4 Valuing diversity in later life
A central tenet of this book relates to the centrality of holistic care when caring for and working with older people. As we develop our discussion within this book as a whole we explore a number of issues that potentially impact on the provision of individualised care for an older person. More importantly, however, and a central theme of the book, is how we can begin to address these challenges in order to develop caring practice that is cognisant of the particular facets that ‘make up’ the individual and that are expressed and recognised through healthcare encounters.
In Chapter 3 we considered ‘attitudes to ageing’ and explored some stereotypes that pervade images of older people. In this chapter we build on this earlier exploration in relation to three main topic areas. While there are numerous facets that are central to personal identity, for this chapter we have chosen to focus on sexuality, spirituality and cultural diversity – we have chosen these as they are often perceived as sensitive topics to approach and also sometimes are not acknowledged as important for older people or poorly defined – although of course they form part of many assessment documents and, as Narayanasamy et al (2004:7) highlight within the specific context of spirituality:
The key means of gaining an awareness of spiritual needs is identified as assessment […] the traditional notion of merely noting the religious affiliation of the client fails to explore the full range of possible spiritual orientations.
In this chapter we invite you to explore your knowledge base and awareness of these concepts and in so doing begin to develop your practice when working with and caring for older people. In essence, we also develop in a more structured way (using the available evidence base) some of the issues relating to attitudes that we have touched upon in Chapter 3 regarding stereotyping and attitudes towards older people.
As you progress in your nursing career you will become more familiar with the assessment process for all individuals that you work with. Many assessment frameworks, documents or models that you will encounter are based around a holistic philosophy of care, for example models such as Roper, Logan and Tierney (Holland et al 2008) that are based on activities of living (AL).
As we have already highlighted, many assessment documents that you may have used or will use in practice also contain fields for the consideration of sexuality, spirituality and cultural care. In subsequent chapters we consider other facets that make up a holistic model of assessment and care but, for the purposes of this chapter, we have chosen these areas in particular as they are very personal and as such can be difficult to know how to approach with an older person – though arguably they are a pivotal part of individual experience and need to be considered in terms of the individual’s wishes and with sensitivity.
We start each of the sections with a reflective activity. We start with a reflective activity so that you can begin to explore your own perceptions of these concepts and also how your own values and experiences may impact on the way in which you approach or respond to these topics with older people.
Each of the topic areas we have chosen in this chapter are complex in nature and we hope that you will explore your own thoughts and feelings and as such increase your understand and knowledge base and ultimately your caring practices with older people. In many respects there are overlaps within the themes that we have identified in this chapter – this is the nature of holistic care. As we have identified and continue to develop as a central theme within this book, populations are diverse and nurses will need to possess the requisite skills to work across a range of dimensions, changing life circumstances and contemporary experiences of ageing and diversity.
Take a few moments to think about what you understand by the term ‘sexuality’ and then note down your thoughts. You might try to construct a paragraph which expresses your definition of sexuality. At the end of the following section, compare your own thoughts to our developing discussion and consider if you would like to amend or add anything to your own notes. We would also like you to start to consider some of the points raised and focus on any aspects of further learning that you feel you need to explore.
Sexuality is an intrinsic part of our individuality and forms a central part of personal identity throughout our lives. However, while sexuality is a central construct in terms of ‘who we are’, it is a concept that is not easily defined. The World Health Organisation (WHO) has defined sexuality as encompassing (cited in Bauer et al 2007:64):
… sex, gender identities and roles, sexual orientation, eroticism, pleasure, intimacy and reproduction. Sexuality is experienced and expressed in thoughts, fantasies, desires, beliefs, attitudes, values, behaviours, practices, roles and relationships.
As this definition illustrates, sexuality is multifaceted in nature. Moreover, Bauer et al (2007) further report that ‘sexuality is a social construction and as such reflects the judgements of society’. If you think about this from the particular perspective of older people, it may not surprise you to find that the literature also highlights that as such older people are often perceived to be ‘asexual’ (Bauer et al 2007) and that issues that arise in practice surrounding sexuality and older people are seen by healthcare professionals as a ‘problem’ or a ‘conundrum’ (Price 2009). Moreover, Gott & Hinchliff (2003) argue that the stereotypical view of the ‘asexual’ older person has been perpetuated at a policy level through a number of key documents, for example the National Service Frameword for Older People and the National Sexual Health Strategy where there is an absence of explicit reference to older people.
Likewise, there is largely an absence of evidence or engagement within the literature surrounding sexuality, ageing and diversity. Heaphy et al (2004), in their paper Ageing in a Non-heterosexual Context, for example, alert readers to the issues surrounding the continued invisibility of older lesbian and gay men.
As we noted in a Chapter 3, older people in contemporary contexts include the ‘baby boomers’ who, as Bauer et al (2007) illustrate, ‘were credited with bringing about the sexual revolution of the 1960s and 1970s’ and as they enter old age may raise further challenges in terms of how we as healthcare professionals conceptualise sexual expression. While sexuality is a personal and sensitive subject area, it is not one that can be ignored by nurses when they are working with older people.
In the following section we highlight some of the barriers to sexuality and sexual health identified within the literature (Bauer et al 2007, Price 2009) and you may also consider how healthcare professionals might develop their awareness in terms of some of these issues.
We have already considered in the introduction how social constructs may constrain the expression of sexuality in later life. For example, as Bauer et al (2007) highlight, ‘ageism has infiltrated deeply into society and many older people see themselves as too old for sex’.
Ill health or disability may be particular issues for the older person, for example a number of health-related conditions, hypertension, diabetes, rheumatoid arthritis, certain medications, pain and fatigue, and altered body image.
While, as we have identified, sexuality in later life is an important issue for older people, Price (2009) has highlighted that historically healthcare professionals have found approaching the subject of sexuality with older people difficult. For example, healthcare professionals may be unclear about social conventions, what might be discussed in same-sex groups, between sexes or across age groups. Price (2009) further highlights that there is considerable ambiguity that surrounds sexuality and the older person in terms of the extent to which discussion might be acceptable or the kind of terminology that might be used. Price (2009) also highlights that nurses may be unsure whether ‘frank exchange or polite code’ is the most appropriate approach with an older person when discussing sexuality and sexual health.
Bauer et al (2007) and Price (2009) both highlight that institutional care environments present particular issues for older people in terms of the lack of privacy and the associated challenges of residential living.