, medicine, and social work.

First, a search of the CINAHL database was performed using the same list of keywords as those used by Eliason et al. (2010), limiting the search to articles published between 2010 and 2014. The number of “hits” in any text field, titles, and abstracts were recorded, and the percent change from the number of documented hits reported for these same terms for 2005–2009 was calculated (Table 1). This calculation yielded a sense of whether there had been an increase in the overall number of publications that included reference to LGBT individuals or issues. These inclusion criteria were then combined with a Boolean search string that included the terms “older adult,” “senior,” “elder/ly,” “retired,” “aging,” “gerontological,” and “geriatric” to target articles specific to LGBT older adults. This string was then used to search the 2005–2009 and 2010–2014 literature (Table 2). These two searches provided a point of comparison for the number of articles with LGBT older adult–specific references during both timeframes.


LGBT-Related Terms in CINAHL, 2010–2014

Table 1:

LGBT-Related Terms in CINAHL, 2010–2014


LGBT Older Adult–Related Terms in CINAHL, 2010–2014

Table 2:

LGBT Older Adult–Related Terms in CINAHL, 2010–2014

Second, the Journal of Citation Reports was used to identify the 10 nursing journals with the highest 5-year impact factor ratings for each year for 2010–2013 (impact factor data for 2014 was not available at the time the current article was written), which generated four separate lists based on impact factor rating by year. Each of these journals were reviewed and compared for consistency across the 4-year span; the 2013 top 10 nursing journals by impact factor list was representative of the time span, with the addition of two journals (i.e., Nursing Research and Journal of Nursing Scholarship) that appeared in 2 of 4 years. Three nursing journals were added to this group that, despite having lower impact factor scores, have been leading publications in the specialty field of gerontological and geriatric nursing: Journal of Gerontological Nursing, Geriatric Nursing, and Research in Gerontological Nursing.

These 15 nursing journals were then searched twice, first using the search string <<lesbian OR gay OR bisexual OR transgender OR homosexual OR queer>> (as in the original study), then in combination with the search string <<older adult OR senior OR elder OR elderly OR retired OR aging OR gerontological OR geriatric>>. This search was further limited to peer-reviewed articles reporting original research studies, literature reviews, quality improvement projects, and reports on education and training programs and interventions; editorials, commentaries, letters to the editors, and book reviews were excluded. For each of these journals, the number of hits for (a) any mention of LGBT content, (b) a specific research focus on LGBT participants in general, and (c) a specific research focus on LGBT older adults were recorded. To confirm these results, the table of contents for every issue of the 15 identified journals published in 2010–2014 were reviewed for articles related to LGBT or LGBT older adult health content, and this review was cross-checked against the list of hits generated by the initial search of the 15 journals. Results of this search and review are presented in Table 3.


Relevant Publications in the Top 10 Nursing and Gerontology/Geriatric Nursing Journals, 2010–2014

Table 3:

Relevant Publications in the Top 10 Nursing and Gerontology/Geriatric Nursing Journals, 2010–2014

Third, a PubMed search was performed using the same combination of the two search strings previously mentioned (i.e., LGBT and aging search terms) and the nursing journal subset filter to identify any nursing articles published from January 2010 to March 2015 appearing in the database, regardless of impact factor or specialty focus of the nursing journal. PubMed filters were set to include publications in nursing journals only and to exclude publications that were not peer-reviewed research or clinical reports, literature reviews, quality improvement projects, or reports on education and training programs and interventions. This search yielded 70 hits; for each hit, the title and abstract were reviewed, revealing 21 articles specifically focused on either LGBT adult health or health care. These 21 articles were collected and reviewed for content; only those that specified a focus on LGBT older adult issues or the inclusion of LGBT older adult participants were included in the final sample for review and analysis of content (n = 16) (Dickinson, Cook, Playle, & Hallett, 2012; Ferron, Young, Boulanger, Rodriguez, & Moreno, 2010; Gabrielson, 2011; Hardacker, Rubinstein, Hotton, & Houlberg, 2014; Jablonski, Vance, & Beattie, 2013; Kushner, Neville, & Adams, 2013; Lim & Bernstein, 2012; Lomas, 2013; McIntyre & McDonald, 2012; Peate, 2013a,b; Ridgers, 2013; Slater et al., 2013, 2014; Thomas, Wootten, & Robinson, 2013; White & Boehmer, 2012).

Finally, a full PubMed search was performed with the assistance of a health science librarian and information technology specialist. A search string was constructed using medical subject headings (MeSH) deemed most likely to generate specific hits in this database: (((Lesbian*[tw] OR gay[tiab] OR bisexual*[tw] OR transgender*[tw] OR homosexual*[tw] OR LGBT[tiab] OR queer[tiab] OR transsexual*[tw] OR “Homosexuality”[MeSH] OR “Transgendered Persons”[MeSH] OR “Transsexualism”[MeSH] OR “Health Services for Transgendered Persons”[MeSH]) AND (aged OR elderly OR aging OR older adult*[tw] OR old age[tw] OR older women[tw] OR older men[tw]))) NOT ((“Animals”[MeSH] NOT “Humans”[MeSH])).

This string was combined with a search filter limiting publication dates from January 1, 2010 through December 31, 2014, and a subsequent series of searches were performed:

  • LGBT older adult–related articles on PubMed (N = 2,528);
  • PubMed subset “Nursing Journals” (n = 63);
  • Top 10 impact factor and gerontological or geriatric nursing journals, but using more sophisticated MeSH strings (n = 4);
  • Top 10 gerontology journals for LGBT older adult content (n = 2);
  • Top 10 medicine journals (n = 100); and
  • Top 10 social work journals (n = 18).

Selection of gerontology, medicine, and social work journals was based on 2013 impact factors (Table 4). The proportion of positive hits for LGBT older adult–related terms was then compared to the number of articles published in these journals within each discipline, and the proportions were compared across disciplines by calculating Z scores to test for significant differences between ratios.


Comparison of Nursing, Gerontology, Medicine, and Social Work Literature, 2010–2014

Table 4:

Comparison of Nursing, Gerontology, Medicine, and Social Work Literature, 2010–2014

Results

Although there was an increase in the number of nursing publications from 2010–2014 with general LGBT references compared to the 2005–2009 timeframe reported by Eliason et al. (2010), the nursing literature appears to remain relatively silent on issues related to LGBT older adults and aging, with several notable exceptions. Review and analysis of the content of nursing articles not addressing LGBT older adult health reveals both informative patterns in how LGBT health and aging is conceptualized and discussed, and areas in need of more attention. Comparison of the prevalence of LGBT older adult–related literature across nursing, gerontology, medicine, and social work is also informative, as it demonstrates that although social work leads the way in research and scholarship on LGBT older adult health and aging, there has still been an exceedingly small percentage of publications in all four areas concerning these topics.

Comparison of LGBT-Related Terms from 2005–2009 Versus 2010–2014

There was an overall increase in the prevalence of LGBT-related terms when comparing literature published in CINAHL 2005–2009 versus 2010–2014. As indicated in Table 1, there was a substantial increase in use of several terms, particularly those related to gender diversity and minority status; the terms “gender atypical” and “gender nonconforming” increased 700%, “gender minority” increased 200%, “transgender” increased 143%, and “sexual minority” increased 218%. Although use of “gay” and “lesbian” increased somewhat, use of “bisexual” and “transgender” increased more considerably. The only term that appeared to become less prevalent was “non-heterosexual,” which decreased in use by 50%.

LGBT Older Adult–Related Terms in CINAHL 2005–2009 Versus 2010–2014

The second CINAHL search added aging- and older adult–related qualifiers to the general LGBT search terms and compared the number of hits for the two time periods. Altogether, combining LGBT-related and older adult– or aging-related terms yielded fewer hits than LGBT-related terms alone for both time periods. The most prevalent terms concerning LGBT older adults during both periods were “gay,” permutations of the LGBT acronym, “lesbian,” “bisexual,” and “transgender,” suggesting that a limited range of terms were being used largely to identify and describe older research participants in a manner akin to demographic categorizations. Although there were again seemingly substantial increases in the number of articles related to LGBT older adults, in many cases this meant going from no title hits to a single title hit (Table 2); overall increases were modest compared to increases noted in all LGBT literature (Table 1). The proportion of LGBT to LGBT and aging/older adult terms further suggests that LGBT aging and LGBT older adult health have received substantially less focus in health science research than research with younger groups.

LGBT Older Adult References in Top 10 and Gerontology/Geriatric Nursing Journals

There were 71 published articles with mentions of LGBT terms published in the top 10 nursing journals and in the gerontological and geriatric nursing journals from 2010–2014. Of these, 11 provided evidence of a substantive LGBT health focus on review of abstract and text. Only four specifically mentioned LGBT older adults and only two had a substantive focus on LGBT older adult health or aging. Just one of these articles was published in the top 10 nursing journals (White & Boehmer, 2012), whereas the other two appeared in two of three gerontological or geriatric nursing–focused articles (Table 3).

Characteristics of Nursing Publications Focusing on LGBT Older Adults from January 2010–March 2015

A PubMed search for LGBT older adult–related terms in publications appearing in all nursing journals from January 2010 through March 2015—regardless of impact factor (not only those listed in Table 3)—yielded 70 hits. Close review of titles and abstracts indicated that 21 articles (30%) referenced LGBT health issues and 19 (27%) had a direct or indirect focus on LGBT older adult health or LGBT aging. These 19 articles were reviewed for content and subsequently 16 (23%) were identified as being explicitly focused on LGBT older adult health or aging, or as including older LGBT participants.

Only one of these 16 articles appeared in a top 10 nursing journal (i.e., Oncology Nursing Forum) by impact factor for 2010–2014 (White & Boehmer, 2012); the majority appeared in lower impact journals, and two appeared in journals focused on gerontological and geriatric nursing. Seven articles focused on older gay men (three of which focused on older gay men with HIV) (Dickinson et al., 2012; Kushner et al., 2013; Peate, 2013b; Ridgers, 2013; Slater et al., 2013, 2014; Thomas et al., 2013). Two studies focused on older lesbians (Gabrielson, 2011; White & Boehmer, 2012), and one case study focused on a transgender patient (Ferron et al., 2010). Six articles presented original research (Dickinson et al., 2012; Gabrielson, 2011; Kushner et al., 2013; Slater et al., 2013; Thomas et al., 2013; White & Boehmer, 2012) and one presented secondary analysis (Slater et al., 2014). Six articles were literature reviews outlining documented issues in LGBT older adult health disparities, issues with lack of provider competency and knowledge, and gaps in nursing student and health provider education regarding LGBT aging and older adults (Jablonski et al., 2013; Lim & Bernstein, 2012; McIntyre & McDonald, 2012; Peate, 2013a,b; Ridgers, 2013). One article discussed integration of LGBT older adult content into baccalaureate nursing education (Lim & Bernstein, 2012). One article described the development of a competency training and education program aimed at nurses and health professionals (Hardacker et al., 2014). Two thirds of these publications (n = 11) were authored by researchers and scholars outside the United States.

Content analysis of these 16 articles demonstrated a general focus among the authors on health disparities, illness experiences, and pathological processes specific to participants' status as sexual and gender minorities. The majority therefore focused on disparity and illness rather than wellness or aging as a process that may present unique features for individuals who identify as LGBT. Many discussed health disparities in relation to historical contexts that included marginalization, former criminalization, and public policies that disadvantaged members of the LGBT community, locating the experiences of individuals in relation to a larger social, medical, and legal context that has systematically disenfranchised them, increased burden of risk, and caused harm. All articles, either through extended argument or briefer statements, called for greater awareness and education of nursing professionals with respect to LGBT older adults and the context of their health status and health care experiences.

Comparison Among Nursing, Gerontology, Medicine, and Social Work Literature from 2010–2014

A comprehensive search of PubMed for LGBT older adult– or LGBT aging-related literature across top tier nursing, medicine, gerontology, and social work journals provided a sense of the comparative prevalence of relevant articles in these fields (Table 4). Of 36,224 articles published over the 5-year span in the 15 nursing journals, three (<0.01%) were positive hits for the study inclusion criteria of LGBT and aging/older adult search terms. A similar search of the top 10 journals in the gerontology literature yielded two of 42,288 (0.005%) LGBT aging/older adults articles; for medical journals, the ratio was 100 of 546,000 (0.02%) articles. The leader in prevalence of LGBT older adult–related content appeared to be social work; within the top 10 social work journals (two of which explicitly focus on children and young adults), there were 18 of 13,340 (0.13%) articles focused in the target area.

Z tests were used to calculate whether differences between the fields in terms of the proportion of articles published on LGBT older adult–related content in top tier journals were significant (Table 4). Social work published significantly more literature in this area than nursing, gerontology, or medicine individually and combined. There were no significant differences in prevalence of related articles between nursing and medicine or gerontology, and medicine published significantly more articles than gerontology. Despite the statistically significant differences (Table 4), all fields demonstrated a remarkable lack of any content in this area.

Discussion

Results of the current critical literature review demonstrate that although the health sciences as a whole, and nursing specifically, have made progress in including more LGBT-related terminology and foci, a relative and pervasive silence persists regarding the health of LGBT older adults and the aging LGBT community. The current study found that of 16 articles specifically about LGBT older adults, only one appeared in a top 10 nursing journal (i.e., Oncology Nursing Forum); two additional articles appeared in gerontology and geriatric nursing specialty journals, 15 appeared in journals with lower impact factors, and the majority appeared in non-aging–related publications. This silence is telling: recent nursing literature demonstrates a lack of attention to LGBT older adult health and aging and an apparent lack of inclusion—or attempts to include or identify—LGBT older adults in nursing research, even in areas that should be highly relevant (e.g., chronic illness, cancer, dementia, caregiving).

This silence persists despite the 2011 Institute of Medicine report calling for increased attention to LGBT health issues, and the Joint Commission's 2011 mandate to improve health care delivery for members of the LGBT community, including LGBT older adults. The American Academy of Nursing (2012), American Medical Association (2015), the National Institutes of Health (2013), and the U.S. Department of Health and Human Services (2012) have all identified health and service providers' need for additional knowledge and competency related to the LGBT community, including increased research focused on LGBT health and aging. It would be difficult to overstate the implications of these findings for research and practice. As nurses, we cannot practice what we do not know (just as we cannot question, or take intervening action in, issues of which we remain unaware and do not address scientifically or clinically). Lack of systematic, contextual, and practical knowledge regarding the collective and individual histories and experiences of LGBT older adults compromises our ability to be fully competent in research and practice.

Without an understanding of how historical issues and experiences shape the aging and health status of LGBT older adults, nursing as a field ignores an important source of diversity and health disparity for a growing number of older adults. Without relevant LGBT-specific research, inquiry, and evidence to inform practice guidelines, nurses will not be equipped within their specific practice areas (e.g., oncology, mental health, critical care, community, public health, education) with the knowledge needed to provide the best care possible (i.e., individualized, patient-centered care) to older patients who are among the most vulnerable, and those most in need of support and meaningful intervention. Moreover, nurses specializing in gerontological, geriatric, and geropsychiatric practice will be operating on the basis of normative models and assumptions that fail to address the realities (histories, experiences, and responses) of LGBT older adults who are most at risk for isolation, marginalization, and poor health outcomes.

The state of the science for LGBT older adult health and aging is still in early stages and has been predominantly epidemiological and descriptive. Because of this, to promote diversity and inclusivity of work in this area, the “high impact” nursing journals may need to adjust review and publication criteria to accommodate the state of the science and increase visibility of work in this area. Nursing researchers need to learn about and incorporate best practice recommendations for increasing diversity and inclusivity in their study designs and procedures. Such recommendations exist and are being refined and offered with increasing accessibility on a regular basis, with many promulgated by expert research, health care, and advocacy organizations. However, these recommendations will not work if nursing researchers remain unaware or do not make efforts to follow them.

All nursing researchers should consider how their study designs, methods, and procedures support or discourage inclusion and visibility of LGBT participants. In the majority of health research, LGBT older adults are not counted. Surveys and questionnaires continue to be designed in ways that perpetuate invisibility, and require revision to offer options for participants to state their orientation and identity instead of the default assumption of heterosexuality and the conventional cisgender binary still prevalent in medicine and social science. The term “cisgender” has etymological roots in Latin, where “cis” means “on this side of,” whereas “trans” means “on the other side” (the term is also used in science to connote mirror versions of naturally occurring structures). Cisgender was coined to highlight pervasive social construction rooted in a male–female dichotomy, where each category conforms to traditional and conventional social gender stereotypes that preclude the possibility of alternative genders or gender identities, and which serves as a dominant norm that is rarely noted as such. Cisgender describes individuals whose gender identity aligns with their visible physical and sexual characteristics (usually male or female). Use of cisgender arose in the LGBTQ (queer) community to highlight how being seen as transgender, as a potential identity, depends on the assumption of a cisgender norm.

Although some researchers worry that older adults may be confused or upset by additional orientation or gender options (or simply a blank space within which to write their orientation and gender), current research suggests that this is not the case and is likely to become less so as Baby Boomers and other cohorts age (Fredriksen-Golden & Kim, 2015). It also may not be long before federal granting agencies will expect to see LGBT designations as part of their minority target enrollment requirements; systematic inclusion of LGBT participants or sound rationale for purposeful exclusion will be required. Because of the multiple health issues studied that also disproportionately affect the LGBT community, even studies not explicitly focused on LGBT issues should include LGBT participants. Finally, nursing research has historically been strong in the use of frameworks, such as community-based participatory research and action research, that are eminently suited to partnering with the LGBT aging community.

The theoretical conventions that underpin the current research also require examination for heteronormative assumptions that will limit its generalizability and explanatory power (McDonald, 2010; Röndahl, 2011). As more complex theories and models are developed to account for the effects of intersectionality and heteronormativity, as well as behaviors on individual and group health outcomes, efforts should be made to include analyses of positive and protective factors. For example, resilience has been identified as a defining characteristic of many LGBT community members, especially older adults; other relevant concepts, such as posttraumatic growth, may help identify salient concepts and develop models that move beyond pathology to incorporate recognition of specific strengths that may be translated into health-supporting actions.

A number of practice recommendations for providing health care services to LGBT older adults have also been developed and offered at increasing rates by multiple organizations over the past several years. The idea that additional LGBT-focused education is unneeded because of providers' beliefs that they “treat everyone the same” is now recognized as being a naïve and likely inaccurate claim because of unconscious heteronormative biases; “treating everyone the same” is most likely to mean that “everyone is treated as if they are straight and cisgender.” This presents clear challenges to practicing patient-centered care or cultural competency. A number of well-designed and useful competency resources for creating safe and affirming care environments and practices with LGBT older adults have been published and made widely available in recent years. For example, the National LGBT Health Education Center, supported by the Fenway Institute, is a leader in providing education, training, and print resources to health and service providers (access http://www.lgbthealtheducation.org). The national organization, Services and Advocacy for Gay, Lesbian, and Transgender Elders, focuses on services, programs, advocacy, and policymaking for LGBT older adults, including a national network of state and local chapters (access http://www.sageusa.org). Use of these resources for nurse orientation and development will help promote (a) awareness of the fact that a subset of older patients will be LGBT and (b) practices that have been identified by LGBT older adults as critical to maintain a sense of safety, dignity, and respect as they seek and receive health care and aging services. These resources exist, but unless nurses in leadership positions (e.g., educators, managers, principal investigators) incorporate them into practice, they—like the individuals they are meant to represent—effectively remain invisible to the majority of nurses.

Finally, several leaders have stressed the need to incorporate LGBT older adult focus into nursing and health science curricula at all levels of education, not only as a specialty topic, but threaded throughout. A 2011 Journal of the American Medical Association study of medical school curricula indicated that medical students in the United States and Canada receive an average of 5 minutes of LGBT-focused education or training throughout their programs (Obedin-Maliver et al., 2011). Although no study has yet quantified the amount or impact of LGBT-related education and training in nursing programs, Lim and Bernstein (2012) documented a systematic lack of LGBT content in baccalaureate nursing education. LGBT-related content should, at minimum, include a basic understanding of what sexual orientation and gender identities are, related terms, and the historical contexts within which they have been used as terms of oppression, identification, and community. There is also a need to link practice and education frameworks with research through systematic empirical studies that demonstrate the effectiveness of LGBT-specific interventions with patient and community outcomes; in general, there has been little study of whether and how cultural competency-based training changes provider or patient outcomes.

Limitations

Limitations of the current analysis are associated with its central dependence on electronic databases and literature searching techniques. Even using carefully selected search terms, consistent procedures for combining terms and applying database filters, every iteration of even the same search introduces the potential for error as bytes of information are processed and repackaged. For example, clearing or not clearing the browser cache after each search or group of searches may affect results. This can be at least partially mitigated by consistent procedures and multiple replications of the same searches to check for consistency. The health science librarian who assisted with the final search confirmed that even the same search procedures will sometimes produce somewhat differing results; being as methodical as possible may limit these differences to only a small number of publications. Nonetheless, although replication of the procedures outlined here may produce slight differences, the systematic nature of the review enhances the likelihood that overall findings would remain largely the same, and would therefore not substantially change the interpretation of results.

Conclusion

The current study provides empirical evidence that a relative silence has persisted across health sciences concerning LGBT older adult health and aging, and that this silence may be especially profound within nursing. Although important strides have been made (particularly by colleagues in social work and some notable nursing leaders in research, education, and clinical practice), there remains a clear opportunity for nurses working in every venue to help lead efforts to strengthen the evidence base and engage in practices that will improve the health and well-being of older members of the LGBT community.

References

  • Addis, S., Davies, M., Greene, G., Macbride-Stewart, S. & Shepherd, M. (2009). The health, social care and housing needs of lesbian, gay, bisexual and transgender older people: A review of the literature. Health & Social Care in the Community, 17, 647–658. doi:10.1111/j.1365-2524.2009.00866.x [CrossRef]
  • Administration on Aging. (2015). Aging statistics. Retrieved from http://www.aoa.acl.gov/Aging_Statistics/index.aspx
  • Albelda, R., Badgett, M.V.L., Schneebaum, A. & Gates, G.J. (2009). Poverty in the lesbian, gay, and bisexual community. Retrieved from http://scholarworks.umb.edu/csp_pubs/34
  • American Academy of Nursing. (2012). Position statement on health care for sexual minority and gender diverse populations. Retrieved from http://www.aannet.org/assets/lgbtq%20overachstatement%20final%207%2011%2012.pdf
  • American Medical Association. (2015). AMA policies on LGBT issues. Retrieved from http://www.ama-assn.org/ama/pub/about-ama/our-people/member-groups-sections/glbt-advisory-committee/ama-policy-regarding-sexual-orientation.page
  • Brennan-Ing, M., Seidel, L., Larson, B. & Karpiak, S.E. (2014). Social care networks and older LGBT adults: Challenges for the future. Journal of Homosexuality, 61, 21–52. doi:10.1080/00918369.2013.835235 [CrossRef]
  • Buchmueller, T. & Carpenter, C.S. (2010). Disparities in health insurance coverage, access, and outcomes for individuals in same-sex versus different-sex relationships, 2000–2007. American Journal of Public Health, 100, 489–495. doi:10.2105/AJPH.2009.160804 [CrossRef]
  • Centers for Disease Control and Prevention. (2013). The state of aging and health in America 2013. Retrieved from http://www.cdc.gov/features/agingandhealth/state_of_aging_and_health_in_america_2013.pdf
  • Croghan, C.F., Moone, R.P. & Olson, A.M. (2014). Friends, family, and caregiving among midlife and older lesbian, gay, bisexual, and transgender adults. Journal of Homosexuality, 61, 79–102. doi:10.1080/00918369.2013.835238 [CrossRef]
  • Cronin, A. & King, A. (2010). Power, inequality and identification: Exploring diversity and intersectionality amongst older LGB adults. Sociology, 44, 876–892. doi:10.1177/0038038510375738 [CrossRef]
  • Dickinson, T., Cook, M., Playle, J. & Hallett, C. (2012). “Queer” treatments: Giving a voice to former patients who received treatments for their “sexual deviations”.Journal of Clinical Nursing, 21, 1345–1354. doi:10.1111/j.1365-2702.2011.03965.x [CrossRef]
  • Eliason, M.J., Dibble, S. & DeJoseph, J. (2010). Nursing's silence on lesbian, gay, bisexual, and transgender issues: The need for emancipatory efforts. Advances in Nursing Science, 33, 206–218. doi:10.1097/ANS.0b013e3181e63e49 [CrossRef]
  • Family Caregiver Alliance. (2012). LGBT caregiving: Frequently asked questions. Retrieved from https://caregiver.org/lgbt-caregiving-frequently-asked-questions
  • Feng, Z., Fennell, M.L., Tyler, D.A., Clark, M. & Mor, V. (2011). The care span: Growth of racial and ethnic minorities in US nursing homes driven by demographics and possible disparities in options. Health Affairs, 30, 1358–1365. doi:10.1377/hlthaff.2011.0126 [CrossRef]
  • Ferron, P., Young, S., Boulanger, C., Rodriguez, A. & Moreno, J. (2010). Integrated care of an aging HIV-infected male-to-female transgender patient. Journal of the Association of Nurses in AIDS Care, 21, 278–282. doi:10.1016/j.jana.2009.12.004 [CrossRef]
  • Flaskerud, J.H., Lesser, J., Dixon, E., Anderson, A., Conde, F., Kim, S. & Verzemnieks, I. (2002). Health disparities among vulnerable populations: Evolution of knowledge over five decades in nursing research publications. Nursing Research, 51, 74–85. doi:10.1097/00006199-200203000-00003 [CrossRef]
  • Fredriksen-Goldsen, K.I., Cook-Daniels, L., Kim, H.J., Erosheva, E.A., Emlet, C.A., Hoy-Ellis, C.P. & Muraco, A. (2014). Physical and mental health of transgender older adults: An at-risk and underserved population. The Gerontologist, 54, 488–500. doi:10.1093/geront/gnt021 [CrossRef]
  • Fredriksen-Goldsen, K.I., Emlet, C.A., Kim, H.-J., Muraco, A., Erosheva, E.A., Goldsen, J. & Hoy-Ellis, C.P. (2013). The physical and mental health of lesbian, gay male, and bisexual (LGB) older adults: The role of key health indicators and risk and protective factors. The Gerontologist, 53, 664–675. doi:10.1093/geront/gns123 [CrossRef]
  • Fredriksen-Goldsen, K.I. & Kim, H.J. (2015). Count me in: Response to sexual orientation measures among older adults. Research in Aging, 37, 464–480. doi:10.1177/0164027514542109 [CrossRef]
  • Fredriksen-Goldsen, K.I., Kim, H.-J., Barkan, S.E., Muraco, A. & Hoy-Ellis, C.P. (2013). Health disparities among lesbian, gay, and bisexual older adults: Results from a population-based study. American Journal of Public Health, 103, 1802–1809. doi:10.2105/AJPH.2012.301110 [CrossRef]
  • Fredriksen-Goldsen, K.I., Kim, H.-J., Muraco, A. & Mincer, S. (2009). Chronically ill midlife and older lesbians, gay men, and bisexuals and their informal caregivers: The impact of the social context. Sexuality Research & Social Policy, 6, 52–64. doi:10.1525/srsp.2009.6.4.52 [CrossRef]
  • Fredriksen-Goldsen, K.I., Kim, H.J., Shiu, C., Goldsen, J. & Emlet, C.A. (2015). Successful aging among LGBT older adults: Physical and mental-related quality of life by age group. The Gerontologist, 55, 154–168. doi:10.1093/geront/gnu081 [CrossRef]
  • Gabrielson, M.L. (2011). “I will not be discriminated against”: Older lesbians creating new communities. Advances in Nursing Science, 34, 357–373. doi:10.1097/ANS.0b013e3182300db8 [CrossRef]
  • Giger, J., Davidhizar, R.E., Purnell, L., Harden, J.T., Phillips, J. & Strickland, O. (2007). American Academy of Nursing Expert Panel report: Developing cultural competence to eliminate health disparities in ethnic minorities and other vulnerable populations. Journal of Transcultural Nursing, 18, 95–102. doi:10.1177/1043659606298618 [CrossRef]
  • Grady, P.A. (2011). Advancing the health of our aging population: A lead role for nursing science. Nursing Outlook, 59, 207–209. doi:10.1016/j.outlook.2011.05.017 [CrossRef]
  • Hansen-Kyle, L. (2006). A concept analysis of healthy aging. Nursing Forum, 40, 45–57. doi:10.1111/j.1744-6198.2005.00009.x [CrossRef]
  • Hardacker, C.T., Rubinstein, B., Hotton, A. & Houlberg, M. (2014). Adding silver to the rainbow: The development of the nurses' health education about LGBT elders (HEALE) cultural competency curriculum. Journal of Nursing Management, 22, 257–266. doi:10.1111/jonm.12125 [CrossRef]
  • House, J.S., Lantz, P.M. & Herd, P. (2005). Continuity and change in the social stratification of aging and health over the life course: Evidence from a nationally representative longitudinal study from 1986 to 2001/2002 (Americans' Changing Lives Study). Journals of Gerontology. Series B, Psychological Sciences and Social Sciences, 60, S15–S26. doi:10.1093/geronb/60.Special_Issue_2.S15 [CrossRef]
  • Hurst, L., Stafford, M., Cooper, R., Hardy, R., Richards, M. & Kuh, D. (2013). Lifetime socioeconomic inequalities in physical and cognitive aging. American Journal of Public Health, 103, 1641–1648. doi:10.2105/AJPH.2013.301240 [CrossRef]
  • Institute of Medicine. (2011). The health of lesbian, gay, bisexual and transgender people: Building a foundation for better understanding. Retrieved from http://www.ncbi.nlm.nih.gov/books/NBK64806/pdf/TOC.pdf
  • Jablonski, R.A., Vance, D.E. & Beattie, E. (2013). The invisible elderly: Gay, lesbian, bisexual, and transgender older adults. Journal of Gerontological Nursing, 39(11), 46–52. doi:10.3928/00989134-20130916-02 [CrossRef]
  • Joint Commission. (2011). Advancing effective communication, cultural competence, and patient- and family-centered care for the lesbian, gay, bisexual, and transgender (LGBT) community: A field guide. Retrieved from http://www.jointcommission.org/assets/1/18/LGBTFieldGuide.pdf
  • Jönson, H. & Larsson, A.T. (2009). The exclusion of older people in disability activism and policies—A case of inadvertent ageism?Journal of Aging Studies, 23, 69–77. doi:10.1016/j.jaging.2007.09.001 [CrossRef]
  • Kushner, B., Neville, S. & Adams, J. (2013). Perceptions of ageing as an older gay man: A qualitative study. Journal of Clinical Nursing, 22, 3388–3395. doi:10.1111/jocn.12362 [CrossRef]
  • Lick, D.J., Durso, L.E. & Johnson, K.L. (2013). Minority stress and physical health among sexual minorities. Perspectives on Psychological Science, 8, 521–548. doi:10.1177/1745691613497965 [CrossRef]
  • Lim, F. & Levitt, N. (2011). Lesbian, gay, bisexual, and transgender health. American Journal of Nursing, 111, 11. doi:10.1097/01.NAJ.0000407277.79136.91 [CrossRef]
  • Lim, F.A. & Bernstein, I. (2012). Promoting awareness of LGBT issues in aging in a baccalaureate nursing program. Nursing Education Perspectives, 33, 170–175. doi:10.5480/1536-5026-33.3.170 [CrossRef]
  • Lim, F.A., Brown, D.V. & Justin Kim, S.M. (2014). Addressing health care disparities in the lesbian, gay, bisexual, and transgender population: A review of best practices. American Journal of Nursing, 114, 24–34. doi:10.1097/01.NAJ.0000450423.89759.36 [CrossRef]
  • Lomas, C. (2013). You've got a friend. Nursing Standard, 27, 20–21. doi:10.7748/ns2013.02.27.23.20.s9 [CrossRef]
  • McCabe, S.E., Bostwick, W.B., Hughes, T.L., West, B.T. & Boyd, C.J. (2010). The relationship between discrimination and substance use disorders among lesbian, gay, and bisexual adults in the United States. American Journal of Public Health, 100, 1946–1952. doi:10.2105/AJPH.2009.163147 [CrossRef]
  • McDonald, C. (2010). Orienting to difference: Beyond heteronormative sexualities. In McIntyre, M & McDonald, C (Eds.), Realities of Canadian nursing: Professional, practice and power issues (3rd ed., pp. 387–396). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins.
  • McIntyre, M. & McDonald, C. (2012). The limitations of partial citizenship. Advances in Nursing Science, 35, 127–134. doi:10.1097/ANS.0b013e31824fe6ca [CrossRef]
  • Meisner, B.A. & Hynie, M. (2009). Ageism with heterosexism: Self-perceptions, identity, and psychological health in older gay and lesbian adults. Gay and Lesbian Issues and Psychology Review, 5, 51.
  • Muraco, A. & Fredriksen-Goldsen, K. (2011). “That's what friends do”: Informal caregiving for chronically ill midlife and older lesbian, gay, and bisexual adults. Journal of Social and Personal Relationships, 28, 1073–1092. doi:10.1177/0265407511402419 [CrossRef]
  • National Institutes of Health. (2013). The NIH Director: Plans for advancing LGBT health research. Retrieved from http://www.nih.gov/about-nih/who-we-are/nih-director/statements/plans-advancing-lgbt-health-research
  • Obedin-Maliver, J., Goldsmith, E.S., Stewart, L., White, W., Tran, E., Brenman, S. & Lunn, M.R. (2011). Lesbian, gay, bisexual and transgender-related content in undergraduate medical education. Journal of the American Medical Association, 306, 971–977. doi:10.1001/jama.2011.1255 [CrossRef]
  • Peate, I. (2013a). Caring for older lesbian, gay and bisexual people. British Journal of Community Nursing, 18, 372–374. doi:10.12968/bjcn.2013.18.8.372 [CrossRef]
  • Peate, I. (2013b). The health-care needs of the older gay man living with HIV. British Journal of Community Nursing, 18, 492–495. doi:10.12968/bjcn.2013.18.10.492 [CrossRef]
  • Ridgers, H. (2013). Caring for older HIV-positive men who have sex with men. Nursing Standard, 27, 44–49. doi:10.7748/ns2013.02.27.23.44.e7332R1 [CrossRef]
  • Röndahl, G. (2011). Heteronormativity in health care education programs. Nurse Education Today, 31, 345–349. doi:10.1016/j.nedt.2010.07.003 [CrossRef]
  • Slater, L.Z., Moneyham, L., Vance, D.E., Raper, J.L., Mugavero, M.J. & Childs, G. (2013). Support, stigma, health, coping, and quality of life in older gay men with HIV. Journal of the Association of Nurses in AIDS Care, 24, 38–49. doi:10.1016/j.jana.2012.02.006 [CrossRef]
  • Slater, L.Z., Moneyham, L., Vance, D.E., Raper, J.L., Mugavero, M.J. & Childs, G. (2014). The multiple stigma experience and quality of life in older gay men with HIV. Journal of the Association of Nurses in AIDS Care, 26, 24–35. doi:10.1016/j.jana.2014.06.007 [CrossRef]
  • Thomas, C., Wootten, A. & Robinson, P. (2013). The experiences of gay and bisexual men diagnosed with prostate cancer: Results from an online focus group. European Journal of Cancer Care, 22, 522–529. doi:10.1111/ecc.12058 [CrossRef]
  • U.S. Department of Health and Human Services. (2012). Better health and well-being: Making improvements for lesbian, gay, bisexual and transgender (LGBT) Americans. Retrieved from http://www.hhs.gov/sites/default/files/lgbt-health-update-2011.pdf
  • Van Wagenen, A., Driskell, J. & Bradford, J. (2013). “I'm still raring to go”: Successful aging among lesbian, gay, bisexual, and transgender older adults. Journal of Aging Studies, 27, 1–14. doi:10.1016/j.jaging.2012.09.001 [CrossRef]
  • White, J.L. & Boehmer, U. (2012). Long-term breast cancer survivors' perceptions of support from female partners: An exploratory study. Oncology Nursing Forum, 39, 210–217. doi:10.1188/12.ONF.210-217 [CrossRef]
  • Witten, T.M. (2014). End of life, chronic illness, and trans-identities. Journal of Social Work in End-of-Life and Palliative Care, 10, 34–58. doi:10.1080/15524256.2013.877864 [CrossRef]
  • Woody, I. (2014). Aging out: A qualitative exploration of ageism and heterosexism among aging African American lesbians and gay men. Journal of Homosexuality, 61, 145–165. doi:10.1080/00918369.2013.835603 [CrossRef]

LGBT-Related Terms in CINAHL, 2010–2014

Search TermNo. of Hits, Any FieldNo. of Hits, Title OnlyNo. of Hits, Abstract% Change 2005–2009a
Sexual orientation1,02530679361
Homosexual6102044288
Sexual identity403118311127
Gender identity2,64316439667
Gay3,9581,8441,99738
Lesbian1,6589071,10639
Mostly heterosexual27227100
Bisexual1,5207571,11968
MSM1,211292834136
WSW275180
Sexual preference60844300
Sexual minority368181271218
Transsexual123559649
Gender atypical27722700
Gender nonconforming17815700
Same sexb954244817N/A
Same sex (couple or marriage)56363020
Transgender961558574143
Bi-genderb101N/A
Queer159909727
Two spiritb18874N/A
Gender minority891871200
LGBT, GLBT, LGB1,16421226333
LGBTQb643747N/A
Non-heterosexual14213−50
Heterosexualb2,0975911,696N/A
Asexualb811174N/A

LGBT Older Adult–Related Terms in CINAHL, 2010–2014

Search Term2005–20092010–2014% Changea
No. of Hits, Any FieldNo. of Hits, Title OnlyNo. of Hits, AbstractNo. of Hits, Any FieldNo. of Hits, Title OnlyNo. of Hits, Abstract
Sexual orientation10052117100
Homosexual9030000
Sexual identity6011014100
Gender identity321145120
Gay5581199113027
Lesbian25557282038
Mostly heterosexual0001010
Bisexual20346562450
MSM600711100
WSW0000000
Sexual preference1001010
Sexual minority2008030
Transsexual0002000
Gender atypical2000000
Gender nonconforming0000000
Same sexb160727111100
Same sex (couple or marriage)210601−100
Transgender14535781938
Bi-genderb0000000
Queer100311100
Two spiritb0000000
Gender minority2003020
LGBT, GLBT, LGB2732117211886
LGBTQb000510100
Non-heterosexual0000000
Heterosexualb293102006−300
Asexualb4041000

Relevant Publications in the Top 10 Nursing and Gerontology/Geriatric Nursing Journals, 2010–2014

Journal2013 Impact FactorNo. of LGBT MentionsNo. of LGBT FocusesNo. of LGBT Older Adult MentionsNo. of LGBT Older Adult Focuses
Journal of the Oncology Nursing Forum2.93723111
International Journal of Nursing Studies2.8456100
Birth2.6852000
Cancer Nursing2.4880000
Journal of Advanced Nursing2.46227500
Worldviews on Evidence-Based Nursing2.2963100
Research in Nursing and Health2.2163100
American Journal of Critical Care2.2110000
European Journal of Oncology Nursing2.1541000
Journal of Cardiovascular Nursing2.1281000
Nursing Researcha2.105 (2012)0000
Journal of Nursing Scholarshipa2.043 (2012)1000
Geriatric Nursing1.2973121
Research in Gerontological Nursing0.9860000
Journal of Gerontological Nursing0.8681111
Total711143

Comparison of Nursing, Gerontology, Medicine, and Social Work Literature, 2010–2014

Comparisons of Proportion of LGBT Older Adult/Aging PublicationsZ Scorep ValueaInterpretation
Nursing versus gerontology0.98470.38No significant difference between fields, although nursing had slightly more publications.
Nursing versus medicine−1.00190.32No significant difference between fields, although medicine had slightly more publications.
Nursing versus social work−5.80760*Significant difference; social work had more publications than nursing.
Gerontology versus medicine−2.01020.045**Significant difference; medicine had more publications than gerontology.
Gerontology versus social work−6.84570*Significant difference; social work had more publications than gerontology.
Medicine versus social work−9.16640*Significant difference; social work had more publications than medicine.
Authors

Dr. Cloyes is Associate Professor, College of Nursing, University of Utah, Salt Lake City, Utah.

The author has disclosed no potential conflicts of interest, financial or otherwise. This work was supported by the National Hartford Center for Gerontological Nursing Excellence Claire M. Fagin faculty fellowship and a grant from the Mayday Fund.

Address correspondence to Kristin G. Cloyes, PhD, RN, Associate Professor, College of Nursing, University of Utah, 10 South 2000 East, Salt Lake City, UT 84112; e-mail: Kristin.cloyes@nurs.utah.edu.

Received: July 20, 2015
Accepted: November 17, 2015
Posted Online: December 29, 2015

10.3928/19404921-20151218-02

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