Directors’ leadership styles and operational policies on intimacy and sexuality in Christian-inspired nursing homes: a qualitative study
This qualitative study of 21 directors in Christian-inspired nursing homes in Flanders reveals that leadership styles—ranging from participatory and proactive to reactive-avoidant—critically determine how institutional guidelines on residents' intimacy and sexuality are translated into operational policies, staff training, and physical accommodations.
Original paper licensed under CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). This is an AI-generated explanation of the paper below. It is not written or endorsed by the authors. For technical accuracy, refer to the original paper. Read full disclaimer
Human beings do not stop needing connection, touch, or intimacy simply because they grow old or move into a care facility. In fact, modern healthcare increasingly recognizes that emotional and sexual well-being are essential parts of a person's life, not just medical needs to be managed. For decades, nursing homes have often treated these aspects of life as taboo, shrouded in silence or dismissed as inappropriate for the elderly. Yet, as care models shift toward a more personal, human-centered approach, the question of how to support residents' relationships has moved from the shadows into the light. The challenge is no longer just about whether it is right to allow intimacy, but how to make it a reality within the complex, structured environment of a home for the elderly. This is where the people in charge of these institutions play a decisive role. The leaders of nursing homes hold the keys to the doors, the budgets for renovations, and the authority to set the tone for how staff talk about love and sex. Their decisions determine whether a resident's desire for closeness is met with open doors and supportive words, or with awkward silence and closed rooms.
A team of researchers from KU Leuven in Belgium set out to understand exactly how these leaders navigate this sensitive territory. They focused on twenty-one directors of nursing homes in the Flemish region, all of which have a Christian heritage. These institutions are significant because, despite a society that has become increasingly secular, they still make up nearly one-fifth of all nursing homes in the area, representing a unique blend of traditional religious values and modern care needs. The researchers conducted deep, one-on-one conversations with these directors, asking them to share their experiences, their struggles, and the specific choices they make when residents express a need for intimacy. The goal was not to judge them, but to listen to how they translate broad ethical ideas into the daily, concrete reality of a care home.
The study revealed that there is no single way these leaders handle the issue. Instead, the directors fall along a spectrum of three distinct approaches. At one end of the spectrum are the "reactive-avoidant" leaders. These directors often feel stuck or paralyzed. They may personally want to support residents, but they feel trapped by rigid rules from their governing boards, a lack of clear guidelines, or a culture of fear within their own homes. In these environments, the topic of intimacy is often treated as something to be avoided or hushed up. Staff members might feel embarrassed to discuss it, or they might make jokes to cope with the discomfort, which ultimately pushes the residents' needs further into the background. The directors in this group often feel they cannot act because they do not have the permission or the tools to do so.
Moving toward the middle of the spectrum are the "participatory" leaders. These directors actively try to break the silence by bringing everyone into the conversation. They believe that decisions about intimacy should not be made by one person in an office, but through a dialogue involving the resident, their family, and the care staff. They see their role as a mediator who helps these different groups find common ground. For example, if a resident wants to be with a partner, a participatory director will sit down with the family and the nurses to discuss how to make that happen safely and respectfully. They often rely on the wisdom of their staff to find solutions, treating the care team as partners rather than just employees who follow orders. However, even these leaders sometimes struggle because they lack a clear, written plan from the top, forcing them to handle each situation as it comes, which can be exhausting and inconsistent.
At the other end of the spectrum are the "proactive" leaders. These directors do not wait for problems to arise or for residents to ask for help. They have a clear vision that intimacy is a normal and healthy part of life for everyone, regardless of age. They actively create an environment where this is possible. They might have already arranged for couples' rooms, installed special mattress connectors that allow two single beds to be joined, or set up a system where residents can easily request privacy. They train their staff in advance so that everyone knows how to handle these conversations with confidence. When a family member objects to a resident's relationship, a proactive director is ready to step in, explain the home's values, and advocate for the resident's right to love. They see their job as building a culture where intimacy is supported from the very beginning, not just reacted to when a crisis occurs.
The research found that the way a director leads directly shapes what happens in the rooms down the hall. It influences whether a resident can knock on a door and have it respected, or whether they are interrupted by staff who do not know how to ask for permission. It determines if a couple can share a meal in a decorated room for their anniversary, or if such a celebration is never considered. It even affects whether a nursing home will help a resident access professional sexual services if that is what they need. The study showed that directors who are proactive or participatory are much more likely to provide these supports. They are the ones who have turned the abstract idea of "human rights" into practical things like "Do Not Disturb" signs on doors, private spaces for couples, and training sessions that help staff feel comfortable discussing sex with older adults.
One of the most striking findings was that these leadership styles are not fixed traits. The researchers noticed that during the interviews themselves, many directors changed their minds. Those who started the conversation feeling hesitant or bound by rules often began to see new possibilities as they spoke. They realized that they could be more open, that they could talk to their families and staff in new ways, and that they did not have to be paralyzed by fear. This suggests that leadership in this area is not a permanent state but a skill that can grow. When given a safe space to reflect and discuss these difficult topics, leaders can move from a place of avoidance to a place of action.
The study also highlighted a gap between what leaders say they believe and what they actually do. Many directors expressed that they support residents' rights to intimacy, yet they often fail to put systems in place to make it happen. They might assume that if a resident asks for a sexual aid or a private room, it will be fine, but they do not have a clear process for how to provide it. This leaves the initiative in the hands of the most vulnerable people—the residents themselves—rather than the institution taking responsibility. The researchers found that without a clear vision from the top and a supportive board, even well-meaning directors struggle to move beyond small, reactive steps.
Ultimately, the paper paints a picture of a system in transition. Nursing homes are slowly moving away from a culture of silence and toward one of openness, but the speed of this change depends heavily on the person at the helm. The directors who are willing to engage in honest conversations, to train their staff, and to redesign their spaces are the ones creating homes where residents can live with their full humanity intact. The study suggests that to help more homes reach this point, leaders need better support, clearer guidelines, and the confidence to trust that supporting intimacy is not a risk to be managed, but a fundamental part of caring for a human being. The path forward is not about finding a perfect rulebook, but about fostering a leadership style that is open, collaborative, and brave enough to treat love and connection as essential needs for the elderly.
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