Archives of Nursing Practice and Care Care of Older Residents: One Man among Many Women

Background: Men and women are differently bodily, as well as have distinctive ways of thinking; consequently, their health care needs are not always the same. For some older adults who enter long-term care facilities, the impact of gender upon their care may not be recognized by staff. Research questions: Two questions guided this project: (1) what is known about gender specific differences that may influence resident care in long-term care facilities? And (2) what recommendations might be made specific to residents’ care in long-term care facilities based upon identified gender differences? Method: A literature review, an account of what has been published on the topic of gender by accredited scholars and researchers, was conducted. Attention was paid to the context of located research findings and their applicability to the population of interest. Findings: Gender appears to be identified as an ‘add on’ aspect of care, rather than an integral component. This may be due to limited understanding by staff of gender specific needs within long term care facilities. Implications for practice: Staff, of all levels, must reflect upon their understanding of gender and how it may influence the care that they provide.

in Canada serving 149,488 residents [12]. While exact numbers of females versus males are unknown, it is documented that one-third (32%) of women age 85 and older lived in such settings compared with one-fifth (21%) of men in this same age group [13]. This paper is a beginning attempt to explore the gendered nature of care for older residents living in long-term care facilities. We have organized it into three sections. In the first, we identify the method which we followed in this review of the literature. In the second section, the findings are examined. The third section discusses the implications of these findings for long-term care practices.

Method
Developing a search strategy requires a structured approach. As Gillespie and Gillespie [14], wrote "Start by framing a simple question...this can be refined to specify all the concepts of interest to the …condition" (p. 139). The question will influence the selection of the search terms.

Selection of guiding questions for the literature review
The research team facilitated the development of the following questions to guide the subsequent literature search: 1. What is known about gender specific differences that may influence resident care in long-term care facilities? 2. What recommendations might be made specific to residents' care in long-term care facilities based upon identified gender differences?
While question 1 drove the literature search, the remaining question is answered in the discussion of the findings. To obtain

Case Report
Mr. Peter Nice, an 87 year old male, sits in his wheelchair by the window. He has just finished eating his breakfast with help from one of the aides. He struggled a bit trying to hear her. Peter never married and lived alone all his life with some support from his niece. Last year, his niece and her family moved across the country and can no longer take an active role in her uncle's care. He was admitted to long-term care from the local hospital when the attending physician decided that adequate care could not be provided to Peter at home. Most of the residents on his assigned unit are female as are the majority of staff in the facility.
Gender is a socially constructed concept that defines what it means to be male (such as Mr. Nice), or female in a given society; it describes expected roles and behaviours at various stages of the life course. In the past, gender differences were not so clearly acknowledged in research. Now, gender issues have surfaced significantly in the research. This includes studies on quality of life [1], disability [2,3], walking and activity patterns [4][5][6], cardiac function [7], and emotional health [8][9][10][11]. However, these studies have been primarily conducted within the context of community, and in which gender is usually an identified variable. The implications of how the findings might apply to care practices within long-term care facilities has not been well studied. In other words, how does gender influence the care that older residents of long term care facilities should receive?
The majority of residents within long-term care facilities are female, as are the staff that provided care. Yet, males, such as Mr. Nice, also reside in these same facilities. the research findings upon which this paper was based, a literature review was conducted. Four peer reviewed data bases (Age Line, Cumulative Index to Nursing and Allied Health, Medline, Psyc INFO) were searched using key terms, which included gender, aging, long-term care, nursing homes, and aged. In addition, the reference lists of located articles were manually searched for additional references. Theoretical articles were not included since they do not provide scientific evidence to guide practice. The literature review was not intended to be all-inclusive but rather to provide the authors with preliminary evidence to guide care practices within long-term care facilities. Only English language articles were obtained. We specifically sought studies in which gender comparisons were made. Articles which studied only one gender were excluded. We initially imposed no time restriction on our search. However, when the initial search yielded an overwhelming number of articles, a fifteen year limitation was imposed (from 2000 to 2015). This large number was due to studies in which gender was identified but gender comparisons were only identified in reading abstracts. Studies in which participants were not identified as older adults were also excluded.

Findings are described specific to the first of the two guiding questions
What is known about gender specific differences that may influence resident care in long-term care facilities? While older adults may experience similar health care problems, some diseases processes are more common to one specific sex [15]. Gender also has an effect on psychosocial and emotional functioning. Table 1 highlights some of the differences found in the research literature which can potentially influence an older resident's quality of life within a long-term care facility.

Discussion of findings
The research clearly indicates that there are differences between men and women. While it is not our intent to expand upon the reasons for gender differences as cited by individual researchers, it is important to highlight that differences do exist. Some of the differences can be accurately attributed to physical differences in body structure for example. However, others might be due to the societal and cultural shaping of gender roles and responsibilities. With age, gender differences may be magnified because of the different life trajectories of men and women. As with most aspects of ageing, identified gender patterns cannot be ascribed to all older adults of one sex or another. Yet, recognition of such differences may enhance the ability to provide the uniqueness of care that each older resident deserves.
The relationship between facility staff and older residents is itself gendered. Men and women tend to have differing styles of communication based upon societal socialization. Studies suggest that health care providers differ in the way they communicate with Table 1: Gender differences.

Variable studied Females Males
Physiological functioning delirium Delirium severity was related to dementia severity [21] physical activity Had greater walking speed and habitual activity [5].

hip fractures / falls
reported higher rates of falls [22] were more functionally dependent in locomotion, transfers and sphincter control after hip fracture [10] had higher rate of hip fractures specific to being in institutions [3] nutrition increased vulnerability to lower dietary intake, increased body mass, and poor physical performance [24] were at higher risk for aspiration pneumonia [25,26] sleep / fatigue rested more often because of physical tiredness [27] reported more insomnia symptoms [28,29] experienced more fatigue with advancing age [30,31] reported higher level of daytime sleepiness; rested significantly more often as a result of daytime sleepiness [27] urinary more likely to experience urinary incontinence [32,33] more likely to limit outings as a result of incontinence [34] bowel experience more constipation [35,36] Psychological / Social functioning religious participation experienced greater desire for a dignified death [37] experienced greater preference for life-sustaining treatments [37] depression more likely to experience depression and anxiety [15,[38][39][40][41] severely disabling conditions like stroke were more strongly associated with depression in men [10] memory had significantly higher performance levels for episodic memory [42] outperformed men for verbal recall [43] outperformed women for spatial orientation [43] kin relationships and social supports blood pressure reactivity to dementia care giving stress viewed loneliness as sometimes liberating [44] Greater blood pressure reactivity to dementia caregiving stress [45] Viewed loneliness more as a sense of deprivation [44]. Less blood pressure reactivity to dementia caregiving stress than women [45] Intervention practices medication intervention were less likely to receive atypical antipsychotics [46] Predicted benzodiazepine prescription [48]. received more pain medication [47] assistance with activities of daily living In nursing homes, require more assistance [12].
their patients [16,17]. Women tend to talk to build community and men use talk as a means of establishing status and independence. In the nonverbal domain, women tend to be more expressive and more accurate at perceiving emotions than are men [18].
These findings have important implications for long-term care facility administrators, educators, and staff. They are all in key positions to build a supportive culture for residents, which acknowledge gender related care needs. This leads to the second of the two guiding questions for this study. What recommendations might be made specific to residents' care in long-term care facilities based upon identified gender differences?
Recommendations for administrators: Administrators are responsible for the overall operations of the facility. It is their role to design and maintain clinical environments that support best practices for optimal resident care. In other words, they create the contextual milieu necessary to provide gender sensitive care by staff to older residents. To ensure incorporation of a gender perspective into resident care, there is a need to strategize regarding gender specific policy. Staff need to be knowledgeable about the issues, demographics, specific problems and relevant policies, and governmental laws that have implications for long-term care facilities. There is also the need for administrators to tackle specific problems relating to gender issues; one way is through education of staff. While education may help somewhat to reduce gender bias, education alone is not likely to overcome stereotypes in care. This strategy may be delegated to on-site educators.

Recommendations for Educators:
It is imperative for onsite educators to invest in creating gender sensitive environments. Educators may be advance practice nurses with strong knowledge and skills specific to resident care; they also have skills in individual and organizational behaviour change strategies. Educators can work directly with staff to consistently implement and sustain gender sensitive care practices.

Recommendations for staff:
It is unreasonable to expect any single staff member to know all there is to know about even one gender. And, societal and cultural expectations surrounding gender roles vary over time. However, every staff member can incorporate gender principles into resident care. To illustrate this point, differences seem to exist between genders in some basic physiological needs, communication styles, emotional responses, and available social resources. If males and females rest for different reasons during the day, then, perhaps the daily routine of the unit and resident care plans might have to be modified to address this reality. Sleep quality has a restorative function and promotes health and a feeling of wellbeing, in the presence of a balance between rest and sleep and activity.
Staff need to approach gender reflectively to understand its influence upon older residents and other members of the long-term care facility culture. Personal stereotypes and attitudes towards men and women may generate assumptions about the abilities, and pain levels of older residents. These types of stereotypes may interfere with the one's ability to see residents as unique individuals [19,20]. They may be manifest in the way that a female staff talks to a male resident or how a resident's behaviour is interpreted. Even positive stereotypes about gender make assumptions about residents that may be inaccurate and restrict the staff member's ability to use professional practice skills effectively.

Recommendations for further research:
Research is needed to inform policy and practice in long-term care facilities. Numerous questions emerged during this literature review, such as how gender specific findings translates into behaviours and expectations of residents. However, answers were not evident in the located literature. With few exceptions, all located studies focused on community residing older adults or those temporarily in acute care. How does long-term care facility influence gender behaviours, if at all? In reviewing the studies, the junction of gender and staff relationships was underdeveloped. This includes how staff themselves interact with residents because of their own gender. This then is another area fertile for investigation.
Researchers have used different approaches in studying gender.
Research on aging has tended to be quantitative and concerned with how older adults adjust to their reduced physical and social status. However, there is strong emerging qualitative studies with women as the primary participants. The latter has been primarily theory-driven, contextualizing women's experiences. Neither method by itself offers an adequate examination of gender. Gender is generally included in studies on physiological and psychological aging, either implicitly or explicitly. However, with few exceptions, many mainstreamresearchers studying older residents have overlooked gender as a possible influencing variable. The account of the literature presented here is not meant to be exhaustive but rather to provide an illustration of the state of development regarding gender and care for older residents. The lack of knowledge on gender as a potential influence upon behaviours, relationship building, and care needs in long-term care facilities is striking.

Limitations
This examination of the literature described gender differences, which have the potential to influence the care of older residents. It did not provide an in-depth review of the literature, nor did it assess the quality of the retrieved studies. Further collection of research studies may have yielded contrary evidence to what was located in this preliminary search. There may have been documentation in the grey literature that would have contributed to this preliminary review. However, these limitations do not negate the value of understanding the influence of gender upon care within long-term care facilities.

Conclusion
The present study was a preliminary attempt to understand gender specific factors that might influence care provided to older residents of long-term care facilities. We were successful in this regard. However, research is required to expand knowledge regarding gender influences upon the care that older residents living in long term care facilities. Numerous questions arise from this review, including: does gender physiology influence specific nursing care practices, for example support with personal care, and if so, how? Is nutritional support (e.g. feeding techniques) different due to gender? What are the needs of gender minorities, is care influenced, and if so, how? In addition, the field of gender specific research in longterm care facilities currently lacks adequate measurements of the outcomes of women focused versus male resident focused therapeutic interventions, which are essential to empirical validation of effective treatment approaches. These questions need to be answered.
To provide a gender perspective to resident care requires a change in the attitudes and behaviors of both staff and facility administrators. Staff within these facilities have a role to play in providing quality care, but administrators are best positioned to create an enabling environment for the gender specific care needs of older residents to be met. Men and women's bodies differ, so too do their health care needs.