**7. Homosexuality**

priate, to talk about it publicly, while the younger generations were becoming much more relaxed and ready to discuss it among themselves and in public. Also, in their opinion sexuality was related to health. They not only explained this relation in terms of pathology and sexually transmitted diseases, they often defined it as a vital human need and an element of happiness and quality of life. In broader terms, they explained it as an intimate relation between two people who loved and cared for each other, which means they also took consideration of partnerships in terms of a much wider perspective. Focusing on the intercourse, they stressed:

*Sexual intercourse with the right person relaxes, which bears influence on wellbeing, means less stress.*

*It is known that during sexual intercourse the hormones of happiness are released. Our body is more relaxed and at the same time it is a type of physical exercise and contributes to our health. (M19)*

These aspects become very important when interpreting standpoints expressing negative attitudes towards homosexuality and the rights of homosexuals. If sexual relations with the partner of one's own choice can have such positive effects on a person's health and wellbeing, why is it acceptable for heterosexuals but not homosexually oriented people?  Even the younger generation was not always willing to discuss it seriously and frankly with anyone. As one of the students said, she was more likely in public to exaggerate, make things up, and present herself in a more socially favourable light. For the practice of midwifery it is important to stress that in the opinion of one of our respondents, some people also considered health professionals (poten‐ tially also midwives) as strangers, that is, people they did not feel able to discuss their sexuality

*I can talk about it quite relaxed with friends and my partner. But I feel uncomfortable to discuss it with*

On the one hand, therefore, sexuality is perceived as a highly intimate matter, but on the other hand, it also exposes the influence on public health and is a topic of public discussions and

Midwifery students included in our study expressed their understanding that midwives were involved in the most intimate and vulnerable aspects of the lives of women and couples:

*(M5)*

172 Sexology in Midwifery

health, wellbeing, and general quality of life.

with completely openly and frankly:

*strangers (a nurse at gynaecologist). (M18)*

*Midwives "enter" the intimate sphere of human beings. (M4)*

*A midwife deals with the intimacy of a woman in her most frail moments. (M8)*

political action.

**6. Midwifery**

The presentation of the students' standpoints and attitudes towards homosexuality is divided into several thematic parts. First, the established distinction between public and personal opinions is illustrated and interpreted. Several adverse judgements were found, the most controversial among them being related to homosexual parenting. The analysis then focuses on different defensive strategies our respondents used in trying to avoid giving the impression of being discriminatory. The most common justification strategies to keep an apparently tolerant social demeanour despite expressed disregard were: the necessity of parents of different sexes, the social exclusion of children of homosexual parents, the questioned normality and naturalness of homosexuality, and the perception of homosexual orientation as a voluntary and conscious decision. The revealed tensions testified to the complexity of expressed attitudes towards homosexuality, which was further illustrated by reported feelings of being caught in contradictions among social norms, public opinion, and personal attitudes.

### **7.1. The society is discriminatory — I am not**

Almost all respondents agreed that society at large persisted in being very negative, preju‐ diced, and discriminatory towards homosexuals, although they judged that the overall situation was becoming more tolerant. A common strategy of denying their own homophobia was to attribute it to others. At least that looked convincing at the beginning of their talk; as it continued, the disclaimers helped to reveal much more prejudiced talk than the speakers were ready to admit:

*I personally do not mind, but I know a lot of people who do mind very much, even though I do not know why. Everyone should live as they want. I think the most important thing is to be happy and if that makes them happy, that is fine. But I do not agree with homosexual parenting because I would not want to be a child of two mums/dads. (M10)*

*In my opinion most of the people still look at homosexuals in a different way — in a way as if something was wrong with them, in a mocking way... I have no comments against the homosexuals. Everyone has* *the right to decide, choose their partner.  (M16)*

In both cases, the speakers started by establishing a difference between others that disregard homosexuality and themselves, who were not bothered by distinctions in sexual orientation. They even elaborated their views by acknowledging some basic human rights: everyone should live as they want, everyone has the right to be happy, and everyone has the right to make their own decisions. At least that was what they believed in principle. Right after that, a discursive turn followed: in their opinion, homosexuals, unlike heterosexuals, did not have the right to decide they wanted children and attain happiness through parenting. The speakers thereby set limitations to these universal rights and freedoms of people with homosexual orientation, which was very much in contradiction with their alleged tolerant attitude and much closer to the homophobia they attributed to others.

### **7.2. Citizens with limited rights**

As illustrated above, there are still areas of social life where the apparently universal rights and freedom of certain individuals or groups of people clearly end. In our respondents' opinions, homosexually oriented people did not have equal opportunities in today's society, mainly when searching for employment, but they did not agree with that injustice. On the other hand, they identified several types of behaviour that were completely unproblematic for heterosexuals but perceived as endangering their heterosexual identity when observed with homosexuals:

*I have no problems meeting a homosexual couple; they as well are just humans. But I believe they should be a little bit more reserved when showing it in public. (M19)*

### *They do not bother me personally until they wish to have children. (M8)*

In most cases, our respondents were personally bothered by the public appearance and disclosure of homosexuals, even if it was just holding hands. Some of them objected to homosexual marriages.  Homosexual parenting: the social exclusion of children with two mums or dads**

Some midwifery students were supportive of homosexuals in all aspects of their lives, including parenting.  I believe homosexual parents can offer equally warm shelter (if not more) as heterosexual ones. (M3)*

*I support them if they decide to have children as they too have the right to create their own family. (M7)*

I am not prejudiced. It is important that the child feels well.  The inner side of a human is important. (M12)*

*the right to decide, choose their partner.  They even elaborated their views by acknowledging some basic human rights: everyone should live as they want, everyone has the right to be happy, and everyone has the right to make their own decisions. At least that was what they believed in principle. Right after that, a discursive turn followed: in their opinion, homosexuals, unlike heterosexuals, did not have the right to decide they wanted children and attain happiness through parenting. The speakers thereby set limitations to these universal rights and freedoms of people with homosexual orientation, which was very much in contradiction with their alleged tolerant attitude and

As illustrated above, there are still areas of social life where the apparently universal rights and freedom of certain individuals or groups of people clearly end. In our respondents' opinions, homosexually oriented people did not have equal opportunities in today's society, mainly when searching for employment, but they did not agree with that injustice. On the other hand, they identified several types of behaviour that were completely unproblematic for heterosexuals but perceived as endangering their heterosexual identity when observed with

*I have no problems meeting a homosexual couple; they as well are just humans. But I believe they should*

In most cases, our respondents were personally bothered by the public appearance and disclosure of homosexuals, even if it was just holding hands. Some of them objected to homosexual marriages. The most controversial topic of all, however, proved to be homosexual

Some midwifery students were supportive of homosexuals in all aspects of their lives, including parenting.  I believe homosexual parents can offer equally warm shelter (if not*

*I support them if they decide to have children as they too have the right to create their own family. (M7)*

**7.3. Homosexual parenting: the social exclusion of children with two mums or dads**

*is inappropriate, as homosexual partners cannot raise a child. (M16)*

much closer to the homophobia they attributed to others.

*be a little bit more reserved when showing it in public. (M19)*

*They do not bother me personally until they wish to have children. (M8)*

I am not prejudiced. It is important that the child feels well. (M9)

**7.2. Citizens with limited rights**

personal satisfaction and wellbeing:

*more) as heterosexual ones. (M3)*

homosexuals:

174 Sexology in Midwifery

parenting.

*Parents of the same sex could also raise a child appropriately. Also, not all heterosexuals are suitable for parenting and cannot take this responsibility but their pregnancy is not controlled. I do not believe the sex of parents is so important for raising a child. The missing role of a father or a mother could be taken up by somebody else, other relative. (M18)*

*If the parents are OK, I do not see any problems. A lot of children have a father and a mother, but they experience violence or something similar. I think we should ask children how they feel (for example when asked by schoolmates about their mother or father). If they do not mind, neither should we. (M20)*

*They do not have the same rights, but they should, for example, two homosexuals could raise a child better than parents if there is alcoholism, quarrelling or violence present in the family. (M21)*

*I believe a child should grow up in a loving family, traditional or some other, as sometimes living with a father and a mother that do not take good care of their children is worse than with two loving mothers. (M26)*

*Regarding today's' society and events that are reported on radio and TV, I think sometimes homosexual partners could offer a child a better life than parents that have no consideration of when to have a child. (M28)*

Not all students were so straightforwardly supportive. Aware of the potential accusation of intolerance, our respondents' arguments involved quite complex justifications for their prejudiced and discriminatory views.  In my opinion a child needs a man and a woman. (M8)*

*I don't consider it appropriate that some children would have two mums and dads. (M5)*

Literally speaking, a child cannot have two mothers or two fathers, at least if we understand these terms in their traditional, biological sense. Raising and taking care of a child, however, is also or even primarily a socio-cultural phenomenon, which is not unconditionally related to gender, blood ties, or the number of persons involved. The key question in this discussion therefore seems to be: is sexual orientation related to the ability to be a good parent? As one of the respondents, expressing her supportive standpoint towards homosexual parenting, noticed:

### *Sexual orientation is not the only thing that defines a man. (M19)*

Once we deconstruct the misunderstanding of parenthood in purely physiological terms (as an ability to conceive a child), it becomes clear that social acceptability or appropriate‐ ness (who is allowed to take care of a child) is a quite different question. Instead of focusing on the economic/material, socializing, and protective aspects of raising a child, it is frequently turned into a political question that has also been on the public agenda in the past, when laws were discussed and passed regarding adoptions, foster care, and in vitro fertilization, to name just a few.

The second identified strategy used to justify prejudiced claims was intertwined with the first one, and referred to the presupposed negative reaction of society, social exclusion, and victimization of children:

*I don't consider it appropriate that some children would have two mums and dads. Such children would probably be excluded from the society. (M5)*

*Although I said that I have nothing against these persons, I do not agree that they could adopt children. I think it could influence their lives because the Slovenians are still much closed and we do not know how to accept difference and a consequence would be that such a child would be mocked (mockery depression suicidal thoughts). (M14)*

*Although I hold no prejudice towards homosexually oriented people, I consider homosexual parenting unacceptable because of the child, who would be exposed to mockery and rejection. (M27)*

Mockery and rejection by society were mentioned several times in combination with the perception of homosexual parents as two mums and dads as the terms themselves, stressing the biological aspect of parenting, alluded to their very inconsistency. Prejudiced and dis‐ criminatory society was frequently (mis)used as an argument for depriving a certain group of people of the opportunity to establish a family instead of recognizing the urgent need to promote tolerance and acceptance of differences. The most extreme instance of this line of thought can be illustrated by the following excerpt in which the speaker explicitly acknowl‐ edged that homosexual parents could even be more loving than heterosexual ones, before drawing a negative conclusion:

*Homosexuals do not bother me personally, although if I see something like that in the street, it looks strange, because I am not used to it, but it does not bother me. Of course they have the same rights as the rest of citizens; I believe that sexual orientation should not influence human rights. But I do not consider homosexual parenting to be appropriate. Otherwise they can be even more loving as normal parents, but mainly from the child's perspective, I do not think it is appropriate. (M11)*

According to this excerpt that claimed to speak in favour of the child, it was more important to conform to prejudiced social attitudes than to allow the child to be raised by loving homosexual parents. Was this speaker really not bothered personally by homosexuals and convinced that they had the same rights as heterosexuals? The speaker was no expert on homosexual parenting and was repeating prejudiced and superficial judgements about homosexual parenting in general. It was an act of discursive discrimination, because such judgements, not supported by any sound evidence, still have social consequences. Namely, they perpetuate still further the prejudiced social talk that is usually attributed to others and so easily disclaimed by the speaker. Our respondents referred to this public opinion (the society, the others) as very influential in many excerpts. Who, then, is the one that really objects to homosexual parenting? As another midwifery student noticed, social disregard of same-sex parenting is today's reality, but the key question promoting tolerance should be: who is the society? Who creates social relations? Is it them or is it us, perhaps even me?

*I believe that many homosexuals would care for a child better. Homosexual parenting is not problematic for me, I support it. Society is the problem — we teach our children that homosexuals are different. If we didn't then the children of homosexuals would not be condemned by their peers. (M15)*

Changing public opinion is not a new phenomenon. Life is a process involving constant change and one commonly attended by rejection of that change. The social exclusion once experienced by children born out of wedlock is now happening to children in rainbow families and will continue to happen to children of another marginal social group in the future. It is important to recognize that exclusion is never determined by nature or the children themselves but by social relations and the attitudes of adults, by norms reflecting social power.

The second identified strategy used to justify prejudiced claims was intertwined with the first one, and referred to the presupposed negative reaction of society, social exclusion, and

*I don't consider it appropriate that some children would have two mums and dads. Such children would*

*Although I said that I have nothing against these persons, I do not agree that they could adopt children. I think it could influence their lives because the Slovenians are still much closed and we do not know how to accept difference and a consequence would be that such a child would be mocked (mockery*

*Although I hold no prejudice towards homosexually oriented people, I consider homosexual parenting*

Mockery and rejection by society were mentioned several times in combination with the perception of homosexual parents as two mums and dads as the terms themselves, stressing the biological aspect of parenting, alluded to their very inconsistency. Prejudiced and dis‐ criminatory society was frequently (mis)used as an argument for depriving a certain group of people of the opportunity to establish a family instead of recognizing the urgent need to promote tolerance and acceptance of differences. The most extreme instance of this line of thought can be illustrated by the following excerpt in which the speaker explicitly acknowl‐ edged that homosexual parents could even be more loving than heterosexual ones, before

*Homosexuals do not bother me personally, although if I see something like that in the street, it looks strange, because I am not used to it, but it does not bother me. Of course they have the same rights as the rest of citizens; I believe that sexual orientation should not influence human rights. But I do not consider homosexual parenting to be appropriate. Otherwise they can be even more loving as normal*

According to this excerpt that claimed to speak in favour of the child, it was more important to conform to prejudiced social attitudes than to allow the child to be raised by loving homosexual parents. Was this speaker really not bothered personally by homosexuals and convinced that they had the same rights as heterosexuals? The speaker was no expert on homosexual parenting and was repeating prejudiced and superficial judgements about homosexual parenting in general. It was an act of discursive discrimination, because such judgements, not supported by any sound evidence, still have social consequences. Namely, they perpetuate still further the prejudiced social talk that is usually attributed to others and so easily disclaimed by the speaker. Our respondents referred to this public opinion (the society, the others) as very influential in many excerpts. Who, then, is the one that really objects to homosexual parenting? As another midwifery student noticed, social disregard of same-sex parenting is today's reality, but the key question promoting tolerance should be: who is the

*I believe that many homosexuals would care for a child better. Homosexual parenting is not problematic for me, I support it. Society is the problem — we teach our children that homosexuals are different. If*

*parents, but mainly from the child's perspective, I do not think it is appropriate. (M11)*

society? Who creates social relations? Is it them or is it us, perhaps even me?

*we didn't then the children of homosexuals would not be condemned by their peers. (M15)*

*unacceptable because of the child, who would be exposed to mockery and rejection. (M27)*

victimization of children:

176 Sexology in Midwifery

*probably be excluded from the society. (M5)*

*depression suicidal thoughts). (M14)*

drawing a negative conclusion:

The third identified type of justification of prejudiced and discriminatory talk was found in the interpretation of homosexuality, homosexual partnerships, and/or parenting as abnormal and unnatural. This can, again, be done fairly straightforwardly (that is, explicitly stated), or implicitly alluded to (inferring difference from a "normal" couple or family):

*They do not bother me personally; it is not their fault that it is happening to them. But it gets on my nerves that they would have equal rights as couples (marriage, adoption of children) as I do not think it is natural. (M2)*

*My opinion is relative to the matter. As a friend I do not have any problems, but I would personally have to think very hard if it was a very important decision to be made, for example adoption of a child by a normal or homosexual couple. I would prioritize a normal couple as I think every child has the right to live in a normal family, not in a family that is not accepted by the society. (M22)*

It is a common but erroneous belief that "normality" is a property of nature and that both categories exist irrespective of their social context. From the discursive perspective, normality and nature are both social constructs — something is not "normal" or "natural" in and of itself, it is interpreted as such within discourse. Following this line of thought, attention should be put on the speaker's constructions. Instead of claiming that something is normal or natural, a critical thinker should be attentive to what is normal to whom, and to ask according to whose criteria is something is deemed natural? Interpretation is related to the social position and power of the speaker. Abnormality of homosexuality exists only in heteronormative societies.

The fourth strategy apparently justifying the speakers in expressing discriminatory claims was identified in our respondents' conception of sexual orientation as an individual's conscious decision. Within this perception, homosexually oriented people voluntarily decided against the prevailing social heterosexual norm and were thus themselves intentionally challenging society to accept them. Following this line of thought, it is homosexuals themselves who should take the blame and responsibility for the consequences that follow from such socially unfav‐ ourable decisions:

*They have certain rights, but not all, for example the right to adopt children, as it was their own decision to be different, not able to conceive a baby. (M8)*

*I see no sense in homosexual orientation, but I think it is a personal decision of each individual and that is why I have no prejudice towards these people but there appear many doubts when such a couple wishes to adopt a child, because a child could have problems... We all know that it takes a man and a woman to create a new life. Who intentionally decides against this must accept also the facts that follow as a consequence. (M27)*

The same principle of social responsibility for one's own decisions is followed also in contrary cases:

*I accept homosexuality; a man on his own cannot influence his sexual orientation. (M1)*

*I think they are completely normal people like the rest as they do not have any influence over their orientation. (M19)*

People not having any say in or power over the phenomenon were also not to be blamed and punished for the (unintended) consequences. They deserve our sympathy and support.

### **7.4. Torn between social norms, public opinion, and personal attitudes**

It has become evident from the excerpts so far that the current debate about homosexuality involves many contradictory aspects. On the one hand, the prevailing social norm is tolerance and the reduction of inequalities. On the other hand, the alleged public opinion is still very negative and, although dispersed and intangible, very strong and influential. Civil movements are quite active but marginalized. This leaves many people bewildered and wandering among different discourses: the traditional attitudes they were socialized into, and their own experi‐ ences and critical observance of the society they live in. For our respondents, it was sometimes really difficult to form a clear personal standpoint:

*Although I do not want to accept them differently, I keep a certain distance towards them. (M5)*

*I do not yet have a clear opinion on homosexual parenting. I have not thought about it thoroughly, but I feel inclined to think that everyone should have the right to have children, irrespective of their sexual orientation. (M1)*

*I think the important thing for a child is to have loving parents, but it is also true that children today do not yet understand difference and would probably experience much harm from their peers. (M19)*

*I have not taken sides yet. On the one hand I do not support it because of the children, on the other hand I support it because the child and this relationship can be more sound and the child more loved as in certain partnerships...  (M23)*

*Homosexual parenting — why not? Better two mums than none or a careless one. But I think that the public is not ready yet and a child would suffer the consequences in the end. (M25)*

As we learned from sociological research, it is not enough to study attitudes and expect that by changing them, we will automatically change behaviour; it is necessary to simultaneously change social structures:

*I object to homosexual parenting and adoption, because of the child and the society, but I will accept it, if such law will ever be passed. (M24)*

*My opinion towards homosexual persons is not really formed — sometimes it bothers me more, at other times not at all. It is difficult to describe my attitude, mainly because the public opinion is at many occasions clearly stated (that it is not right). (M26)*

The real name of the game therefore seemed to be striving to represent oneself positively to others as well as to themselves. Even when personally tolerant, our respondents felt pressed to conform to what they detected was (negative) common sense as the prevailing public attitude. To mitigate disregarding standpoints and make them conform to the highest social norm of respecting differences, they (we?) learned to apply various justification strategies in order to defend from potential accusations of intolerance.

### **8. Discussion**

The same principle of social responsibility for one's own decisions is followed also in contrary

*I think they are completely normal people like the rest as they do not have any influence over their*

People not having any say in or power over the phenomenon were also not to be blamed and punished for the (unintended) consequences. They deserve our sympathy and support.

It has become evident from the excerpts so far that the current debate about homosexuality involves many contradictory aspects. On the one hand, the prevailing social norm is tolerance and the reduction of inequalities. On the other hand, the alleged public opinion is still very negative and, although dispersed and intangible, very strong and influential. Civil movements are quite active but marginalized. This leaves many people bewildered and wandering among different discourses: the traditional attitudes they were socialized into, and their own experi‐ ences and critical observance of the society they live in. For our respondents, it was sometimes

*Although I do not want to accept them differently, I keep a certain distance towards them. (M5)*

*I do not yet have a clear opinion on homosexual parenting. I have not thought about it thoroughly, but I feel inclined to think that everyone should have the right to have children, irrespective of their sexual*

*I think the important thing for a child is to have loving parents, but it is also true that children today do not yet understand difference and would probably experience much harm from their peers. (M19)*

*I have not taken sides yet. On the one hand I do not support it because of the children, on the other hand I support it because the child and this relationship can be more sound and the child more loved as in certain partnerships... A child should have a mother and a father, but a homosexual couple can love a*

*Homosexual parenting — why not? Better two mums than none or a careless one. But I think that the*

As we learned from sociological research, it is not enough to study attitudes and expect that by changing them, we will automatically change behaviour; it is necessary to simultaneously

*I object to homosexual parenting and adoption, because of the child and the society, but I will accept it,*

*My opinion towards homosexual persons is not really formed — sometimes it bothers me more, at other times not at all. It is difficult to describe my attitude, mainly because the public opinion is at many*

*I accept homosexuality; a man on his own cannot influence his sexual orientation. (M1)*

**7.4. Torn between social norms, public opinion, and personal attitudes**

really difficult to form a clear personal standpoint:

*child very much and a child can grow in a loving environment. (M23)*

*public is not ready yet and a child would suffer the consequences in the end. (M25)*

cases:

178 Sexology in Midwifery

*orientation. (M19)*

*orientation. (M1)*

change social structures:

*if such law will ever be passed. (M24)*

*occasions clearly stated (that it is not right). (M26)*

The respondents in our study were the future providers of health care. Many of them expressed very tolerant and well-supported views. On the other hand, analysis also identified prejudiced and discriminatory standpoints towards homosexuality. It is therefore important to include the deconstruction of common prejudices in health care curricula. They should include knowledge of the roots and consequences of homophobia. Identification of prejudiced talk and instances of discrimination should be followed by open critical discussion, which should result in the weaker presence of prejudices and thereby, hopefully, fewer inequalities in health.

This discourse analysis showed many different types and instances of prejudiced standpoints against gays/lesbians, and especially their families, among the first year students of midwifery. The ratio of supportive answers among midwifery students compared to their colleagues from other programmes was relatively high, yet less than half were supportive in all respects. In general, students interpreted sexuality as a human intimate need that was positively related to a person's health and quality of life if the partner was chosen according to their preferences. By rejecting homosexuals, they therefore deprived gays and lesbians of this basic right and need.  It became evident that choosing the partner of one's own preference was acceptable only within socially accepted heterosexual norms. A code of ethics binds the professional to be objective and apolitical. Professional curricula should therefore also address these topics to enable midwives to become aware of the discriminatory attitudes and norms, and to provide non-discriminatory care.

In the views of our respondents, midwifery spanned private and social spaces. People usually find it difficult to reveal and discuss their private matters with others. Midwives could be experienced as strangers. An important professional question, especially in cases of socially unfavourable sexual practices and relations, was how to develop sensitivity to a person's discomfort and vulnerability, establish a safe, respectful environment, and build trust. Our respondents claimed that midwifery provided a women-centred care. Besides acknowledging individuality and respecting the rights and dignity of a person, this also brought to the fore the question of client involvement. Namely, it is not enough to care for the clients' health and their needs, the clients themselves should be supported to express their own experiences, needs, and preferences. Caring professions should not only provide care but also empower clients to take an active role in decision making related to their care [25].

It was seen from our respondents' answers that homophobia was easily attributed to others and rarely identified in the self. Through the analysis of apparent denials, it was nevertheless found that even students that claimed to be tolerant considered homosexuals as citizens with limited rights. Gays' and lesbians' rights to live as they chose was partly accepted, but tolerance mostly ended when the question of parenting came to the fore. The rejection was explained in terms of social discrimination and victimization of children. Four sub-themes were identified: a child needs parents of both sexes; society rejects same-sex families and victimizes the children; homosexuality is not normal and natural; (homo)sexual orientation is a conscious decision of an individual. We shall address them respectively below.

In Slovenia today, the proportion of families composed of a married couple with children is dominant, but has been on the decrease ever since 1991. In 2011, the ratio of single parent families increased to 25% and the ratio of unmarried couples with children to 10.8%. In the same year for the first time, the national statistical office recorded the ratio of reconstituted families (defined as families composed of two partners with children, where at least one child is not a biological child of both partners) as 4.1% [26]. Other sources estimate the ratio of reorganized families is much higher, around 30% [1]. Statistics about different types of social parenting (especially homosexual parenting) are difficult to obtain and are currently very dispersed, largely because people do not feel comfortable and safe to disclose data about their private lives for the fear of stigma and social exclusion. There is no doubt, however, that many different types exist in growing numbers that cannot be neglected or pushed to the margins. Using terms and numbers alluding to blood ties (two parents; a mother and a father) is therefore primarily a way of naturalizing and normalizing only one of the many existent family relations and thereby implicitly stigmatizing and excluding all the rest.

Social parenting is established in opposition to a blood related conception of parenting. It is primarily focused on care and is as such defined as a social-emotive and intimate relation between an adult and a child that involves economic responsibility and is constant in temporal terms [27]. Blood relation is not unconditionally related to the quality of parenting. The quality of a family is related to the quality of relations and processes within it — such as taking care, taking responsibility, showing respect, enabling a sense of self-worth, allowing autonomy, providing means, and support and security — rather than to its form or structure [28,1,29]. Furthermore, contemporary conceptualizations of the family stress the prime importance of the subjective, lived judgements of people over structural, blood, or legal ones [28]. It is therefore important how family members feel about, treat, and take care of each other, factors not determined by the blood that circulates through their veins.

 Commonly, the exclusion is explained in terms of the harm done to the children, which is said to come from the unfavourable social surrounding itself. The discriminatory society is therefore taken as an argument for not letting gay and lesbian couples take care of children instead of being criticized for being discriminatory. The discrimination of society is thereby sustained instead of challenged. Namely, the same people who accuse society are its very components; they themselves could therefore make a difference and be tolerant. As Urek [28] said, accusing society of being immature only acknowledges and perpetuates discrimi‐ nation but does not contribute to any changes.

It was seen from our respondents' answers that homophobia was easily attributed to others and rarely identified in the self. Through the analysis of apparent denials, it was nevertheless found that even students that claimed to be tolerant considered homosexuals as citizens with limited rights. Gays' and lesbians' rights to live as they chose was partly accepted, but tolerance mostly ended when the question of parenting came to the fore. The rejection was explained in terms of social discrimination and victimization of children. Four sub-themes were identified: a child needs parents of both sexes; society rejects same-sex families and victimizes the children; homosexuality is not normal and natural; (homo)sexual orientation is a conscious

In Slovenia today, the proportion of families composed of a married couple with children is dominant, but has been on the decrease ever since 1991. In 2011, the ratio of single parent families increased to 25% and the ratio of unmarried couples with children to 10.8%. In the same year for the first time, the national statistical office recorded the ratio of reconstituted families (defined as families composed of two partners with children, where at least one child is not a biological child of both partners) as 4.1% [26]. Other sources estimate the ratio of reorganized families is much higher, around 30% [1]. Statistics about different types of social parenting (especially homosexual parenting) are difficult to obtain and are currently very dispersed, largely because people do not feel comfortable and safe to disclose data about their private lives for the fear of stigma and social exclusion. There is no doubt, however, that many different types exist in growing numbers that cannot be neglected or pushed to the margins. Using terms and numbers alluding to blood ties (two parents; a mother and a father) is therefore primarily a way of naturalizing and normalizing only one of the many existent family

Social parenting is established in opposition to a blood related conception of parenting. It is primarily focused on care and is as such defined as a social-emotive and intimate relation between an adult and a child that involves economic responsibility and is constant in temporal terms [27]. Blood relation is not unconditionally related to the quality of parenting. The quality of a family is related to the quality of relations and processes within it — such as taking care, taking responsibility, showing respect, enabling a sense of self-worth, allowing autonomy, providing means, and support and security — rather than to its form or structure [28,1,29]. Furthermore, contemporary conceptualizations of the family stress the prime importance of the subjective, lived judgements of people over structural, blood, or legal ones [28]. It is therefore important how family members feel about, treat, and take care of each other, factors

Society rejects gay and lesbian families, although the usual argumentation follows a paradox‐ ical pattern. Commonly, the exclusion is explained in terms of the harm done to the children, which is said to come from the unfavourable social surrounding itself. The discriminatory society is therefore taken as an argument for not letting gay and lesbian couples take care of children instead of being criticized for being discriminatory. The discrimination of society is thereby sustained instead of challenged. Namely, the same people who accuse society are its very components; they themselves could therefore make a difference and be tolerant. As Urek

decision of an individual. We shall address them respectively below.

180 Sexology in Midwifery

relations and thereby implicitly stigmatizing and excluding all the rest.

not determined by the blood that circulates through their veins.

 According to Golombok [30], children living in single parent families or with social parents (homosexual partners included) from their earliest age showed no more psychological distress than peers from more conventional backgrounds. They had the same positive self-esteem and were considered by their peers to be good friends. The most emotionally stressful experience for the children was not having same–sex or social parents but in witnessing hatred and abuse. According to research, children of same-sex families were happy, intellectually successful, and tolerant [31]. Golombock [30] also proved that the presence of a father (or a mother) was not necessary for the development of sexual identity. Biological parents were considered a prototypical constellation for the development of a child, but children living with a single parent or social (homosexual) parents developed their sexual roles equally well.  The negative effects of single parenting had to do with the negative socio-economic consequences of a divorce: that is, poor economic conditions (if separation was related to diminished social standard) or small social networks and support received by them. If a single parent was well situated and had a large social network, no differences from other children were detected. On the contrary, some reported closer and warmer contacts, which reflected in life satisfaction. The important risk factor in any family type, therefore, was the lack of trust and good communication. All children face problems and dilemmas when growing up. They can all experience rejections and discrimination of some sort, due to their weight, figure, or some other physical characteristic; behaviour; or family arrangements they live in. It is difficult to avoid such negative experiences, but children can be supported in overcoming them. Good quality family life therefore depends on what is going on in the family, not who belongs to it.

It was interesting to observe the persistence of arguments related to normality and nature despite existing evidence that homosexuality had existed in different regimes and cultures at approximately the same ratio throughout history, regardless of social attitudes. Due to varying definitions and favourability of the social context, it is very difficult to calculate exact numbers. The commonly accepted data originate from Kinsey, the famous researcher of sexual behav‐ iour; he claimed that each society included approximately 10% homosexual people [15]. Samesex behaviour was also documented as a nearly universal phenomenon in animals, across species, from worms to frogs and birds, and it was further discussed how it had also contrib‐ uted to the evolution of the species [32]. From the sociological perspective, it is soundly argued that what is established as normal (in opposition to pathological) is at each point in time defined by culture and ideology rather than being grounded in nature [33]. Presuppositions that heterosexuality is natural, normal, and right, thereby marginalizing other orientations and practices as unnatural, abnormal, pathological, and wrong, is one of the basic tenets of heteronormative ideology/discourse/society.

Also, the analysis identified misconceptions about sexuality as a conscious decision. Science has not yet provided its final answer on the origins of homosexuality. Research spanned across various topics, but none has managed to prove the existence of a homosexual gene, specifics in the structure of the brain, or any other physiological differences. Social factors also did not prove to be able to change sexual orientation, they only made people suppress or deny it. Today, homosexuality is understood as a variation in human sexuality [15]. Gays and lesbians themselves typically do not think that they voluntarily chose their sexual orientation and heterosexuals would probably claim the same.

Our respondents' reporting to be torn between the social norm of tolerance, discriminatory public opinion and their own more tolerant attitude could be interpreted as a sign of society's development. It proves the plurality of opinions, but also their competing powers. It is important to support this process by providing places and times for discussion within workplaces, professional education programmes, and public places.

Implications for midwifery already documented in the literature are vast and manifold. For the purpose of inciting further systematic research and study, we shall only briefly outline key areas: the clients' perspective, the midwives' perspective, and the students' perspective. Starting from acknowledging the client perspective, there are many qualitative studies giving voice to lesbians. A study on lesbian parents' experience of antenatal care, childbirth, and postnatal care identified the extensive presence of heteronormative communication, which was experienced as embarrassing for the participant parents as well as for care providers [34]. There is evidence of positive experiences of lesbian women during pregnancy and childbirth. Lesbians, however, also raised worries about postnatal care, parent education, and the structure of the patient records with no place for the female partner. They stressed that confirmation of parenthood was important, especially for the co-partner. In a study of experience of care provided during their partner's pregnancy, childbirth, and the postnatal period [35], the co-mothers' message was that they felt treated like everyone else, but not quite. They pointed out the need for acknowledgement, need for care designed to suit same-sex couples and the need for midwifery staff to recognize co-mothers as an equal parent of the child [36]. The least discussed topic seems to be midwifery acknowledgment of their role in supporting gay parenting. The needs of two men searching for information and possibilities to start a family, attend parental training, and receive good care [37] remains to be put on the professional and political agenda. Our respondents enumerated that midwives give advice and teach about good relations in partnership, sexual practices, the safety of intercourse, contraception, problems related to sexuality, family planning, healthy pregnancy, sexuality during pregnancy, labour, and parental roles. How many of these tasks, and in what aspects, relate to a male gay couple?

Evidence exists that health care outcomes for lesbians improved when health care providers were knowledgeable about and sensitive to the unique needs of lesbian clients [38]. It is of utmost importance to the lesbian's health and specifically to the outcome of labour, potential post-natal depression, and bonding with the baby, for example. The key question arises [21]: how well equipped are midwives to provide effective and appropriate midwifery care to them? Following that finding, guidance for health care providers in supporting the childbearing lesbian couples was prepared on the basis of literature overview regarding lesbian experiences. Four areas of concern were identified: disclosing sexual orientation to caregivers and finding lesbian-sensitive caregivers, considering options of conception, assurance of partner involve‐ ment, and legal considerations related to the protection of both parents and the child [38].

practices as unnatural, abnormal, pathological, and wrong, is one of the basic tenets of

Also, the analysis identified misconceptions about sexuality as a conscious decision. Science has not yet provided its final answer on the origins of homosexuality. Research spanned across various topics, but none has managed to prove the existence of a homosexual gene, specifics in the structure of the brain, or any other physiological differences. Social factors also did not prove to be able to change sexual orientation, they only made people suppress or deny it. Today, homosexuality is understood as a variation in human sexuality [15]. Gays and lesbians themselves typically do not think that they voluntarily chose their sexual orientation and

Our respondents' reporting to be torn between the social norm of tolerance, discriminatory public opinion and their own more tolerant attitude could be interpreted as a sign of society's development. It proves the plurality of opinions, but also their competing powers. It is important to support this process by providing places and times for discussion within

Implications for midwifery already documented in the literature are vast and manifold. For the purpose of inciting further systematic research and study, we shall only briefly outline key areas: the clients' perspective, the midwives' perspective, and the students' perspective. Starting from acknowledging the client perspective, there are many qualitative studies giving voice to lesbians. A study on lesbian parents' experience of antenatal care, childbirth, and postnatal care identified the extensive presence of heteronormative communication, which was experienced as embarrassing for the participant parents as well as for care providers [34]. There is evidence of positive experiences of lesbian women during pregnancy and childbirth. Lesbians, however, also raised worries about postnatal care, parent education, and the structure of the patient records with no place for the female partner. They stressed that confirmation of parenthood was important, especially for the co-partner. In a study of experience of care provided during their partner's pregnancy, childbirth, and the postnatal period [35], the co-mothers' message was that they felt treated like everyone else, but not quite. They pointed out the need for acknowledgement, need for care designed to suit same-sex couples and the need for midwifery staff to recognize co-mothers as an equal parent of the child [36]. The least discussed topic seems to be midwifery acknowledgment of their role in supporting gay parenting. The needs of two men searching for information and possibilities to start a family, attend parental training, and receive good care [37] remains to be put on the professional and political agenda. Our respondents enumerated that midwives give advice and teach about good relations in partnership, sexual practices, the safety of intercourse, contraception, problems related to sexuality, family planning, healthy pregnancy, sexuality during pregnancy, labour, and parental roles. How many of these tasks, and in what aspects,

Evidence exists that health care outcomes for lesbians improved when health care providers were knowledgeable about and sensitive to the unique needs of lesbian clients [38]. It is of utmost importance to the lesbian's health and specifically to the outcome of labour, potential post-natal depression, and bonding with the baby, for example.

There are many barriers that midwives themselves identified within their current practice. Wilton [21], in her discourse analytic study, documented the following five themes: anxiety about sexual difference, fear of female sexuality, the sexualization of lesbianism, the charac‐ terization of lesbianism as "sick" or "unnatural", and an inability to identify lesbians with any certainty. According to Jackson [39], many midwives fell into a conceptual trap stemming from reducing lesbians solely to their sexual orientation: namely, that they did not come into contact with lesbians because by the very nature of their sexuality they could not become mothers. They also made heterosexist and erroneous assumptions about pregnant women being in a sexual relationship with a male. It was repeatedly evidenced in inattentive heterosexist use of language: for example, referring to a father instead of a partner or an important supportive other. It led to malpractice, where lesbians were ignored and left invisible in midwifery care. Many midwives saw the positive side and described the lesbian love-relationship as strong and caring, but also detected their vulnerability stemming from their being different. It was important for midwives to acknowledge their own attitudes and culturally sensitive nonverbal communication, as well as considering the co-mother's needs and role as different compared to those of fathers. Although caring for lesbian couples was seen as unproblematic, midwives described experiences of ambivalence or anxiety in the encounter and they had noticed that some couples had negative experiences with maternity care [40]. The theme is also gaining grounds in Slovenia. Božnar, in a review of foreign literature on lesbian motherhood [41], aimed to motivate midwifes to consider the topic. In the relation of the midwife towards a lesbian, her partner, and their baby she stressed the importance of knowledge, understand‐ ing, and respect for lesbian mothers and their partners. Another important practical concern and research topic is homosexuality among midwives. A literature review showed little relevant literature on lesbian, gay, bi, and transsexual midwifes in the UK. The lack of their recognition carried personal and organizational implications, as it was supposed that homo‐ phobic attitudes negatively affected also their acceptance at the workplace [42].

Research also focused on future health care professionals. Jones [43] in a study of attitudes of higher education students in health profession educational programs showed high levels of discomfort when working with lesbians or gays. The majority of them believed their study programme had not adequately dealt with this issue. It was also one of the main results of our study that students found the topic relevant to their field of expertise and expected their study program to equip them with relevant knowledge. Regarding their unique position in the health care system (the field of sexuality and reproduction), midwives therefore need to know how to establish a safe environment for a lesbian to "come out" to the midwife and the knowledge to understand and support the patient's lesbian lifestyle. Midwives should become knowl‐ edgeable about lesbian culture and sexuality, learn to use nonheterosexist language, be nonjudgemental, to raise awareness, and reject socially constructed prejudice [39]. This should also involve the visibility of homosexuals in informational material on sexuality, family planning, pregnancy, labour, parenting and partner support, and midwifery.


**Improving the Quality of Care in Care Homes Using the Quality Improvement Collaborative Approach: Lessons Learnt from Six Projects Conducted in the UK and The Netherlands**

**Reena Devi 1,\*, Graham Martin 2 , Jay Banerjee 3,4, Louise Butler 5 , Tim Pattison 5 , Lesley Cruickshank 6 , Caroline Maries-Tillott 7 , Tracie Wilson 8 , Sarah Damery 9 , Julienne Meyer 10, Antonius Poot 11, Peter Chamberlain 12, Debbie Harvey 12 , Clarissa Giebel 13,14, Kathryn Hinsli**ff**-Smith 15, Neil Chadborn 16,17 and Adam Lee Gordon 16,17**

Received: 11 September 2020; Accepted: 13 October 2020; Published: 19 October 2020

**Abstract:** The Breakthrough Series Quality Improvement Collaborative (QIC) initiative is a welldeveloped and widely used approach, but most of what we know about it has come from healthcare settings. In this article, those leading QICs to improve care in care homes provide detailed accounts of six QICs and share their learning of applying the QIC approach in the care home sector. Overall, five care home-specific lessons were learnt: (i) plan for the resources needed to support collaborative teams with collecting, processing, and interpreting data; (ii) create encouraging and safe working environments to help collaborative team members feel valued; (iii) recruit collaborative teams, QIC leads, and facilitators who have established relationships with care homes; (iv) regularly check project ideas are aligned with team members' job roles, responsibilities, and priorities; and (v) work

flexibly and accept that planned activities may need adapting as the project progresses. These insights are targeted at teams delivering QICs in care homes. These insights demonstrate the need to consider the care home context when applying improvement tools and techniques in this setting.

**Keywords:** Quality Improvement Collaborative; Quality Improvement; Implementation Science; residential facilities; older people

#### **1. Introduction**

The rising number of older people is a global phenomenon [1]. One option for older people who are not able to live independently is to live in a long-term care facility, such as a nursing home. An internationally agreed definition of nursing homes is provided by Sanford et al., defining these as facilities that "(i) provide 24-h functional support for people who require assistance with activities of daily living and have identified health needs, (ii) may or may not be staffed with health care professionals, (iii) provide long-term care and/or rehabilitation as part of hospital avoidance or to facilitate early hospital discharges (iv) do not function as a hospital ward and are not hospital based, and (v) may play a role in providing palliative and/or hospice care at end of life" [2]. There are differences between countries in the way that facilities operate, the way that care is financed, how quality of care is regulated, and in the mix and type of professionals employed [3]. For instance, nursing homes in the Netherlands employ a mix of health care professionals and care workers, and in the UK, nursing homes employ Registered Nurses and care workers (with wider healthcare input received from community services). On the other hand, residential homes (referred to as care homes in the Netherlands) in both the UK and the Netherlands employ care workers to provide direct care and healthcare professional input is received from community services. The general characteristics of residents living in nursing and residential homes, however, are similar [4]. In this article, we use the general term "care homes" to refer to both nursing and residential homes.

In the UK, the quality of care across the sector varies [5] and several initiatives dedicated to improving the quality and safety of care have been introduced in recent years. Since 2013, 15 regional Academic Health Science Networks (AHSN) across England have supported projects focused on improving quality and safety in care homes [6]. In 2016, National Health Service (NHS) England commissioned the Enhanced Health in Care Home Vanguards, an initiative to implement a suite of evidence-based interventions in care homes located in six areas of England [7]. In the Netherlands, national initiatives focused on improving quality of care in care homes were supported by the Dutch National Care for Frail Elderly Persons Programme, which took place from 2007 to 2016, and comprised a series of Quality Improvement (QI) initiatives and studies clustered around eight academic medical centres [8].

An approach used in several of these initiatives is the Quality Improvement Collaborative (QIC) intervention [9]. Various versions of the QIC intervention exist. One of the most prominent is the Breakthrough Series Collaborative, as developed by the Institute for Healthcare Improvement (IHI) [10,11]. A QIC based on the Breakthrough Series model is a multifaceted intervention that typically lasts 6–15 months [12] and generally includes five essential features: (1) a team of clinical and QI experts bring clinical and QI knowledge and lead the QIC; (2) local multi-professional teams take part and form the collaborative; (3) the collaborative focuses on a specific topic; (4) participants engage in structured activities; and (5) they use the IHI's Model for Improvement to guide change [13]. The Model for Improvement is a framework used to guide improvement projects where goals are set and a process called the Plan–Do–Study–Act (PDSA) cycle is used to test the impact of changes [14]. A PDSA cycle is a cyclical process of planning change (plan), actioning plans (do), observing and reflecting on the result (study), and modifying plans to address what has been learnt (act) [14]. Previously, collaboratives have been studied mainly in hospital settings [9]. The recent use of QICs with care homes in the UK and the Netherlands provides an opportunity to examine and learn whether and how this approach works in this setting.

A recent scoping review conducted by Chadborn et al. highlighted that while there is a body of evidence around QI strategies used in the care home setting, without detailed descriptions of how strategies are applied, the extent to which others can replicate and learn from them is limited [15]. The aims of this paper are firstly to provide detailed descriptions of six QIC projects carried out in care home settings in two countries, and secondly, to share insights and learning from these projects.

#### **2. Method**

Representatives of teams delivering QIC interventions were identified through our networks and UK national organisations including the British Geriatrics Society, AHSNs, the Health Foundation Q Network, and Health Services Research UK. Representatives attended an initial face-to-face meeting where detailed descriptions of each QIC intervention were presented and structured using the Template for Intervention Description and Replication (TIDieR) standardised reporting template [16]. This was followed by a series of face-to-face, electronic, and telephone meetings where the TIDieR framework descriptions were used to elicit discussion about lessons learned during conduct of the QICs. The focus was to find lessons that applied across more than one QIC initiative and those specific to the care home setting, as opposed to generic lessons that might apply to QICs conducted in other contexts. A list of lessons learnt is provided and each is summarised, outlining the challenges faced and the ways that these were addressed. The learning is targeted at teams leading and facilitating QICs in care homes.

#### **3. Results**

#### *3.1. QICs in the Care Home Setting*

The insights in this article are based on six QIC projects. Five were conducted in the UK and one in the Netherlands:

Projects took place in five areas of England (Nottinghamshire, Salford, Essex, Walsall and Wolverhampton, and Bootle) and one area in the Netherlands (Leiden). The earliest project started in 2009 (MOVIT), the most recent started in 2017 (Safer Care Homes), and the length of completed programmes ranged from 13 months (Safer Care Homes) to 42 months (MOVIT), with one project still ongoing since 2014 (PROSPER). Projects' specific aims varied. The PROSPER, Safer Care Homes, and SPACE QICs focused on improving safety and reducing avoidable harms. The PEACH QIC aimed to improve healthcare and used Comprehensive Geriatric Assessment (CGA) as a template to guide discussions. The MOVIT project aimed to improve fragmentation of medical care and the CHIP QIC focused on reducing ambulance conveyances.

#### *3.2. Descriptions of the Quality Improvement Collaborative Initiatives*

Detailed descriptions of each QIC are provided in Tables 1–6, broadly following the TIDieR template, with the addition of information on evaluation activities undertaken for each project.

#### *Int. J. Environ. Res. Public Health* **2020**, *17*, 7601

Essex (Tendring,

 Colchester,

Chelmsford,

 Basildon,

 and Harlow).

 Care home support

 visits were held at care home locations.

Recognition/sharing of best practice:

• • • - Bi-monthly newsletters to highlight achievements, share learning, notify about forthcoming training events, and signpost to useful resources. Care home managers and sta ff also provided content (e.g., photos and articles describing events held at their home). Annual awards ceremony and "celebrating success" forum as part of the shared learning events, to recognise and reward

Programme sustainability: resource toolkit and best practice guidelines developed. Facilitator role in Wolverhampton integrated into the CCQ Quality Nurse Advisor (QNA) role, and quality assurance o fficers trained in QI. In Walsall, QI nurses undertake joint quality visits with the localauthority.

#### *3.3. Delivering a QIC in the Care Home Sector: Lessons Learnt*

Five "lessons learnt", specific to the care home sector and observed across more than one QIC initiative, were identified. These are listed in Box 1 and summarised below.

**Box 1.** Applying the QIC approach in the care home sector: what have we learnt?

	- a. Collecting the data needed to test the impact of change. Data collection burden could be reduced by identifying ways that data collection might be incorporated into care home routine practice in an intuitive way (e.g., the Falls Safety Cross approach).
	- b. Processing and interpreting data. Ensure data are presented in an accessible way, particularly for those who have not previously used data to evaluate change.

#### *3.4. Plan for the Resource Needed to Support Collaborative Teams with Collecting, Processing, and Interpreting Data*

Collaborative teams taking part in a QIC carry out projects where changes are made that aim to improve the quality of care, and PDSA cycles are used to test the impact of those changes. Data are an essential ingredient in assessing whether or not changes result in improvement. However, the data to inform PDSA cycles are not readily available in care homes in the same way as they are in health sector settings (Box 1, point 1a). Or, if data are available, the specific nature of the data might not match the specific aims of the QI projects. For example, collaborative teams in the Safer Care Homes collaborative faced challenges with establishing a baseline number of falls with harm and medication errors in care homes, and for this reason, the QIC facilitators worked closely with care homes to support data collection. Indeed, QIC facilitators were needed to provide support in all projects assessed in this paper. Collaborative team members provided data and the QIC facilitators then processed the data, constructing data dashboards and runtime charts. In some cases, QIC facilitators also helped with collecting data. In addition to this, the frontline staff taking part in the collaboratives may not have worked in this way before, where changes to care are made and data are used to evaluate the impact, and for this reason, QIC facilitators helped with interpreting data and reviewing PDSA cycles, arranging meetings where the data were interpreted and discussed.

A shared observation across projects was the importance of presenting data in an easy-to-digest way that enabled collaborative teams to review the impact of their changes (Box 1, point 1b). The level of support with data collection, processing, and interpretation required substantial resources from the QIC facilitators, which was not always anticipated during the planning phases of projects. To reduce data collection burden, the SPACE and PROSPER projects looked for ways that data could be collected within care home routine practice in an intuitive way. Both the SPACE and PROSPER projects used the Falls Safety Cross (for example, see https://www.livingwellessex.org/media/571058/falls-safety-cross.pdf), a data collection tool where care workers indicated the number of falls per resident on a prominent visual aide memoire display. This allowed falls-related data to be collated over time and allowed the data to be used to link to the improvement aim. Over time, care homes modified the Falls Safety Cross to also capture additional aspects of care quality such as incidents of challenging behaviour or resident hydration. An additional benefit for the care home was that the collection of data provided evidence of their safety culture, which was noted positively during inspections by the English regulator, the CQC.

#### *3.5. Create Encouraging and Safe Working Environments*

Care homes are heavily regulated, face negative public perceptions and stigma, and the majority of care homes are run by private companies (in the UK), and thus, there can be a sense of competitiveness between care home organisations. For these reasons, those working in care homes might be wary of and have reservations towards both those external to the care home sector (for example, academic researchers and those working in an NHS or commissioning role) and those from other care home organisations.

Across all QICs projects, conscious efforts were made to help create environments where participants felt safe and valued (Box 1, point 2). One technique was the use of appreciative language when asking collaborative teams for project progress updates. This could involve, for example, asking teams to focus on "*What worked well and why?*", "*How would you want things to be?*", "*How can we work together to make this happen?*", and "*What needs to be in place to make it happen more of the time?*". Phrasing questions carefully using appreciative language helped to focus on moving forward instead of focusing on barriers or problems. Another technique used by QIC facilitators was to create a celebratory atmosphere during shared learning events by congratulating collaborative teams, sharing positive stories. Ice-breaker activities helped to create an atmosphere of inclusivity and encourage connections amongst collaborative teams. Establishing agreed ways of working (e.g., listen to whoever is speaking, no question is a silly question, do not speak using acronyms) helped to create a safe environment and reduce perceived hierarchical imbalances, particularly where teams were mixed in seniority and/or professional status. In some projects, backfill payments were provided to care home staff to reimburse the cost of the time taken to attend meetings and help with arranging staff cover. Small gestures also helped to create an atmosphere where collaborative members' attendance and input was valued, such as providing high-quality catering at collaborative shared learning events. An observation across all projects was that over time, trust, relationships, and a sense of community developed where care homes started to work more collaboratively, openly sharing their ideas and learning and resources (e.g., training resources).

#### *3.6. Seek Out Collaborative Teams and Leads*/*Facilitators with Existing and Longstanding Relationships*

A shared observation across QIC projects was the time needed to establish teams, build trusting relationships, and develop and implement improvement projects should not be underestimated (Box 1, point 3). The MOVIT project's experience suggests that recruiting and forming collaborative teams takes at least one year, establishing team rapport and developing QI projects could take up to six months, and depending on the improvement projects, the time required to be able to notice effects could be a matter of years. The PEACH study recognised this and actively sought out collaborative teams where there were established relationships, enabling teams to "hit the ground running". Similarly, good working relationships between the collaborative members and the QIC leadership team also help with project progress. The Safer Care Homes project leads used their pre-existing relationships and recruited care homes known to the QIC leads and facilitators, and found faster progress where collaborative team members knew the facilitating staff. In projects where the QIC project facilitators were not known to the care homes taking part, it was found that progress became easier once trust was established and any previous disputes or misunderstandings resolved.

#### *3.7. Clarify Collaborative Member Priorities and Lines of Responsibilities*

The care home sector is distinctive in that there are multiple organisations and multiple and different health or social care professionals provide health- and care-related services to residents. When delivering a QIC project, those leading and facilitating need to ensure collaborative teams develop QI projects which are directly related to team member job roles and responsibilities, and in which team members believe their job role and responsibilities could have some influence (Box 1, point 4). For example, the Safer Care Homes project set out to reduce falls, pressure ulcers, and medication errors. In the initial stages, care home staff viewed the cause of these issues as external to the home, believing that pressure area damage was acquired during hospital admissions and not inside the care home. In this case, QIC leads sought to discuss the factors which affected resident safety both inside and outside the homes, and participants started to engage when they saw they had some influence. The variety and mix of health and social care professionals may also mean differences in perceived priorities. In a similar way, it is worth spending time checking collaborative teams are invested and view QI project topics as a priority. For example, in the MOVIT project, collaborative teams spent some time at the beginning of the project reflecting on and choosing project ideas that aligned with their priorities. This ensured collaborative teams worked on topics that mattered to them. Allowing teams to work on their local priorities helped to maintain the ownership and buy-in needed to implement change. Working in this way and allowing local priorities to take precedence might not be possible if projects are funded to achieve objectives focused on a predefined topic.

#### *3.8. Work Flexibly and Modify Planned Activities Where Needed*

The experience shared across projects is that whilst QIC facilitators may have had project activities planned, they often had to work flexibly and adapt activities in response to collaborative teams, adapting their activity plans as they went along (Box 1, point 5). This is true in all QICs, but particularly when working in care homes because processes and principles which work for community healthcare or hospital teams will need adaptation to work in this setting. For example, the CHIP project reduced original meeting durations to enable greater focus and maximum attendance, and the PEACH project changed the programme remit from one around Comprehensive Geriatric Assessment, which members found difficult to understand, to one around delivering holistic care to residents. More examples around how QICs projects were modified are provided in Tables 1–6. We suggest that project teams carry out initial pilot/set up phases. This would help to "test" planned activities, check feasibility, and examine potential modifications that might be needed. Initial pilot/set up phases would also help to build in the time needed to establish collaborative teams and build trusting relationships (Box 1, point 3).

#### **4. Discussion**

The extent of what we can learn from publicly available reports of QI in care homes is limited due to the lack of detailed reporting in this field [15]. This article helps to address this gap by providing detailed descriptions of how the QIC method has been applied and insight into the experiences of six projects using this methodology in care homes in the UK and the Netherlands. The insights described in this paper are also likely to be of value to those working in healthcare settings. While there is a wide-ranging QI evidence base, there is also a wide-ranging care home evidence base, with limited interaction between the two. Currently, insightful learning from each literature base has not yet been brought together, and thus, insights which may surprise experts in QI may not surprise those who are expert in care homes, and vice versa. Bringing insights and learning together in one paper is an important step forward.

One common observation across projects was that QIC leads and facilitators had not anticipated the extent of support collaborative teams would need with collecting, processing, and interpreting data. Use of baseline data and comparison groups to determine the effect of changes made to practice is rare in the care home sector, but of great importance to robust evaluation. It is important to take time establishing the data needed at the beginning of the project so its implementation and impacts can be properly monitored. The observation around data collection is perhaps unsurprising in countries where care home sector data are not routinely available and are held across different organisations. The collaborative nature of the QIC approach, though, could bring together key stakeholders from across organisations where data are held, and thus, help with accessing relevant data. This is an issue in countries as diverse as England, Austria, Portugal, and Brazil. In England, numerous ongoing research studies are focused on addressing this [25,26]. Countries such as the Netherlands and the United States have more consistent approaches to collecting care home quality benchmarking data [27,28].

Our other observations provide practical recommendations that are consistent with, and build upon, the wider care home literature. Previous findings show when dialogue with care homes is appreciative and focused on what is working well, this helps to develop practice in care homes [29]. Evidence also shows that working relationships in the care home sector are of particular importance, as successful innovations in care homes are established on a foundation of longstanding collaboration and trust [30]. In addition, previous evidence highlights how the lines of responsibility for those working in and with care homes are not always clear, as people living in care homes receive care from professionals working in different organisations. Thus, there can be uncertainty and dispute over roles and responsibilities for particular aspects of care [31].

#### *Strengths and Limitations*

A key limitation is that the learning described here reflects the experience and perspectives of those who led and facilitated QICs, and not the views of collaborative participants. The insights we present were developed through a relatively unstructured, discussion-based approach, though our use of the TIDieR framework enabled us to identify, present, and compare key points of similarity and difference across the cases. Some of our observations might be unsurprising to those working in care homes; however, we believe these care home-specific insights may not be fully appreciated by improvement practitioners who work outside the care home setting.

The main strength of our article is that it addresses a gap in the existing QI and care home evidence base. A recent review of QI strategies applied in care home settings included 65 studies, and reported that to date, the evidence in this field lacks comprehensive reporting, limiting the extent to which others can replicate and learn from existing work [15]. This paper makes a start in addressing this gap. To our knowledge, this article is the first to provide detailed descriptions of multiple QICs applied in the care home setting and describe learning from across these projects. Our detailed descriptions are structured using standardised reporting (the Template for Intervention Description and Replication—TIDieR). Reporting templates have not yet been used in the existing evidence base. Nevertheless, we have only begun to scratch the surface of learning from collaborative projects in care homes. We recommend that future research builds on this foundation by continuing to comprehensively describe how QICs are applied in this setting and conducting in-depth process evaluations to generate more learning about how to apply QIC methodologies in the care home sector.

#### **5. Conclusions**

As Marshall et al. put it, "frontline practice is messy, it is never possible to do things perfectly, and good improvers are always learning" [19]. The experiences described here illustrate that improvement tools and techniques cannot to be taken "off-the-shelf" and applied without adaptation to the local context [19]. Our detailed descriptions of how the QIC approach has been applied in care homes, and the practical lessons learnt, will enable future teams to progress more quickly. We recommend that teams leading QICs in this sector continue to share detailed descriptions, given the paucity of literature available on the topic to date.

**Author Contributions:** All authors contributed to the insights described in this paper (R.D., G.M., J.B., L.B., T.P., L.C., C.M.-T., T.W., S.D., J.M., A.P., P.C., D.H., C.G., K.H.-S., N.C., and A.L.G.). R.D. and A.L.G. wrote an initial draft and co-authors (G.M., J.B., T.P., L.C., C.M.-T., T.W., S.D., J.M., A.P., P.C., D.H., C.G., K.H.-S., N.C.) contributed to reviewing and editing the paper. All authors have read and agreed to the published version of the manuscript.

**Funding:** The PEACH programme was funded by The Dunhill Medical Trust (grant number FOP1/0115). The Safer Care Homes collaborative was delivered by a local organisation called Haelo; an innovation and improvement science centre based in Salford commissioned by Salford Clinical Commissioning Group. The PROSPER collaborative was originally funded by the Health Foundation and has been sustained with Essex County Council and Better Care Fund funding. The SPACE programme was funded by the West Midlands Academic Health Sciences Network (WMAHSN) Patient Safety Collaborative. The MOVIT project was funded by the Dutch Ministry of Health via the National Programme on Elderly care. The CHIP project was funded by the South Sefton Clinical Commissioning Group. C.G. is funded by the National Institute for Health Research (NIHR) Applied Research Collaboration (ARC) North West Coast, A.L.G. is funded by the NIHR ARC East Midlands, and S.D. is funded by the NIHR ARC West Midlands. The views expressed in this publication are those of the author(s) and not necessarily those of the NIHR, the NHS, or the Department of Health and Social Care.

**Acknowledgments:** The authors would like to thank and acknowledge the teams who participated in each of the QIC projects described in this paper.

**Conflicts of Interest:** The authors played a key role in leading and facilitating the PEACH (A.L.G., J.M., J.B., R.D., N.C., K.H.-S.), Safer Care Homes (L.B., T.P.), PROSPER (L.C.), SPACE (C.M.-T., T.W., S.D.), MOVIT (A.P.), and CHIP (P.C., D.H., C.G.) QICs.

#### **References**

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International Journal of *Environmental Research and Public Health*


**2.6.1 Solution combustion method**

Combustion synthesis is an effective, low-cost method for production of various useful materials. Today, it has become a very popular approach for preparation of nanomaterials.

Solution combustion synthesis (SCS) is a versatile, simple and rapid process, which allows effective synthesis of variety of nanosize materials. This process involves a self-sustained reaction in homogeneous solution of different oxidizers (e.g., metal nitrates) and fuels (e.g., urea, glycine, hydrazides). Depending on the type of the precursors, as well as on conditions used for the process organization, the SCS may occur as either volume or layer-by-layer propagating combustion modes. This process not only yields nanosize oxide materials but

freeze-dryer will carry out its function: to provoke the sublimation of the solvent. For that, the frozen solution undergoes an important vacuum created by a pump, allowing the solvent to sublimate and being the latter frozen once again into a big drum at a very low

After one/two day(s) the dried solution – called now *precursor* – is disconnected from the freeze-dryer and treated at certain temperature in order to allow the reaction between the different reagents which are mixed in extremely fine and close way. This method allows much lower both dwelling times and heating temperatures, at the time that makes easier the

One method often employed is to melt the reagents together and then later anneal the solidified melt. If volatile reagents are involved these are usually put in an ampoule that is evacuated (the reagent mixture is kept cold – by keeping the bottom of the ampoule in liquid nitrogen, e.g.) and then sealed. The sealed ampoule is then put in an oven/furnace

Pechini method is a widely used method consisting of the mix of metal nitrate solution of the starting materials with a stoichiometric amount of citric acid. The resulting solution is stirred on a hot plate and the temperature stabilized at about 90ºC, at which point ethylene glycol is added at a mass ratio of 40:60 with respect to citric acid. The temperature is maintained constant up to the resin formation, which polymerizes at about 300ºC. The

This method, as a soft-chemistry one, leads to homogeneous and low crystalline products at relatively low temperatures, but they usually require expensive initial compounds and/or

Some relative new methods are worth being mentioned, like the solution combustion

Combustion synthesis is an effective, low-cost method for production of various useful materials. Today, it has become a very popular approach for preparation of

Solution combustion synthesis (SCS) is a versatile, simple and rapid process, which allows effective synthesis of variety of nanosize materials. This process involves a self-sustained reaction in homogeneous solution of different oxidizers (e.g., metal nitrates) and fuels (e.g., urea, glycine, hydrazides). Depending on the type of the precursors, as well as on conditions used for the process organization, the SCS may occur as either volume or layer-by-layer propagating combustion modes. This process not only yields nanosize oxide materials but

precursor powders are heated for several hours at various temperatures.

method, the sonochemical method, and the microwave assisted synthesis.

temperature inside the device.

and given a certain heat treatment.

complicated synthesis procedures.

**2.6.1 Solution combustion method**

way to get pure phases.

**2.4 Melt method**

**2.5 Pechini method**

**2.6 Other methods**

nanomaterials.

also allows uniform (homogeneous) doping of trace amounts of rare-earth impurity ions in a single step.

### **2.6.2 Microwave assisted method**

Microwave heating allows a rapid heating rate, however, the final yield decreases compared with the conventional methods. It leads to the synthesis of materials by consumption of less energy.