ABSTRACT
Lesbian, gay, bisexual, trans and/or queer (LGBTQ) people experience profound health and social care inequalities. Research suggests that staff with negative attitudes towards LGBTQ people, are more likely to hold strong, traditional, religious beliefs. This article reports on a single case study with a newly qualified UK nurse who has since left the National Health Service. This is based on a single interview taken from a larger dataset derived from a funded scoping research study exploring religious freedoms, sexual orientation and gender identity rights in older age care spaces. The interviewee described a toxic nursing culture on a hospital ward for older people. She recounted various incidents involving homophobic and transphobic practice and LGBTQ microaggressions which reportedly impacted the quality of nursing care. The findings are considered in relation to standards for anti-oppressive practice in nursing care, and how nursing students and staff can be supported in addressing practice relating to equality and diversity issues, specifically LGBTQ issues. They confirm the direct significance of addressing the needs and circumstances of LGBTQ people in nursing curricula and ongoing professional practice, and the need to further research, evaluate and progress translation of learning into improved quality care for diverse populations.
Introduction
There is growing awareness about lesbian, gay, bisexual, trans and/or queer (LGBTQ) health and social care inequalities in the UK (Women and Equalities Committee Citation2019). Older LGBTQ people, in particular, are concerned that care providers will not understand their needs, and that they may encounter homophobic and/or transphobic prejudice and discrimination (Guasp Citation2011; Westwood Citation2016; Westwood and Price Citation2016; Almack Citation2018; Löf and Olaison Citation2020). This can lead to them missing health promotion opportunities, and their assessments, diagnosis and treatment being delayed, with associated poorer health outcomes. With over one million older LGBTQ people in the UK (Age UK Citation2020), that number set to rise with the ageing population, this is a pressing concern.
As a key profession, nursing holds a pivotal role in the delivery of healthcare to older people: in the community, on hospital wards, and in care/nursing homes. Nurses can potentially take on an emancipatory role in healthcare delivery through anti-oppressive practice and culturally competent compassionate care (Papadopoulos, Shea, and Taylor Citation2016), which understands the impact of minority stress (Baiocco et al. Citation2022). Nursing also has the potential to compound minority exclusions, via implicit or explicit bias and/or the reinforcement of oppressive values and ideologies. The UK Nursing and Midwifery Council (NMC) Code (Nursing and Midwifery Council (NMC) Citation2018) states that nurses, midwives and nursing associates must: ‘Treat people with kindness, respect and compassion’ (1.1); ‘Respect and uphold people’s human rights’ (1.5); ‘Avoid making assumptions and recognise diversity and individual choice’ (1.3) and ‘Act as an advocate for the vulnerable, challenging poor practice and discriminatory attitudes and behaviour relating to their care’. However, the Code makes no specific reference to LGBTQ-inclusive and/or LGBTQ anti-oppressive nursing care (Nursing and Midwifery Council (NMC) Citation2019).
There is a growing body of literature suggesting that some nurses, nursing assistants, student nurses and nurse educators hold negative attitudes towards LGBTQ people (Westwood Citation2022) and that this is heightened among highly religious individuals. However, there is a dearth of literature on whether/how those attitudes inform practice and how these are experienced by and impact LGBTQ people. This article considers a single case study, taken from a larger scoping study which explored what is known about the balancing of religious freedoms, sexual orientation and gender identity rights in older age care spaces. The scoping study comprised a small survey and interviews. The case study is based on one of the interviews with a survey participant, ‘Clare’ (pseudonym), whose survey responses suggested she had first-hand experience of encountering problematic practice towards LGBTQ patients, and that she was willing to be interviewed. Her detailed and insightful narratives are discussed within the context of current literature. They are not intended to indicate issues of scale, but rather some of the ways in which negative attitudes towards LGBTQ people can potentially affect practice. Exploring and reflecting on such issues can provide a way of thinking through the points of learning and change, to inform what anti-oppressive practice means in day-to-day care and understand some of the barriers and facilitators from professional perspectives (Baiocco et al. Citation2022). It may also contribute to wider debates on the role of religiosity and spirituality for LGBTQ people and the challenges for integration of their own beliefs and support systems to develop resilience, coping strategies and enhance wellbeing (Halkitis et al. Citation2009; Westwood Citation2017).
Background
Regulatory context
The UK Equality Act 2010 prohibits discrimination in the delivery of goods and services on the grounds of nine protected characteristics, including sexual orientation and gender reassignment. UK regulations relating to the delivery of healthcare in general and nursing in particular emphasise the importance of respectful, non-discriminatory practice. The English NHS Constitution (NHS England Citation2021) refers to valuing ‘every person’ and making sure ‘nobody is excluded, discriminated against or left behind’ The Scottish Charter of Patient Rights and Responsibilities (NHS Scotland Citation2019) also commits to the patient expectation that ‘I will be treated fairly and equally and will not be discriminated against’ and that ‘I have the right to be treated with consideration, dignity and respect when accessing and using NHS services’. Similarly, Principle 5 of the NHS Wales Core Principles (NHS Wales Citation2016) also emphasises ‘valuing and respecting each other’, and ‘zero tolerance of bullying or victimisation of any patient, service user or member of staff’.
Nursing practice concerns
There are ongoing concerns about prejudice and discrimination in nursing, particularly in relation to racism (Brathwaite Citation2018; Kline Citation2015), homophobia and transphobia (Fish and Evans Citation2016). There is a growing body of literature which suggests that nursing staff lack basic knowledge and understanding about LGBTQ people and their holistic healthcare needs, with calls for increased inclusion of LGBTQ issues into nursing curricula (Carabez et al. Citation2015). Research has also suggested that some nurses may make heteronormative and/or cisnormative assumptions about patients, rendering LGBTQ patients and their needs invisible (Stewart and O'Reilly Citation2017). Some nurses may also hold negative attitudes towards LGBTQ people, particularly highly religious nurses (Westwood Citation2022).
In the UK, research has highlighted the under-preparedness of nursing to meet the needs of LGBTQ people, both in general and in certain specialties, notably cancer care (Berner, Webster, and Hughes Citation2021), dementia care (Westwood Citation2016), mental health services (Fish Citation2020), midwifery (McCann et al. Citation2021), stoma care (Chandler Citation2020), and end-of-life care (Curie Citation2016). Studies have suggested that there may be ‘unhealthy attitudes’ (Stonewall Citation2016) towards LGBTQ people in the NHS, involving bullying, harassment and abuse, negative comments, support for conversion ‘therapies’, and a reluctance to challenge colleagues who make disparaging remarks about LGBTQ people (Royal College of Nursing (RCN) Citation2016).
Many older LGBTQ people have experienced prejudice and discrimination in healthcare contexts across their lifespans, some having been subjected to forcible psychiatric ‘cures’ or ‘conversion’ attempts in earlier years (Government Equalities Office Citation2021). Many have also supported older friends and family members at the end of life. These experiences inform present-day concerns about needing formal care in later life. Older LGBTQ people are afraid that they will again experience prejudice and discrimination, while also being less able to defend themselves due to vulnerabilities associated with older age (Westwood Citation2016; Citation2022). While religiosity is known to promote wellbeing among some older LGBTQ people (Bower et al. Citation2021; Foster, Bowland, and Vosler Citation2015; Halkitis et al. Citation2009), many are concerned about receiving care from religious organisations and/or staff who may hold negative religious beliefs about them (Westwood Citation2017).
However, despite this growing body of literature, there is little evidence about actual nursing practice in relation to older LGBTQ people, including care delivered by nurses who hold negative attitudes towards them. This article contributes to remedying this knowledge gap, considering the narratives of a single nurse who recently encountered problematic attitudes towards LGBTQ people on a UK hospital ward for older people.
Methodology
This article reports on a single case study, based on an interview with a newly qualified nurse (NQN) who has recently left the nursing workforce. A case study approach involves intensive study of individuals and/or groups, which can enable thorough study of particular phenomena, and, in terms of nursing, taking an holistic approach to nursing practice (Sandelowski Citation1996). It can afford researchers an in-depth understanding of a particular theme, issue or concern, allowing for a more continuous and less fragmented analysis than that offered by other approaches such as thematic analysis (Heale and Twycross Citation2018). Anti-oppressive case studies provide an opportunity to identify and reflect upon when and where discriminatory and/or oppressive practices and systems require challenging and deconstruction, how this can be most effectively achieved, and associated barriers and facilitators (Raineri and Calcaterra Citation2018). They can be of particular use in workforce development and professional education, for example in Schwartz Rounds, i.e. structured discussions involving both clinical and non-clinical staff aimed at reflecting on the personal and social aspects of working in healthcare (Flanagan, Chadwick, and Goodrich Citation2020).
The data informing this paper were taken from an interview conducted as part of a scoping study which explored what is known about the balancing of religious freedoms, sexual orientation and gender identity rights in older age care spaces. The project was approved by the University of York’s Economics, Law, Management, Politics and Sociology Ethics Committee (ELMPS). It was fully data protection compliant, maintained participant anonymity, confidentiality, and participants were provided with a detailed information sheet prior to giving their informed consent to participate.
The study comprised a small survey of older LGBTQ people and health/social care providers, focus groups with older LGBTQ people, and expert interviews. Survey participants could indicate if they were interested in being invited to participate in an interview. One survey participant who indicated she was willing was Claire (pseudonym), whose survey responses suggested she had first-hand experience of encountering problematic practice towards LGBTQ patients. She was invited to interview. The interview was recorded, transcribed, anonymised, and analysed using content analysis (Krippendorff Citation2018). The data were so original, rich, insightful, and raised such significant themes, they merited more detailed analysis which now forms the basis of this article.
Participant profile
Claire (pseudonym) is a White British woman, aged 41, who qualified as a nurse just over two years ago, but has since left the NHS.
Findings
Context: a toxic working environment
Claire experienced bullying from her first day on the hospital ward for older people. She felt that she was disrespected because she was both newly qualified and new to the ward:
There’s an odd culture in nursing which is often referred to as “eating the young” where there seems to be kind of running through nursing as a thread, a general kind of tendency towards bullying, towards not being supportive of colleagues or newer nurses.
… this was on my first day, on my first shift. [I felt] awful because you feel like, in front of a whole bay of patients who, bless them, didn’t know where to look because they were just embarrassed for you and you can’t really come back at them, because it’s not professional and you don’t want to make it any more awkward for your patients …
… I sort of said, “Can I just ask, have I done something to upset you?” … And [the other nurse said] “No, I just don’t like you.”
And there are good places, I’ve seen them, I’ve worked in them, there are good wards out there, it’s like a lottery, you never know … Funnily enough, they never need staff because they don’t have turnover because people are happy, they’re productive.
… the worst one had been there 30 years, same band, but had a lot of experience, had been passed over for promotion a number of times because of their attitude … And it turned out, when I started to go down the formal process of, you know, saying, “Look, there’s a problem here,” it turned out that there had been hundreds of complaints [about her] … [but she is] still there.
Encounters with homophobia and transphobia among nurses
Claire encountered some problematic attitudes towards LGBTQ people. She gave several examples of casual homophobia among nursing colleagues:
… everybody thinks older people just become asexual, inanimate objects. And it’s like … “Oh, but you know, they couldn’t be gay, they’re 82.”
It’s the snide, side comments … It’s things like, “Oh, well they’re a gay.” “They’re a what?” “They’re a gay and I don’t agree with that, it goes against my beliefs.” … Or, “I don’t like going in there. I don’t like being around them.”
And it’s other things like, oh, well, “Their husband [gay male patient] wants to visit but I don’t want to let them in because it’s just encouraging their lifestyle.” I’m like, “How about you jog on. How about that?”
It’s all things like I was saying, you know, [colleague saying] “I don’t want to go into the room because I don’t trust them,” is one I’ve had a lot. “I don’t feel it’s right. I don’t feel we should be supporting them. I don’t feel they should be on this ward.” “Why?” “Because they’re [referring to a trans woman] not a woman.”
… somebody who is gender fluid who uses they/them pronouns. They [a nurse colleague] failed to get their name right about six times, deadnaming them. And then when I challenged them on it, said, “Well, it’s ridiculous … God created man and woman and that is all there is.”
‘I’ll pray for you’
Some older LGBTQ people are particularly fearful about receiving care from religious providers (Guasp Citation2011; Westwood Citation2016; Westwood Citation2017; Citation2022). Claire described a worrying incident involving a religious nurse:
It was a bank nurse … [a man was in] for a bit of a rehab, get their COPD [Chronic Obstructive Airways Disease] under control before they headed home. And … we were chatting … and it came up just in conversation about [his] husband and we were chatting away … and, you know, he was telling me about his life … And then this bank nurse said, ‘You have a husband.’ And he went, ‘Oh, yes, yes, we’ve been together 20 odd years.’ … And he said, ‘Yes, he doesn’t tend to visit me in hospital because [..] it just always causes bother.’
I said, “Well, if you want [him] to come in and I can just say he’s a friend, that’s fine, we can. I’d rather, obviously we didn’t have to, but if you’re worried, we could just put him down as your next of kin as a friend and then no one needs to know if that concerns you.” And he was like, “Oh, that would be great.”
… And then this nurse just went, “Oh, well, I’ll pray for you.” And I was like, “I’m sorry, what?” To the patient, “I’ll pray for you.” … He looked pretty bemused, I don’t think he’d clicked, like that she didn’t mean in terms of, like the whole situation with getting his husband in safely …
And then I caught her, because she was at the meds trolley and went, “Look, I just want to ask, what did you mean when you said you’d pray for him?” … . I think she was in her early 40’s … And then she went, “Oh, no it was because he’s a gay, he’s going to go to Hell.” … I said, “I understand that you have, you know, deep seated religious beliefs that you believe that is the case, but you can’t express it to patients, that’s not acceptable, because you are basically disapproving of their life and that’s not good.” … Well, she looked at me, I don’t think anyone has ever called her on it before, she sort of looked at me sideways and went, “Well, I’ll pray for you too.”
Claire observed that there was a racialised element to religious objections to LGBTQ people, which can heighten tensions and potential to openly discuss the issues:
… there’s a lot of nurses who are very strongly religious … Christian mostly … and there’s a significant proportion of them who do not support LGBTQ + people. But then there is a minority of those people who let it affect their work.
Claire reflected on the distinction between religious doctrine and individual interpretation:
I think you can be a fantastic carer and strongly religious, there’s nothing saying if you have a strong religious identity you can’t be … It doesn’t matter that if it’s religious or if it’s not religious, any extreme view is dangerous. And I think that’s the key for me, I don’t want to demonise people who have faith, there’s nothing wrong with having faith, it’s when it becomes bigoted that the problem is there.
Impact on care quality
Claire observed that qualified staff are often reluctant to challenge colleagues who are behaving in discriminatory ways:
But it’s hard work, and a lot of people can’t be bothered to put it in and are just like, “Oh, just ignore them.” And I’m like, “Well, no, because that doesn’t achieve anything.” Most of them will, to be perfectly honest, most people will just walk away and just not be bothered. Those guys, they would say it didn’t affect their care.
Most of them it did [affect their care] because you could see it … . It’s the way, if someone comes into a room to care for you, you can tell, straight away from 100 little clues how happy they are to be there … So, even though they may not say anything, or act deliberately in a way that is, you know, exclusionary or prejudiced, you can tell, it’s the million clues.
Claire highlights here the impact for care quality, not in terms of whether but rather how tasks are performed:
Like, I’ve had patients say to me, “ … I’m pretty sure that other nurse doesn’t like me very much.” Even though they’ve never said anything or done anything and they’ve delivered everything, they’ve dotted all the I’s and crossed the T’s of care that needed to be given, but the difference is, they’re not giving care, they’re performing tasks. So, they have helped them to have a wash, they have helped them to get dressed or they have helped them with their medication and they have done everything, you know, appropriately, nothing untoward or wrong has happened, but they have basically ticked a list of tasks, they haven’t actually provided care, that’s the difference. And I think that’s what the patients pick up on.
[He said] “It’s the difference between tasks being done and care being given.” And he said, “You can tell, in here, which nurses do which. And it’s about what you don’t say and do, more than what you do.” And that’s always kind of stuck with me.
Discussion
The literature calls for the need for more evidence on how negative attitudes towards LGBTQ people can mediate practice and impact care quality, particularly among staff with strongly held religious objections to LGBTQ people. Claire’s observations offer insights into how negatives attitudes towards LGBTQ people can sometimes inform practice, and that these can be, but are not always, informed by strongly held religious beliefs. These challenges are beginning to emerge in UK case law. For example, Sarah Kuteh, an evangelical Christian nurse, has recently claimed unfair dismissal after being sacked from her job in a UK hospital run by Dartford & Gravesham NHS Trust (Kuteh v Dartford and Gravesham NHS Trust Citation2019). She interrogated patients about their religious beliefs, asked those who said they did not believe in God to explain why not, told a cancer patient about to undergo major surgery that ‘if he prayed to God he would have a better chance of survival' (Adams Citation2019), gave patients bibles they had not requested, told patients she would pray for them, and asked them to sing psalms with her. She gave hospital managers assurances that she would desist but did not. Mrs Kunteh’s claim failed.
This may be an extreme and unrepresentative case, but it was widely reported in the national press (Adams Citation2019), and serves to fuel the fears of older LGBTQ people. It also highlights the tensions for healthcare, social care and social work practitioners with strongly held religious beliefs, in terms of balancing those beliefs with secular, liberal, professional norms and values. Overt discrimination towards LGBTQ people by healthcare professionals, while it clearly does take place, will likely be rare, because it is explicitly prohibited by law and professional standards. However, it is possible that not all such cases are reported (Jack et al. Citation2021). It is also likely that less obvious, casual, everyday prejudice (such as microaggressions) of the type described in this article, is of greater concern, while also posing challenges for formal regulatory mechanisms (Dean, Victor, and Guidry-Grimes Citation2016).
Nursing can intervene in reducing LGBT health inequalities in a range of ways (Medina-Martínez et al. Citation2021; Traister Citation2020), including by: being sensitive to, and promoting better understandings of, those inequalities; advocating for LGBTQ healthcare rights; modelling LGBTQ-inclusive practice; including LGBTQ health inequalities and LGBTQ-inclusive practice in nurse education curricula; and establishing health equality audit procedures to ensure there is not only anti-discriminatory nursing care but also anti-oppressive nursing care. The silence on explicit commitment to LGBTQ-inclusive practice in the NMC Code (Nursing and Midwifery Council (NMC) Citation2019) is a concern and a statement to that effect would go a long way to set an important tone in the profession about the unacceptableness of intolerance towards LGBTQ people and the importance of anti-oppressive practice.
It is important that nurse education is underpinned by anti-oppressive principles (Brathwaite Citation2018; Traister Citation2020). Good practice in relation to minority groups, including LGBQ people, should be addressed theoretically and practically, including via simulated learning opportunities (McCann and Brown Citation2020). It is essential, too, for students and qualified nurses to be helped to explore their own personal values and how they might impact the quality of their nursing practice (Morris et al. Citation2019). Papadopoulos, Shea, and Taylor (Citation2016) and Papadopoulos (Citation2018) refer to the significance of culturally competent compassion in nursing, which engages with human qualities beyond demonstrating sympathy and empathy, and requires proactive behaviours. Baiocco et al. (Citation2022), in their study of nurses in seven European countries, concluded that there is an urgent need for nurse education to become more LGBT-inclusive, focusing on reducing negative stereotyping and bias; improving LGBTQ knowledge, awareness and understanding; and developing ‘the specific skills and attitudes that could lead to increased quality of care for vulnerable and minority groups’ (Baiocco et al. Citation2022, 33). Increased critical reflection via training, formal guidance, leadership through constructive challenge, and learning around cultural and religious tensions, could help to develop essential skills, knowledge and, most importantly, positive attitudes towards LGBTQ people and their care.
The wider healthcare systems within which nurses practice and their LGBTQ inclusivity also need to be explored, to ensure they provide safe, supportive nursing cultures in which good practice, including anti-oppressive nursing practice, can flourish (Dean, Victor, and Guidry-Grimes Citation2016). This should start at the top, via systems and policies which mandate these behaviours and interventions, cascaded down via implementation strategies and nursing leadership, and encouraged/facilitated at an individual level, supported by healthy nursing cultures where there is zero tolerance for prejudice and discrimination of any kind.
Limitations
While a case study approach offers the opportunity to analyse in-depth experiences, its limitations include that it is not amenable to generalisations, is not indicative of scale, and it is particularly susceptible to researcher bias. The participants in the wider study self-selected and were therefore more likely to have strongly held views about religion and LGBTQ rights in older age care. The narratives analysed in this article were chosen because they gave specific practice examples, which are lacking in the literature. However, they do not give examples of good practice with LGBTQ people, which engagement with a wider sample would very probably have provided.
Conclusion
This paper has confirmed that there can be occasions of prejudiced/discriminatory nursing practice towards LGBTQ people in the UK, suggesting that the fears and concerns of older LGBTQ people are not unfounded. There is a need for more research in this area, to better understand the extent to which attitudes reported in this study are present among nursing staff, ways in which they can be addressed, and the complexities involved in promoting integrated, culturally compassionate and sensitive holistic care. This is not only in relation to nursing, but also other healthcare professions, social care and social work. Until this happens, older LGBTQ people, and LGBTQ people of all ages, cannot be guaranteed that they will experience equitable, LGBTQ-inclusive and safe care.
Ethics approval
This project was granted ethical approval by the University of York’s Economics, Law, Management, Politics and Sociology Ethics Committee (ELMPS).
Acknowledgements
Our sincere thanks to Rhiannon Griffiths for her excellent research assistance, and to the anonymous reviewers for their helpful comments on an earlier draft of this article.
Disclosure statement
No potential conflict of interest was reported by the author(s).
Additional information
Funding
Notes on contributors
Sue Westwood
Dr Sue Westwood is Senior Lecturer at York Law School, University of York, UK. She has previously been a research fellow/research associate at several universities, including the University of Oxford, UK, and the University of Surrey, UK, where she was a member of the Centre for Research on Ageing and Gender (CRAG). Sue was previously a Visiting Scholar at the Vulnerability and the Human Condition Initiative, Emory University School of Law, Atlanta, US. She has also taught law at Keele University, UK and Coventry University, UK, and the Chinese University of Hong Kong. Sue's research interests relate to LGBTQ ageing and equality in regulatory contexts. She has published extensively in the field, including in relation to health and social care provision, and has recently co-authored the following good practice guide: Westwood, S. and Price, E. (2023) LGBTQ People and Dementia: A good practice guide. Good Practice Guides in Dementia Care series, University of Bradford and Jessica Kingsley.
Jemma James
Jemma James is a qualified nurse and a PhD candidate in the Department of Nursing Midwifery and Health, Northumbria University, UK. Her professional interests include older peoples' nursing, care home nursing, integrated care, community and social care. Jemma has a background in project management and service design and delivery. She is passionate about research, particularly its implementation, and is a keen campaigner on nursing & older peoples' issues, from grassroots to government level.
Trish Hafford-Letchfield
Professor Trish Hafford-Letchfield is a qualified nurse and social worker with 18 years practice experience in social work. She is Head of the School of Social Work and Social Policy at the University of Strathclyde, UK. Prior to joining Strathclyde, Trish was Professor of Social Care at Middlesex University, London, UK. Trish has a strong interest in the rights of LGBT+ communities and is a founder member of the international LGBTQI social work network. She has over 100 publications including 19 key books covering a range of topics on leadership, management, organisational development, feminism, sexual and gender identities, values and ethics, gerontology, social work supervision. Trish has been involved in a wide range of funded research and knowledge exchange. She has recently co-authored a learning framework, produced for Skills for Care, the strategic workforce development and planning body for adult social care in England: Hafford-Letchfield, T., & Roberts, L. (2023). (LGBTQ+) Care in Later Life: A Learning Framework for Knowledge, Skills and Values for Working Affirmatively with LGBTQ+ People in Later Life. https://strathprints.strath.ac.uk/84379/
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