CPD for healthcare, social care and social sciences professions

Higher education institutions offer some supplementary courses and elective courses for professionals in healthcare, social care and social sciences, including knowledge about gender, sexuality and LGBTI perspectives, with a particular focus on professional groups that interact with children and young people (Solberg, 2017; Stubberud et al., 2018). In this section, we will look at short CPD initiatives that have been and still are important for how professionals in these professions acquire knowledge. The CPD initiatives are also important because many in the elder care sector do not have higher education, received their education some time ago, or did not acquire LGBTI perspectives from their education.

The material is based on studies of CPD and interviews with course providers in different countries conducted in connection with the knowledge inventory. The knowledge about the Norwegian context is mainly taken from the author herself, who has worked in CPD in elder care in Oslo in recent years.

Janne Bromseth worked as a training manager for FRI Oslo Viken’s training programme Skeiv kunnskap (Queer knowledge) with special responsibility for the elder care field in 2017–2022.

CPD is mainly provided by civil society organisations, especially LGBTI organisations and other organisations working with SRHR-related issues. In Sweden and Norway, the national LGBTI organisations have their own education units, and training is provided in all the Nordic countries and in Åland to a greater or lesser extent. These education activities are mainly financed by state and municipal funding in most of these countries, while the Swedish Federation for Lesbian, Gay, Bisexual, Transgender, Queer and Intersex Rights (RFSL) offers courses as a limited company, where LGBTI certification comprises a considerable part of its contract education, largely for public sector activities.

LGBTI certification has been offered in Sweden since the early part of the 21st century. These are longer, process-oriented training programmes with mandatory participation, and require an action plan for the period of validity of the certification. The certification results in a visible mark after the course has been completed if the organisation has met a number of requirements to be certified in relation to equivalent services and a gender-equal, non-discriminatory work environment. The certification model exists in different variants in several European countries, and has expanded as statutory protection against discrimination on the grounds of gender identity, gender expression and sexual orientation has been instituted, along with stricter requirements for preventive efforts (Christophersen, 2021; Pijpers, 2022).

In Sweden, there are several different models due to organisations in municipalities and regions having developed their own model, LGBTI certification, which is often shorter and aimed at healthcare and social care staff

Västra Götaland Region’s Närhälsan’s LGBTI certification was established in 2009 and Region Stockholm’s LGBTI certification for healthcare centres in 2015. The City of Stockholm also has its own LGBTI certification.

(Linander & Nilsson, 2021). National funds to increase knowledge for more equal access to care for LGBTI people in the regions have also been allocated (Linander & Nilsson, 2021). In the Nordic countries, variants of certification of operations are also offered in Finland, Iceland, Norway and Åland. In Denmark, civil society organisations hold courses but do not offer certification. The Finnish LGBTI organisation SETA developed certification specifically for elder care activities in 2018, based on the Dutch Pink Passkey model which has been available to healthcare and social care institutions with older LGBTI people as target groups since 2008. The Pink Passkey model is based on older LGBTI people themselves being an active part of the training process, which the Swedish and Norwegian models do not do. The Norwegian Regnbuefyrtårn is based on the experiences of Swedish actors and was launched by FRI Oslo Viken in 2020. Reykjavik Municipality has an employee who holds courses for the municipality’s employees in various activities. This employee has also developed a short certification process. The pedagogical approach in different models seems to have been developed based on other actors’ experiences and approaches. Learning exchange has been documented in some cases, mainly on order from the responsible CPD coordinator (Ahlsdotter, 2017; Johansson Wilén & Lundsten, 2019; Tapper, 2016; Linander & Nilsson, 2021).

It is worth noting that a majority of these courses today are based on norm-critical perspectives, which are highlighted as a key starting point for change by several people in the studies referred to in Part 2 (Tengelin et al., 2019; Lundberg, Malmqvist & Wurm, 2018). But what results do they produce in practice?

There is a lack of qualitative knowledge data on how CPD initiatives affect healthcare activities, which Linander and Nilsson point out in their study of LGBTI certification from a patient perspective in Västerbotten County in Sweden

This study is mainly used to look at the structural and educational framework of the training, and not the patient perspective as it is based on patients between 20 and 40 and their experiences of certified healthcare activities in Region Västerbotten.

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There are a few studies that look at the results of CPD initiatives among the staff who have been trained (see also Part 1). However, they do not specifically address elder care activities, but may have older adults as part of their target group. Several of the Swedish studies of professional practitioners’ knowledge and practice in healthcare, social care and social sciences also include participants who have taken part in CPD initiatives even if the training itself is not the main focus (Sommarö et al., 2017; Smolle & Espvall, 2021; Johansson Wilén & Lundsten, 2019; Solberg, 2017). Johansson, Wilén and Lundsten (2019) investigated the Kunskapscentrum för sexuell hälsa (the knowledge centre for sexual health) process-oriented course on norm-conscious treatment on behalf of Västra Götaland Region (which funds the LGBTI certification). The study is based on both interviews with people identifying as LGBTI seeking care from certified activities about their experiences, and employees’ experiences of the training and how it subsequently affected their activities. KSH has certified different types of healthcare activities: Närhälsan (primary care), hospital services, healthcare centres, administrative units in healthcare in the Västra Götaland region and all midwifery clinics and most youth clinics in the region.

Since its inception in 2009, the certification has undergone two major changes, gradually increasing its focus on norm-conscious interaction as a goal and process-oriented activity analysis as a pedagogical approach with fewer lectures, and this study was carried out just before the last revision. Employees who participated in the study worked in two different activities: a therapy clinic and a healthcare provider. Their experiences differed in several ways:

While the therapy clinic was able to build on already established practice of reflecting on conversations and interactions in lunch breaks and the workplace community, with norm-conscious interaction and LGBTI perspectives becoming an extension of this, this was much more challenging in a healthcare practice with high staff turnover. At the therapy clinic, practice has changed in several ways in routine work according to an employee:

Routines concerning gender-neutral language and asking about pronouns are now an integral part of the clinic’s practice. In the healthcare activity, there were similar positive experiences of integrating new knowledge into existing procedures come. At the same time, the healthcare activity faced major challenges related to high staff turnover, which also meant temporary workers from other departments who had not undergone certification, as well as a lack of time in the system to integrate the knowledge sufficiently.

Knowledge about LGBTI people often becomes the responsibility of employees who themselves identify as LGBTI. The need for patients to train healthcare staff is also a common experience among older LGBTI people, especially for trans people (see Part 1). Even in certified organisations, employees who identify as LGBTI feel that they have to take greater responsibility for implementing LGBTI perspectives than their colleagues, write Johansson Wilén & Lundsten (2019):

In Sommarö et al. (2017)’s study of gender, sexuality and LGBTI perspectives in two habilitation units for people with learning disabilities, all employees of two out of four teams had also undergone LGBTI certification:

The CPD led to important changes in the organisation: inclusive and gender-neutral language in schedules, gender-neutral toilets and increased awareness that they were affected by heteronormativity in their thoughts and working methods, and willingness to use this insight to continue a norm-conscious, self-reflexive approach in their work. Despite this, several people still found it difficult to discuss LGBTI-related topics in conversations with patients unless the patient initiated the conversation, and could feel uncertain about what to do, especially in connection with norm-breaking gender identities. There was also no clear integration of LGBTI perspectives into the provider´s policies and guidelines that were visible to new employees and patients.

Lack of knowledge and uncertainty about gender identity and gender expression were also evident in Smolle and Espvall’s interviews with social workers who interact with older people. Among their informants, about half had participated in CPD courses in the form of certification or similar (Smolle & Espvall, 2021). However, they could not see any major difference in how the informants talked about how knowledge about norms, gender identity, gender expression and life experiences and inclusive interaction with users and patients had influenced them, whether they had attended a course or not. However, evaluating the training process and its conditions was not their main focus and they wanted more research into the effects of training initiatives on knowledge about gender and trans experiences.

In light of their results, Johansson Wilén & Lundsten (2019) recommend specific frameworks and conditions for CPD initiatives that build on and learn from the experiences of the activities studied:

The certification process studied underwent a major change after this evaluation, and today focuses mainly on organisation-based, process-oriented analysis and has fewer lectures, something that was requested in the study.

Since the effects of CPD initiatives will depend on its content and how it is taught, as well as structural and organisational frameworks for the activity (municipal/private, size, general working conditions, part of municipal strategy, etc.) and other contextual factors, the effects of CPD initiatives must be seen in the broader context of these factors.

The demand for courses and certification has increased over the past five years, say trainers interviewed for this study. This is a result of both stricter anti-discrimination laws and explicit policy to increase competence and the fact that the knowledge provided in professional qualification study programmes is insufficient. This leads to a significant gap between requirements to work to prevent discrimination and being able to do so in practice. Svandis Anna Sigurdadottir has been employed by Reykjavik Municipality since 2017, and is its only employee to develop resources and hold courses in all of the municipality’s activities on gender, sexuality and LGBTI. In 2019, she developed a short 4.5-hour certification course for these activities, with a requirement that each activity establish their own action plan and follow-up course after three years Today, 90 activities are certified. But no elder care service has contacted her: “I have not received any trainings from departments providing elder care. This is an underdeveloped topic in Iceland, I experience.”  Over the years, positive changes in various municipal activities have clearly taken place, she thinks, which she has been able to follow from within over time:

Now there are 40 activities in the queue, but there are no more resources in the form of employees, which has led to exhaustion and frustration. Especially when she sees positive results over time in the activities that have been trained. She says: “I’ve got really conflicted feelings because I’ve just been burnt out, because of work, and I can’t see how it will change in the future because there is no funding and obviously the political will is mainly there around pride week, but they do not want to put real money into it. 

 “It is a political issue in itself,” says Svandis, “that the municipality should take responsibility for the issue, and own the knowledge: Shouldn’t we as an arena be responsible for these issues, shouldn’t we build up the competence within the system, not always buy it from external parties who we do not have control over?”

The Icelandic LGBTI organisation Samtökin 78 also provides training in Iceland, and among other things has held short training courses for healthcare staff, in schools, and in teacher education. There is a lot of good will, according to Daniel Arnarsson of Samtökin 78; the organisations want knowledge. However, Samtökin 78 has not been involved in elder care organisations either:

Civil society organisations engaged in education and training with central government or municipal support talk about stressful conditions, both in terms of the scope of support and the possibility of continuity (Nordic Council, 2021). SETA has been a driving force in creating better healthcare and social care for older LGBTI people since the early 21st century in Finland. In 2010, a knowledge base document was written for an older peoples initiative to create an ‘elementary perception of the situation of older LGBTI people in Finland with a focus on healthcare needs’ (Irni & Wickman, 2010, in Wickman, 2013). They received funding for two projects in which older LGBTI people were the main target group, with the development of training for healthcare and social care services as part of the project Likställd ålderdom (Equal ageing), which was funded in 2012. After two years of development of materials and a separate model based on the Dutch Pink Passkey, two senior citizens’ centres were certified. The funding then quickly ran out, says Touko Niinimäki, who was responsible for the training. SETA currently has no special support for training elder care services, says Outi Tjurin of SETA:

However, the material – a knowledge resource with interviews with older LGBTI people aimed at healthcare and social care staff, and a short film, Jag skulle kunna berätta (I could tell you some things) – remains. Tanja von Knorring, the head of Sateenkaariseniorit – Regnbågsseniorer (Rainbow Senior Citizens), says that the organisation’s activists now provide training under the theme ‘How to interact with older rainbow people in healthcare contexts’ free of charge:

Regnbågsseniorer are also active in political advocacy work to improve LGBTI perspectives in professional qualification study programmes: “We are also active in policy work and are trying to influence on the education schemes of vocational and higher education institutes, thus that they would include enough teaching on rainbow related questions”. In the Aland Islands, LGBTI certification was developed, but unfortunately there was no further funding after the project ended:

De säljer nu utbildningen, men hon tvivlar på om någon äldreomsorgs­verksamhet har råd med att betala vad den kostar.

In Denmark, LGBT+ Danmark holds courses for employees in the LGBTI-profiled nursing home Slottet. There is also a three-year visiting friend project in connection with LGBT+ Danmark with support from the City of Copenhagen. After having tried to establish the project within the City’s elder care services, it became clear how important it was to boost knowledge in the City’s general work to counteract social isolation among older people. Project manager Kamille Hjuler Kofoed started to hold courses for employees in elder care but is unsure whether there will be further funding or whether the project will again have to be run on a non-profit basis in the future. Aids-Fondet (the AIDS Foundation) also trains healthcare staff in sexuality and SRHR-related issues, and constantly struggles to maintain funding, which is provided in the short term and is insufficient to meet the demand.

Of 158 people over 50 who tested for HIV and STI at AIDS-Fondet, only 30 say they would have taken a test at their own doctor’s if they had not done so at the AIDS-Fondet test station (AIDS-Fondet, 2023).

In Norway, Rosa kompetanse (Pink skills), the national training body of the association FRI, has received very few requests from elder care, and does not have any special funding for this. However, the local association FRI Oslo Viken has worked politically and socially with older LGBTI people’s conditions in the ageing process for a long time (Møllerop, 2013). Since 2015, they have received annual funding from the municipality to train healthcare staff, with elder care as a priority area, and have their own training unit, Skeiv kunnskap (Queer knowledge), which primarily works in the City of Oslo. Since 2018, work has been intensified because directives to increase LGBTI competence were included in the sector’s budget guidelines for two years, which was crucial since the activities then had to prioritise it. Elder care services currently represent a significant proportion of training activity’s clientele, and the sector has its own action plan and works closely with Skeiv kunnskap on various CPD initiatives.

Six senior citizens’ centres became Regnbuefyrtårn in 2021–2022.

The Swedish company RFSL Utbildning, which is not run with central government or municipal support, has found that, despite a huge increase in demand for LGBTI certification, very few elder care services have been certified. This is what Åsa Wern of RFSL Utbildning has to say:

Elder care services are prioritised when this is a particular focus of projects or a political priority, as in Finland and Norway, but otherwise they seem to form a small part of the actors’ training initiatives. The same is true for the regionally driven LGBTI certification schemes in Sweden (Johansson Wilén & Lundsten, 2019; Linander & Nilsson, 2021). It seems here that there is an unfortunate combination of invisibility in older age, scant resources for CPD on gender, sexuality, LGBTI perspectives and non-discriminatory practice, and scant resources generally in the elder care sector.

A positive trend is that LGBTI perspectives appear to be more often integrated into CPD courses or existing knowledge resources for healthcare and social care staff who interact with older people. An example is the City of Oslo in Norway, where funding for CPD in the elder care sector has been prioritised since 2016. This has also enhanced the sector’s internal knowledge over time, which creates greater potential to integrate the knowledge into routine quality work. An easy-to-read CPD resource, Veier til inkluderende eldreomsorg. Skeive perspektiv (Paths to inclusive elder care. Queer perspectives) (Bromseth, 2019) was published in collaboration with the City of Oslo and a collaborative project on a documentary film, Gammel og skeiv (Old and queer), (both of which were externally funded) and other learning resources for healthcare staff in elder care were developed in 2019–2021. These are based on norm-critical perspectives and, since 2021, they have also been included in Eldreomsorgens ABC (An ABC of elder care), which is a regionally organised introductory course for everyone who works in elder care and has some 5,000 participants every year. The Norwegian Directorate of Health’s national competence centre Aldring og helse (Ageing and health) is responsible for the training material for the courses.

In Denmark, there is a digital resource at the Danish Health Authority’s competent centre Videnscenter for værdig ældrepleje (Knowledge centre for dignified elder care) on how services should work on norm-critical approaches to equivalent and LGBTI-inclusive elder care based on experiences from the City of Copenhagen’s nursing home Slottet. Slottet gained an LGBTI profile in 2015, and one of the strategies for proactively creating a knowledge-based inclusive environment has been a close collaboration with LGBT+ Danmark, which holds workshops three times per year, at which all new employees receive a total of nine hours of skills enhancement; and continuously supervises employees when needed over the year. Simon Meggers Matthiesen’s mapping is used as a teaching resource, and was funded by the Ensomme Gamles Værn (social inclusion of older adults) foundation (Meggers Matthiesen, 2019, see Part 1). The digital resource describes, among other things, the norm-critical working method used as the framework for the organisation:

The municipality allocated DKK 350,000 to boost knowledge during the transition to a LGBTI-profiled nursing home, and the initiative received a lot of attention. Some of Slottet’s experiences of the process, and central parts of the work on uniform skills-enhancement work, are described in the digital resource, along with films and concrete case studies.

In Sweden, the knowledge centre for sexual health in the region of Västra Götaland published a resource on dementia care and sexuality, Sexualitet och demens (Sexuality and dementia), in collaboration with Svenskt Demenscentrum (the Swedish Dementia Centre), with a norm-conscious approach in the knowledge base and focus in case studies and reflection tasks. In 2021, the research-based resource Queer äldreomsorg (Queer elder care), written by Anna Siverskog, was published by RFSL. It is based on interviews with older LGBTI people with experiences from elder care, with healthcare and social care staff working in elder care as the target group. A year later, the City of Stockholm, on its own initiative, used the resource as the basis for a digital course that is now offered to the City’s employees.

A clear pattern is that local action plans are important for initiating and driving CPD initiatives. Long-term work on CPD in certain Swedish metropolitan municipalities and regions seems to have contributed to a greater integration of responsibility for and implementation of skills enhancement with what several refer to as ‘norm-conscious working methods’ (instead of LGBTI competence), in which municipalities and regions themselves are responsible for CPD (Johansson Wilén & Lundsten, 2019; Linander & Nilsson, 2021). The situation varies greatly, says Åsa Wern. Some municipalities have taken a long-term approach over several years, even a few smaller municipalities. Since RFSL’s certification is also expensive, political support is also required here that also highlights the need in political forums such as municipal executive committees. There is often good will and an understanding that a knowledge boost is necessary, she thinks. But the opposite has also happened in recent years, that organisations want knowledge but not visible certification, especially in Skåne, where right-wing conservative forces have grown strong on municipal executive committees and actively opposed LGBTI CPD initiatives.

Despite positive developments in terms of integrating knowledge about LGBTI perspectives, gender and sexuality in government and municipal resources for healthcare and social care staff, it is insufficient in relation to the knowledge needs of the staff. This is the case in all Nordic countries, with the exception of Sweden, where CPD initiatives are highlighted at central government and regional policy levels in relation to work on equal access to healthcare, and with clearer integration where regions themselves carry out the CPD (see also Wickman, 2013). Insufficient resources easily lead to superficial box-ticking measures in which a short online lesson or a short lecture is intended to meet the need, and to knowledge being considered voluntary and not an integral part of the activity, say several of the trainers interviewed:

The person who often takes responsibility for ensuring that the training takes place is a key individual who has a special interest because they are LGBTI themselves or have a family member who is. The same person also takes responsibility for training healthcare staff when there is insufficient knowledge, which is also discussed by queer employees in Johansson Wilén & Lundsten’s study of certified healthcare organisations (2019):

It is largely the LGBTI organisations and people who identify as LGBTI who provide training with scant resources, with highly trained staff working on short, precarious contracts with project funding that may suddenly run out. These people feel the need for knowledge to exist for their own sakes, that of their friends, the LGBTI community or the lives of rainbow families. Svandis Anna Sigurdadottir explains how she feels a great responsibility to continue to exert influence through her training activities in a small country in which few people have her skills. This is also linked to a clear concern about the political climate in which LGBTI rights and, in particular, trans rights have been actively opposed by anti-gender movements in recent years:

The level of knowledge is low and the organisations have a great responsibility to provide the knowledge that would have been part of the staff’s basic training, says Kamille Hjuler Kofod of LGBT+ Danmark – and at the same time it is random who gets it:

There is no policy for training initiatives specifically for elder care services in Iceland, says Daniel Arnarsson, head of Samtökin 78. However, increased demands on schools to integrate knowledge about sexual orientation, gender identity and gender expression have led to the organisation giving teachers one lesson in year 3 of their training, but it is not enough to ensure change in practice:

Here, too, it is the LGBTI organisation that goes in as a knowledge provider to fulfil a statutory requirement in teacher education, and at the same time concludes that it is not enough to change the teachers’ competence to carry out their task in practice.

The material shows that there seems generally to be a significant gap between the policy and practice levels when it comes to integrating knowledge in healthcare and social care activities that interact with older people. Studies show that CPD initiatives have some effect, but who gets knowledge is random and vulnerable. LGBTI organisations carry out a large part of their CPD initiatives with scant resources and uncertain funding conditions, and feel a great responsibility to raise the level of knowledge. There are examples of strategic measures to integrate knowledge in the municipal sector, especially in Sweden, where municipalities or regions are responsible for training initiatives. However, the elder care sector is rarely represented among the organisations that are trained.