A Qualitative Description of Direct Care Workers of Lesbian,Gay,Bisexual,Transgender Older Adults

Abstract

Purpose: The aim of the study was to examine direct care worker (DCW) perceptions of lesbian, gay, bisexual, transgender (LGBT) older adults living in long-term care, assisted living, and home health settings. DCWs provide the closest interaction with LGBT older adults in these settings. The perceptions DCWs have toward LGBT older adults is important because the quality of care can be influenced by negative attitudes. Methodology: Qualitative description was used to synthesize what is known about DCWs’ perceptions toward LGBT older adults. Results: The overarching theme, “Care is Different, but Not my Care,” was supported by the categories Cues of Stereotyping, Cues of Prejudice, and DCWs’ Social System and Reported Care. Application: Specific implications for practice (i.e., training, recruitment, retention strategies) and policy (i.e., mandated staffing ratios, pay) are explicated to guide future interventions to ensure equitable, quality care in health care.

Keywords

lesbian,gay,bisexual and transgender sexual and gender minorities older adults long-term care perceptions

What this paper adds

• Direct care workers (DCW) social system and reported care influence their perspective toward LGBT older adults.

• DCWs are targets of stereotyping based on their race, ethnicity, or sexual orientation and gender identity.

• Care of LGBT older adults is reported as different from care of non-LGBT older adults.

Applications of study findings

• DCWs request and will require more training to care for higher acuity and more diverse patients; and require healthy work environments.

• Development of innovative recruitment and retention strategies like career training programs and worker-owned cooperative home care associations.

• Mandating safe staffing ratios with institutions being held accountable to these mandates.

The number of lesbian, gay, bisexual and transgender (LGBT), older adults (≥50) in the United States (U.S.) will increase to ≥ 20 million (Fredriksen-Goldsen & Kim, 2017) by the year 2060. Therefore, the LGBT older adult population living in long-term care (LTC), assisted living facilities and using home health services will increase. Direct care workers (DCW) perform care that include bathing, toileting, dressing, feeding; with additional training—dispense medications, wound care, and device management and include certified nursing assistants (CNA), personal care aides, home health aides (United States Bureau of Labor Statistics [USBLS], 2019). The perceptions that DCWs have toward LGBT older adults can influence care provided (Blair et al., 2013) and potentially impact the health and health outcomes of LGBT older adults. This qualitative study describes DCWs’ perceptions of LGBT older adults in LTC, assisted living, and home health settings.

Background

DCW make up 4.7 million members of the health care workforce (USBLS, 2019). CNAs alone make up for 38% of the LTC workforce, 11% in assisted living facilities, and another 5% in home health settings (USBLS, 2019). Thirty-seven percent of nursing assistants are Black or African American, 12% are Hispanic or Latino, over half have had no formal education outside of high school; and 21% were born outside of the U.S., and are primarily female (PHI, 2019). The median annual income of nursing assistants working in LTC is $22,000 (USBLS, 2019). The annual salary remains at the poverty level for a family of three (Assistant Secretary for Planning and Evaluation, 2019). Because of the low-income, estimates show 13% live below the poverty level, with 44% classified as low-income (PHI, 2019). In addition to the low-income, poor-quality work environments result in low retention of nursing assistants (PHI, 2019).

There are other concerns within the DCW workforce—most states’ training programs consist of a minimum of 75 hours of training with 16 hours of supervised clinical time as federally required (PHI, 2019). With the push to move services to the home and community settings, patient acuity levels are higher and DCWs may not be adequately trained to confidently care for patients. Training in care of special populations such as LGBT individuals, is not mandatory in all states, but is a need identified by DCWs, nurses, and other health care workers (Furlotte et al., 2016; Flatt et al., 2022). The perceptions, attitudes, and lack of training of DCWs toward LGBT older adults impact the care provided and perpetuates health disparities and health outcomes in this population (Blair et al., 2013).

LGBT older adults have more health disparities and poorer health outcomes compared to non-LGBT people (Fredriksen-Goldsen & Kim, 2017). Many LGBT older adults have witnessed the evolution of the social and legal context of being LGBT (i.e., McCarthy trials, Stonewall riots, gay liberation, and civil rights movement). Many LGBT older adults have “chosen families” because of lack of acceptance by their biological family and may not have the support system needed. Furlotte et al. (2016) discusses many aging LGBT older adults have concerns about going back “into the closet” when considering LTC, assisted living, or home health services. There have been reports of LGBT older adults encountering covert methods of mistreatment, harassment, and refusal of care when using long-term services and supports (LTSS) (Furlotte et al., 2016).

Methods

The use of qualitative design in this study allowed the participants to describe their perspective of care toward LGBT older adults as they know it. Implicit Social Cognition perspective and experts in implicit bias and qualitative research provided guidance to the first author to the development of the research study and the semi-structured interview questions (Figure 1).

Figure 1.

Direct Care Worker Interview Guide.

The authors are white, cisgender females. The primary author has experience in caring for LGBT older adults in health care as well as her own personal experiences that contribute to her program of research. The second author has experience conducting research on health workers in health care work environments and utilizing non-nursing frameworks in those studies.

Recruitment Procedures

A purposive sample of DCWs were recruited from online social media groups via Facebook, Twitter, using an institutional review board (IRB) approved social media flyer and video recording. Inclusion criteria were: DCWs currently working in LTC, assisted living facility or home health agency in the U.S., employed as a CNA, personal care aide or home health aide, age ≥18, English speaking, and had computer or smart phone access.

Sample and Setting

The sample consisted of 11 DCWs, saturation, when no new information was obtained (Malterud et al., 2016), was becoming evident by interviews 8 and 9, and reached at 10 participants. The 11^th participant was interviewed to ensure there was no new information.

Data Collection

The recruitment survey was used for the collection of participant demographic information, that is, age, race/ethnicity, how long working as a DCW, and sexual orientation, and gender identity (SOGI). The study inclusion criteria, demographic, and contact information were stored in REDCap. Each DCW participated in one 45-to-60-minute semi-structured Zoom interview conducted by the first author following the guide in Figure 1. Examples of questions included: “Tell me about your past experience with individuals in same sex relationships or individuals who identify as a gender different than their birth sex” and “Think back to a time when you observed someone caring for an older adult who it was known or thought to be in a male-to-male relationship or female-to-female relationship. Tell me about what you observed.”

Prior to the interview commencing, the PI explained the study, confirmed the participant was interested in participating, answered any questions regarding the interview process, reviewed the consent form, and obtained verbal consent and permission to audio and video record the interview. Participants were asked to be on camera during the interview. Participants who declined being on camera, but still wanted to participate were allowed to proceed with a voice recorded interview (N = 4). Participants interviewed received a $25-dollar electronic gift card. The Zoom transcript functionality was used to transcribe each interview and was reviewed for accuracy promptly after each interview.

Data Analysis

Interview transcripts were analyzed using content analysis (Noble & Smith, 2014). Transcripts were deductively and inductively coded simultaneously (Fereday, 2006).

Transcripts were reviewed by the PI several times until categories and themes emerged and grouped. The first two transcripts were coded separately by the PI and a qualitative methods expert. After consensus on coding, emerging themes, and categories were reached, the author and expert compared every other transcript throughout the data collection and data analysis phase. A priori categories were cues of stereotyping and cues of prejudice; inductive codes are discussed further below. Consensus of 100% of codes, themes, subcategories, categories was achieved.

Trustworthiness

To ensure validity of the qualitative study, trustworthiness criteria were achieved through credibility (peer debriefing; member checks), transferability (thick description; clarifying meanings), dependability (codebook, field, and data analysis notes), and confirmability (audit trail) (Lincoln, 1985).

Results

Sample Characteristics

Sample characteristics are provided in Table 1. Most of the sample were non-Hispanic white (82%), straight (91%), and female (64%). Ages ranged from 30 to 60 or older. Years of experience as a DCW ranged from less than 1 year to over 30.

Table 1.

Self-Reported Sample Characteristics.

n = 11
Gender identity, n (%)
Female	7 (64)
Male	4 (36)
Transgender female	0 (0)
Transgender male	0 (0)
Gender Variant/Non-conforming	0 (0)
Not listed	0 (0)
Prefer not to answer	0 (0)
Sexual orientation, n (%) (select all that apply)
Asexual	2 (18%)
Bisexual	1 (9%)
Gay	1 (9%)
Lesbian	1 (9%)
Straight (heterosexual)	10 (91%)
Questioning or unsure	0 (0)
Queer	0 (0)
Prefer not to answer	0 (0)
Race, n (%)
Black or African American	2 (18)
American Indian or Alaska Native	0 (0)
Asian	0 (0)
Native Hawaiian or Pacific Islander	0 (0)
White	9 (82)
Other	0 (0)
Ethnicity, n (%)
Not Hispanic or Latino	9 (82)
Hispanic or Latino	2 (18)
Age, n (%)
18–29	0 (0)
30–39	3 (27)
40–49	2 (18)
50–59	2 (18)
60 or older	4 (37)
Years of experience
Less than 1 year	1 (9)
1–5 years	1 (9)
6–10 years	2 (18)
11–20 years	3 (27)
21–30 years	1 (9)
Over 30 years	3 (27)

Findings

The overarching theme was “Care is Different, but Not my Care.” DCWs reported that care of LGBT older adults in LTC, assisted living, or home health settings was different, but reported that only the care other DCWs provided to LGBT older adults was different. The overarching theme was supported by three categories: (1) Cues of DCWs’ Stereotyping, (2) Cues of DCWs’ Prejudice, (3) and the largest category, DCWs’ social system and reported care (Table 2).

Table 2.

Categories, Subcategories, and Themes of Results.

Cues of DCWs’ Stereotyping	Defined as the DCW’s beliefs about the LGBT older adult’s attributes, characteristics, patterns of behavior; beliefs can be negative or positive
Negative belief	Undesirable belief towards LGBT older adults
Positive belief	Desirable belief towards LGBT older adults
DCW as targets of stereotyping	DCW describe feeling they are being categorized by the client (LGBT or heterosexual) because of their race, ethnicity, sexual orientation, and/or gender identity
Cues of DCWs’ prejudice	DCW’s dislike toward LGBT older adults or the subtle indication of dislike toward LGBT older adults
Dislikes	When the participant openly states they have a dislike or bias towards LGBT older adults
Indications of Dislikes	Subtle indication of previous dislike toward LGBT older adults
DCWs’ social system & care practices	Characteristics of the DCW’s work environment and the perspectives, attitudes, and reported care towards LGBT older adults and diverse populations in the LTC, assisted living and/or home health setting
Professional & personal experiences	DCW’s descriptions of the different groups of older adults they care for and the impact of past or present LGBT acquaintances in their life
Diversity	The different ethnicities, races, gender identities, and sexual orientations of the older adult population cared for as described by the DCWs
Influences	The DCWs’ descriptions of past and present LGBT influences that impact the DCW’s perspective towards LGBT older adults
Work environment	The DCW’s narrative on types of diversity training, their likes and dislikes of their work environment and the value perceived others have for their work in the health care setting
Training/Likes/Dislikes	The description of training in diverse populations, institutional assumptions, likes and dislikes related to the DCW’s job.
Seeking validation	The DCW validating their value, knowledge, and need in the work environment and with the researcher who was conducting the interview
Semantics & Ethics	The DCW’s use of language, descriptions of LGBTs and ethical considerations when describing care of LGBT older adults in LTC, assisted living and home health settings
Heteronormativity	Assumptions that all older adults are typically heterosexual and have heterosexual and binary characteristics
Stepping over the line “Ethics”	The DCW’s ethical considerations when discussing asking LGBT older adults sensitive questions
Stigmatizing terminology	The potentially offensive vocabulary used by the DCW in their narrative to describe an older adult or LGBT individual
Othering	The use of distancing language that creates an in-group and out-group division and ignores one’s individual identity
“Live and let live”	The DCWs’ ambivalence about LGBT older adults

Note. DCW = direct care worker; LGBT = lesbian, gay, bisexual, transgender.

Cues of DCWs’ Stereotyping

The first category, Cues of DCWs’ stereotyping, referred to the DCWs’ beliefs about LGBT older adults’ attributes, characteristics, patterns of behavior. Participants had various beliefs about older adults, LGBT individuals, and the LGBT older adult group. Subcategories included Negative Beliefs, Positive Beliefs, and DCW as Targets of Stereotyping.

Negative Beliefs

DCWs primarily had negative beliefs toward LGBT older adults. Negative beliefs were generalizations characterizing LGBT older adults revealing beliefs about both the age group and the sexual orientation that made the group unlikeable. For example, in regard to the older adult population Participant #2 stated, “… some are standoffish or there [sic] are other touchers…you know when you get in your 60s and 70s … something kicks in the brain and you just become extra inappropriate.” Participant #10 stated, “being transgender is a choice and it does not affect others unless they sexually proposition a heterosexual.”

Positive Beliefs

Several DCW participants discussed their belief that older adults in same sex relationships were more organized, clean, and orderly. Participant #2 mentioned that lesbian women’s homes are cleaner because they “have nothing to prove.” Participant #5 stated regarding same sex relationships, “…maybe a little bit more cleanliness, maybe a little bit more organized…” Other positive beliefs that were mentioned were that gay males “stand up for themselves, but I can’t say that for every LGBT person” (#3) and “They’re very, most of them, are very unapologetic for, you know, they like what they like. …that takes a strong person, even if it’s hard for them, you know, they lose family members” (#7).

DCW as Targets of Stereotyping

Defined as DCWs feeling that they were being categorized by the client (LGBT or non-LGBT) because of their race, ethnicity, or SOGI. When participants were asked about their clients being treated differently because of their race, ethnicity, and/or SOGI, the DCW would answer the question as it related to them. Their answers related more to race or sex. DCWs reported different treatment in the care setting because they were African American or male. Participant #9 recalled an encounter with a client, “I’m African American I can feel the way they talk to me…but I just tell them like if you don’t want me here, just let me know. ‘I don’t like black people’ [client says to DCW] …I say that’s fine…I’ve been through a lot.” Participant #2 reported that clients perceived him as gay because “I’m a male working at the bottom tier nursing… you know your sexual orientation must be skewed. I’m like, no, that’s 1950’s logic.”

Cues of DCWs’ Prejudice

The second category, Cues of DCWs’ prejudice, referred to DCWs’ dislike of LGBT older adults or the more subtle indication of dislike toward LGBT older adults.

Dislikes

All, but one participant stated that there was nothing that they disliked about LGBT older adults. Participant #2 disliked gay or transgendered older adults because they were “nitpicky.”

Indications of Dislikes

There was a subtle indication of previous dislike toward LGBT older adults when Participant #9 said that she “hated them [when she was] growing up,” but that her feelings evolved, and she felt more accepting of this group. Participant #10 indicated dislike when stating, “I guess that I probably somewhere down deep have a bias.”

DCWs’ Social System and Reported Care

The third category, DCWs’ social system and reported care, referred to characteristics of the DCW’s work environment and the perspectives, attitudes, and reported care toward LGBT older adults and diverse populations in the LTC, assisted living or home health settings. This category emerged as an important category that described the context of the work environment within which the other two categories were situated.

Professional and Personal Experiences

Diversity

Participants described various populations of older adults they cared for in their current place of employment. “Diverse” older adult populations were characterized by economic status, occupation, gender, age, intellectual level, whether they abused drugs, religions, cultures, and languages. When participants were asked to describe diversity training received, many participants did not include LGBT older adult training. Participant 8 stated, “…one video has addressed when you’re talking to someone of different culture and also, I know they addressed the language barrier.”

When directly asked about care for LGBT older adults, several participants automatically began to discuss specific sexual behaviors. Participant 3: “We had an adult male masturbating, and you got the staff telling him to stop…and I am like ‘no you can’t do that.’” Participant 4 described an older adult visiting her partner in the nursing home: “… they hugged each other goodbye, but it wasn’t like a good slap-smack on the mouth with a kiss or anything…they were tasteful…” Regarding care of diverse populations in the LTC setting, Participant 4 stated, “…with the black community, they’re so appreciative… it’s almost like they go out of their way because they don’t want conflict…I don’t know if they’ve just experienced sometime in their lifetime of mistreatment of [sic] the white community.”

Influences

DCWs shared past and present LGBT influences that impacted the DCWs’ perspectives toward the LGBT older adult population. Influences included: friendships with transgender individuals, participants’ family upbringing, and gay and lesbian family members and children. Participant 10 described a positive influence on her: “…it was the beginning of high school that he had kind of decided this is the way he wanted to start going… it’s not something that has affected my relationship with this person.” Participant 6 described her family upbringing, “I was raised to be open minded and to learn…everybody’s different.”

Work Environment

Training/Likes/Dislikes

All participants stated that overall, they liked caring for their patients, liked watching them “succeed” (Participant #3), and that being able to help others was “satisfying” (#8). When describing what they did not like about their role as a DCW, topics such as low salary, having no or little health benefits, no room for advancement, working nights, clients dying, and overall body strain and feelings of burnout especially during COVID-19.

Participants divulged that training in diverse populations was not provided in their current facility. “I’ve had that in school and other places, but not there…I guess they just assumed I knew it” (#3). Participants felt that training in LGBT older adult care was important and should be provided. Participant 4 reported that formal training in LGBT older adult care was “… a must…because it’s getting to be too common” and that institutions needed to “back up what they say” regarding the intolerance of mistreatment of LGBT older adults. The participant suggested that institutions did not hold true to the standard set regarding mistreatment of LGBT older adults because the facilities were short staffed and “sweep it under the carpet sometimes.”

Seeking Validation

There was a noticeable pattern of DCWs seeking validation from the researcher when describing their years of experience as a DCW or educational pursuits. Seeking validation seemed to occur when the DCW had been challenged by another employee who had more years of experience. Participant 3 reported that her knowledge was questioned by a co-worker with 35 years of experience, “I know I have not been here 35 years, but I know my job.” Being praised and validated in their positions was important. Participant 4 noted this while training DCWs in her former role: “There’s not enough praise for nurse aides when training.” Participant 5 described the importance of showing appreciation to employees by suggesting having “little posters up of the employee of the month or other things.”

Semantics and Ethics

Heteronormativity

DCW participants used heteronormative language during the interview process. Participants generally stated that caring for LGBT older adults did not impact their job performance; all older adults were treated “equal”; and that care provided to LGBT older adults was the same compared non-LGBT older adults. Participant 7 stated that same sex couples were not different than “regular heterosexual couples.” Participant 9 indicated that LGBT partners acted like non-LGBT married couples when describing an LGBT older adult relationship: “This is my partner, my life partner, they will sit on the bed with them, they will kiss. I mean, you know, they would act just like a husband and wife.”

Othering

Throughout the interview process, participants used othering or distancing language when answering interview questions, using distancing language creates an in-group and out-group division and ignores one’s individual identity. Distancing language was used when discussing race or SOGI of the older adult. Examples of othering language were the use of “the” in front of “gays” and “lesbians” (i.e., the gays, the lesbians) by Participant 1 and “blacks” and “whites” (i.e., the blacks, the whites) by Participant 4. Participant 1 also stated that “gay and lesbians are acceptable” and they “blend in.” Othering was exemplified by Participant 9’s use of condescending and demeaning language: “Just thought it was cute. That’s who they love. You know what I’m saying that’s so cute. Like, this is my baby.”

“Live and Let Live.”

When describing their feelings about LGBT older adults, participants expressed ambivalence. Several participants denied prejudice toward older adults because of their SOGI. Most participants reported that although they might not agree with the LGBT older adult lifestyle, they did not let their belief system influence their behavior in care. “People are just the way they are and that has nothing to do with what I’m doing” (#5). Additionally, participants were ambivalent in their answers; Participant 7 stated, “I’m kinda neutral. I don’t get it. I mean, it’s not something I’m against either.” She explained that she did not know enough about gays or lesbians to form an opinion. Some participants were open to expressing they were trying to feel this way: “I noticed I tend to get, I’m better at it now, but I would usually think when some man was like super, super nice and proper that you know maybe that meant he was gay” (#7). Participants who had a religious background and knew it was “wrong” to judge or hate people reported “loving everyone whether you agree with their lifestyle or not” (#8).

Stigmatizing Terminology

Participants casually spoke potentially offensive or incorrect terminology when describing an older adult or LGBT individual. For example, when describing LGBT older adults, Participant 9 stated, “I started in mental health with retardation” when describing her past health care experience. Participants 2 and 6 used potentially offensive, incorrect, and potentially stigmatizing terminology to describe the older adult as “grandpa/grandma” and a trans individual as a “flaming whatever.”

Stepping over the Line “Ethics.”

DCWs felt it unethical to ask the patient what their SOGI was even if it would be benefit care of the older adult. Participants described asking this information as “inappropriate” (# 2), “not ethical and private” (# 1), and “it’s their business” (# 3, # 4). Participant 7 said it would depend on the “vibe” of their relationship with the older adult if they felt comfortable asking about SOGI: “I don’t like to interfere. If I feel like they’re a standoffish kind of person … you know you can read off of them whether they want you to ask or, you know, if they didn’t want you to know anything about that.” Participant 4 stated, “I would feel uncomfortable asking.”

Reported Care

Through the DCW Lens: Described Client’s Perspectives

DCWs provided perspectives on how they thought non-LGBT older adults would feel about LGBT older adults in the care facility. Overall, DCWs described non-LGBT older adults as “not tolerant” (#2), having a “hard time” (#4) accepting LGBT older adults, and “pretty [much] against that belief” (# 10) when discussing acceptance of LGBT older adults by non-LGBT older adults. Participant 8 stated that the LGBT older adult would not be socially accepted by the non-LGBT older adults in the care facility: “They would probably be ignored by the fellow residents.” Participant 4 heard non-LGBT older adults say snide comments (“Like them queers”) under their breath regarding an LGBT older adult couple that lived in the LTC facility. In Participant 6’s perspective, it was the non-LGBT older adults who treat the LGBT older adults differently, not the DCWs.

Participants also discussed other various client perspectives regarding race, the SOGI of the DCW, and the religious views of the older adult. Participant 4 discussed her experience with an older adult when there was another non-Latina DCW who was in a relationship with an African American. In Participant 4’s perspective, older adults were not accepting of interracial couples, concluding this by the comment told to her by a non-Latina older adult “…did you know, Sally [pseudonym] that takes care of me on third, she is shacking up with a Blackie.” Later during the interview, Participant 4 discussed the fact that the non-LGBT non-Latino residents were “getting younger and more accepting of the gay and African American community.” It was perceived that care provided by an LGBT DCW to a non-LGBT older adult would be looked down upon by the non-LGBT older adult. Participant 6 mentioned that non-LGBT older adults did not like to be cared for by a DCW who was openly gay because that was “wrong, blasphemy, and against God.”

Through the DCW Lens: LGBT Older Adult Described and Observed Care

The care witnessed by DCWs toward LGBT older adults overall was described as “different” compared to care toward non-LGBT older adults. Other differences in care were based on older adults’ race/ethnicity, regions of the country (Northern vs Southern), and SOGI of the DCW themselves. Participants specifically stated that care toward the older adult was different based on the SOGI of the older adult. Participant 9 said that DCWs would trade assignments if they knew the older adult was LGBT, “I’m not going in that room, I’m not working with them.” Additionally, Participant 9 had previously observed that nurses do not follow confidentiality and openly discuss patients’ SOGI without regard to the privacy of the LGBT older adult. This participant also described a situation in which the LGBT older adult confided in her that another DCW had asked the LGBT older adult’s sexual orientation; after the LGBT older adult told this DCW they were gay the LGBT older adult stated to the participant, that the DCW “had an attitude or acts different or she don’t want to wait on me if I ring the bell…they don’t come.”

Participant 10 also mentioned that DCWs would trade assignments if they did not like the SOGI of the older adult and stated, “negative attitudes affect care.” Participant 1 admitted that the care they would give to an older adult would be different if they knew their SOGI. Therefore, the facility where this participant was employed did not disclose or discuss the gender identity and/or sexual orientation of the older adult if it were known. Participant 8 specifically stated, “I almost think they [LGBT older adults] get better care, just because they are a novelty.”

While participants acknowledged that care was different toward LGBT older adults in LTC, assisted living, and home health settings, participants did not admit that the care they provided was different. Participants would describe care by other DCWs in the facility as different and not consider their own care when asked the question. Participant 9 specifically stated when asked if care was different, “here you have people that have stigmas they never got over it. So yeah, they treat them different you know they don’t want to give them the attention they need.”

Participant 1 felt that care from a gay DCW toward another gay older adult would be “preferential” and care from a gay DCW toward a non-LGBT resident would be “casual.” Participant 1 explained that the gay DCW would give preferential treatment to the gay older adult versus a non-LGBT older adult because the gay DCW and gay older adult had a commonality. The non-LGBT older adult would receive standard care, nothing above and beyond.

Discussion

Previous research on perceptions of LGBT older adults by DCWs in these settings has focused on general staff, CNAs, social workers, nurses, nurse managers, psychologists, and psychiatrists (Bjarnadottir et al., 2019). Sampling only DCWs provides richness to what is already known about the perceptions of health care workers who work closely with older adults in these settings.

Direct care staff reported that they would not treat lesbian, gay, or bisexual people differently in residential care settings but would not be accepting of their own family members as lesbian, gay, or bisexual (Neville et al., 2015). Willis et al. (2017) interviewed care staff and managers in Wales about providing inclusive care to lesbian, gay, bisexual adults in residential and LTC facilities. Care staff verbalized that they were not aware of any lesbian, gay, or bisexual older adults living in the facility, but if there were they would be accepted. The assumption that all residents in a facility identify as non-LGBT is heteronormative.

From the LGBT older adult perspective, Butler (2017), describes lesbian participants recalling the difficulty of establishing and maintaining home health care workers. Reasons for not maintaining in home care were related to health care workers finding lesbian related material (website or magazine) in the home, religious views, and lack of eye contact and connection.

In several previous studies the care provided to LGBT older adults was different compared to care provided to their non-LGBT counterparts (Fredriksen-Goldsen & Kim, 2017). As in previous studies DCWs had varying views about caring for LGBT older adults—by not treating them the “same” as other older adults would be viewed as favoritism (Donaldson & Vacha-Haase, 2016).

In the home care setting, lesbian patients experienced many of the same common complaints of home care services (i.e., lazy, incompetence, dishonesty) (Butler, 2017). The care experience was not improved with a health care worker that identified as lesbian caring for a lesbian patient (Butler, 2017).

Othering or distancing and stigmatizing terminology was used when DCWs described their experiences with LGBT older adults. Psychologically the use of distancing language has been used as a way for individuals to regulate negative emotions by “distancing” themselves from situations or people (Nook et al., 2017). Using terms like “the gays” and “the lesbians” facilitate the ability for DCWs to avoid the cognitive and affective outcomes of using singular and plural pronouns (i.e., I, we, our, they, them) when speaking about LGBT older adults. Health care professionals have used stigmatizing language toward patients with mental illness associating mental illness with the term “nuts” (Riffel & Chen, 2020). Stigmatizing language used in patient records was found to be associated with more negative attitudes towards the patient and less aggressive care by medical students and residents (Goddu et al., 2018). Previous studies documented that nurses were not confident in using the appropriate terminology when describing pronouns and descriptors for LGBT individuals (Bjarnadottir et al., 2019). The use of distancing and stigmatizing language by DCWs can be a way to hide their negative attitudes toward this group of older adults or reduce DCW stress in a stressful work environment, or results from their lack of knowledge when using appropriate terminology to describe LGBT older adults.

DCWs’ experiences of stereotyping when caring for the older adult population were expressed particularly by African American participants when caring for non-African American patients. Therefore, the DCW would refrain from caring for the older adult. The DCW wanted the older adult to feel comfortable with their care and would switch assignments. The DCW workplace can be inundated with workplace hazards, including psychosocial hazards. DCW experience racism, negative interactions, and verbal violence by other health care workers and the patients they care for (Walton & Rogers, 2017). DCW whose work environments are hostile, disrespectful, and lack control have shown less job satisfaction and more job strain.

DCWs’ seeking validation of their knowledge and expertise in their current role was referred to in the literature but in a study focused on CNAs. They experienced social-based discrimination with the role reportedly compared to indentured servitude, with CNAs working in poor conditions without resources, autonomy, and with power differentials (Travers et al., 2020). CNAs who felt validated in their job position felt compelled to do a better job and had higher morale and greater job satisfaction (Travers et al., 2020).

Practice and Policy Implications

DCW play a vital role in the LTSS workforce. With the push away from institutional care to home health and community settings, the workforce needs for DCW will increase by 1.2 million (Friedman et al., 2021). A decline in LTC workforce and an increase in home health care workforce has already been seen (Friedman et al., 2021). With the proposed LTC reform to increase the number of LTC workforce members coupled with the projected increase of home health care workers needed to transition LTSS to home and community, it is important to focus on training, recruitment, and retention of DCW working in LTSS settings.

DCWs provide most of the care provided in LTC, assisted living, and home health settings. It is estimated that DCWs provide 8 out of 10 hours of care per day (PHI, 2019). CNAs have a limited amount of training. Other types of DCWs training programs are mandated by states or require little to no training. With the move to more community based and home services, DCWs will be caring for higher acuity patients. Therefore, DCW require expansion of training and knowledge compared to previous generations of DCWs. This should include training on caring for diverse populations, like LGBT older adults, which may improve DCW confidence and the overall care of LGBT older adults.

In addition, strategies to retain DCWs to work in LTC, assisted living, and home health positions need to be addressed. DCWs in this study mentioned that the aspects of their job they did not like were the low salary, little to no health benefits, no room for advancement, and feelings of burnout. The new administration’s call for LTC reform is proposed to reduce high rates of turnover and develop strategies to maintain the appropriate number of staff. Strategies to recruit and retain DCWs in these settings can include salary reviews, proper patient ratios, health care benefits, opportunities for advancement, creating healthy work environments (Lai et al., 2014), career training programs, and worker-owned cooperative home care associations centers. These opportunities advance DCWs careers and work toward breaking down structural racism and sexism (Hostetter & Klien, 2021).

Strengths and Limitations

The strength of the study is that it included a wide range of participants from various age groups, years of experience, and parts of the U.S. It can be difficult to adequately describe the perspectives toward LGBT older adults without a diverse sample of DCWs. The majority of DCWs are African American females and this study included a majority of white, female, straight participants. A variety of participants can provide more transferability to the results to other groups and uncover themes not described in this study. Further, a more diverse sample of participants may have addressed other topics, like the transgender older adult population in care. Participants were directly asked about transgender older adults, but from the researcher’s perspective, they did not seem to know what to say. As mentioned, the participants knew the study was about the LGBT older adult population from the recruitment materials; therefore, they may have had neutral or positive views toward LGBT populations overall. There may have been some response bias in the responses of the participants, although the PI provided a safe and welcoming space, participants may have felt the need to speak to what is socially acceptable.

Conclusion

DCW in LTC, assisted living, and home health settings are caring for the growing population of LGBT older adults. This study offers the overarching theme, “LGBT Care is Different, but Not My Care,” which may indicate underlying implicit bias. Further this study also exposes many DCW workforce challenges that require swift attention. With the increasing need of DCWs in the home and community settings, with higher acuity patients, policymakers, researchers, and agencies must address training, recruitment, retention, and workplace environments to develop a robust DCW workforce that promotes longevity.

Supplemental Material

Supplemental material - A Qualitative Description of Direct Care Workers of Lesbian, Gay, Bisexual, Transgender Older Adults

Supplemental material for A Qualitative Description of Direct Care Workers of Lesbian, Gay, Bisexual, Transgender Older Adults by Jennifer T. May, and Jessica G. Rainbow in Journal of Applied Gerontology

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Authors’ Note

This project was approved by the University of Arizona’s institutional review board (IRB) with protocol number 2006747386A001.

ORCID iD

Jennifer T. May

Supplemental Material

Supplemental material for this article is available online.

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