'Inclusivity is about making people feel comfortable to say who they are, being who they are.'
When students of Brenda Cassidy, DNP, RN, CPNP-PC, at the University of Pittsburgh School of Nursing expressed uncertainty about how to respectfully ask patients about sexual orientation and gender identity, a consult with her colleagues found their students felt the same hesitancy.
Cassidy and those colleagues—Betty Braxter and Andrea Fischl—set about to develop a unique interactive learning module and resource toolbox to provide best practices in LGBTQIA+ healthcare to those students—and all healthcare providers.
The unprecedented resources are available to any healthcare provider who wants to approach patients in a welcoming and inclusive manner, Cassidy says. The module is available with and without CE credit.
The module is not medical training, she notes.
"It’s about having a welcoming environment and having the right terms to be gender neutral," she says. "That’s really what’s missing and causes health disparities and discrimination in this population."
- The module offering CE credit can be found here.
- The module summary without CE credit, plus the toolbox, can be found here.
- The toolbox can be found here.
Cassidy referenced the American Association of Colleges of Nursing’s initiative to improve academic nursing programs’ ability to prepare working nurses for a diverse patient population, including LGBTQIA+ individuals (lesbian, gay, bisexual, transgender, queer and/or questioning, intersex and asexual and/or aromantic).
Fewer than 20% of nursing students get such preparation, and one-third are ill-at-ease when attempting to provide care for LGBTQIA+ patients, according to the association.
LGBTQIA+ individuals are often hesitant to discuss their sexual identity with their clinicians. One study shows that "the disclosure of sexual orientation and provider’s attitude were important influencing factors that negatively affected their experiences about healthcare delivery" and that "lack of training can strain the therapeutic relationship between the providers and patients."
Negative experiences include having their concerns dismissed or being blamed for health problems and the strained relationship can affect quality and appropriate delivery of healthcare, the study notes.
Most providers aren’t deliberately prejudiced, but instead harbor unconscious bias, says Cassidy, a pediatric nurse practitioner whose specialty is adolescent healthcare, particularly sexual reproductive health.
Unconscious biases—also termed implicit biases—"surreptitiously influence judgment and can, without intent, contribute to discriminatory behavior," according to the New England Journal of Medicine.
"Pennsylvania conducts a health needs survey of LGBTQIA+ residents every two years, and they've consistently received responses from residents about having had negative reactions from their healthcare providers when they revealed their status," Cassidy says.
"In 2022, that assessment said that 26% of the respondents—which is one in four of the LGBTQIA+ residents who responded—said that they'd had a negative reaction from their healthcare provider with their disclosure of sexual orientation or gender identity," she says. "So, we have to know our biases, and approach patients from the get-go in an inclusive manner."
Consequences of unconscious bias can be devastating for LGBTQIA+ patients, Cassidy says.
"Unfortunately, it results in discrimination and stigma toward this population who's already vulnerable," Cassidy says. "Negative experiences that they have had creates hesitancy on their part to delay seeking care, which then delays diagnosis and treatment, and that results in negative consequences."
Delaying care results in this population’s higher rates of physical and mental health problems, such as cervical cancer, lung cancer, obesity, smoking, addiction, suicide, and homelessness, she says.
"That is a direct result," Cassidy says, "of not feeling comfortable in the healthcare arena."
Finding a solution
When Cassidy and her colleagues began to research ways to address this issue, there wasn’t a lot to find.
"The first thing we did was go to the literature and say, ‘What are we supposed to teach about?’ What we found in the literature was very little information as far as recommended content on LGBTQIA+ health for nursing," she says.
National curriculum guidelines for such modules in nursing education don’t exist, and it generally is not taught in nursing programs.
So, they used focus group methodology to include the voice of faculty, students, LGBTQIA+ individuals, and healthcare providers who care for this population.
"We used the voices of stakeholders to develop the content," she says. "We didn't decide what they needed to know."
"What we found from our focus group was that the most important thing was to be able to communicate that this is a safe space and a welcoming environment to tell us about you so that we can take care of you," Cassidy says.
The learning module covers LGBTQIA+ terminology, statistics on health disparities, and respectful communication so learners can practice using gender-inclusive language in different scenarios.
The toolbox also covers LGBTQIA+ terminology, along with content about trauma-informed care, youth, older adults, disability status, minority care, homelessness, socioeconomic factors, substance use, healthcare specific to non-binary and transgender care, reproductive care, and care of LGBTQIA+ veterans, alongside local resources.
The first step is for a clinician to be aware of their own biases.
"We all have implicit unconscious biases, and anybody who thinks they don't is kidding themselves," she says. "We have them. It's important to be aware of them. Being aware of them doesn't necessarily make them go away, but it helps us to be aware that we have those biases so that those biases don't impact how we care for our patients and the decisions we make about care."
Providers must be open to learning and using gender-neutral terms, Cassidy says.
Some focus group members said they don’t know what to say, but they don’t want to offend the patient, so they don’t say anything. So, Cassidy demonstrated how she starts each conversation: "Hello, my name is Brenda Cassidy. I use pronouns she, her, hers. You can call me Brenda. What would you like me to call you?"
"We heard loud and clear from both the LGBTQIA+ focus group participants as well as the healthcare providers who work with them that welcoming starts when they walk into the area, whether it's an exam room, a waiting room, or a patient room," she says.
It hasn’t been that long since providers were required to be rigid with LGBTQIA+ patients, Cassidy says.
"I remember when you had to say to someone, ‘I know you want me to call you Chloe, but your legal name is Sam,’ and being told we had to put the legal name in the chart or else the insurance company wouldn't cover the visit," she says.
Now, her students who accompany her to see patients at Children’s Hospital’s Center for Adolescent and Young Adult Medicine are more prepared and much less hesitant to talk openly and honestly with patients, she says.
"In this clinic we see LGBTQIA+ youth," she says, "and my students who have completed this module are so much more comfortable approaching these youth in a more inclusive manner and asking them about sexuality now that they have taken this module."
The learning module and toolbox are now part of a four-year research study between Pitt and the Louisiana State University Health New Orleans School of Nursing, looking at an advocacy program and simulations for undergraduate nursing students. Baylor University also is using the module, and Pitt Nursing is promoting it for more schools to adopt. The National Association of Pediatric Nurse Practitioners has made it available to pediatric nurse practitioners, as well.
"Inclusivity is about making people feel comfortable to say who they are, being who they are," Cassidy says, "and we really have made wonderful, great strides, but our work is not done."
“Being aware of [unconscious biases] doesn't necessarily make them go away, but it helps us to be aware that we have those biases so that those biases don't impact how we care for our patients and the decisions we make about care.”
— Brenda Cassidy, DNP, RN, CPNP-PC, associate professor, University of Pittsburgh School of Nursing
Carol Davis is the Nursing Editor at HealthLeaders, an HCPro brand.
Fewer than 20% of nursing students get preparation for providing care for LGBTQIA+ patients.
One in four of LGBTQIA+ patients surveyed said they'd had a negative reaction from their healthcare provider with their disclosure of sexual orientation or gender identity.
Healthcare providers must be aware of unconscious bias to create a welcoming environment.