In 2011, an Institute of Medicine report suggested a need to educate health care providers about lesbian, gay, bisexual, and transgender (LGBT) issues. Until recently, nursing education has been silent about LGBT issues (Eliason, DeJoseph, & Dibble, 2010), and documents on culturally competent nursing practices and cultural humility ignored LGBT patients and employees (American Association of Colleges of Nursing, 2008a, 2008b; Clark et al., 2011). Nursing, along with the rest of society, is experiencing a shift in attitudes about LGBT issues. Recent studies find lower rates of overt negativity among nursing students (Dinkel, Patzel, McGuire, Rolfs, & Purcell, 2007) and practicing nurses (Blackwell, 2006) than in the past (Eliason & Raheim, 2000). The majority of nurse educators now agree that teaching nursing students about homosexuality is important (79% of more than 1,000 U.S. nurse educators; Sirota, 2013). Nurses constitute the largest subset of the health care workforce; thus, nurses have a significant impact on patient well-being. Unfortunately, a minority of nurses hold negative beliefs about LGBT individuals (Dorsen, 2012; Rondahl, Innala, & Carlsson, 2004). LGBT nurses report instances of being treated unfairly or differently than heterosexual nurses (Eliason et al., 2010), and LGBT patients report discriminatory treatment from their health care providers (Rounds, McGrath, & Walsh, 2013).
Nursing education programs may want to include information on LGBT issues but have questions about placement and priorities within their rigidly organized curricula. Even if programs have begun to include LGBT issues, the dominant mode of education focusing on mastering a set of discrete knowledge points makes it difficult to restructure this understanding within the framework of cultural humility. Sirota’s (2013) study of nurse educators found that 72% were not prepared to teach about LGBT issues.
As attitudes shift and laws change, there is a corresponding need to guide the nursing workforce into culturally sensitive practices. According to Tervalon and Murray-Garcia (1998), “[the] traditional notion of competence in clinical training [is] as a detached mastery of a theoretically finite body of knowledge.” In contrast, training for cultural humility in relation to LGBT health redresses the silencing of LGBT experiences and provides a mode of lifelong learning through “self-evaluation and self-critique” (p. 118). Cultural humility gently nudges the person to be open to other cultural values and beliefs and to be self-reflective about one’s own beliefs (Smith et al., 2007), and includes three components: knowledge, attitudes, and skills.
The scant literature suggests that nurse educators agree that LGBT education is necessary, but they lack specific knowledge and skills to teach about the health care needs of LGBT individuals. This article describes an innovative assignment with multiple student learning outcomes. The assignment fosters the development of skills in researching, interviewing, and understanding LGBT health care issues embedded within a cultural humility framework. The first step to engaging cultural humility is to establish what is not known, then to provide avenues to acquire knowledge (Tervalon & Murray-Garcia, 1998). This assignment does both through diverse teaching strategies and preinterview and postinterview surveys of student knowledge. This article describes the changes in student knowledge from the beginning to the end of the semester through a description of the assignment and an analysis of the preinterview and postinterview surveys.
More than 30,000 students are enrolled at this urban public university, which is one of the most diverse public institutions in the United States, located in a diverse metropolitan area. The mission of this school of nursing is to embrace the diversity of its student population and to educate nurses who serve diverse populations, with a focus on social and environmental justice and health equality. At the time of this study, 525 baccalaureate and generic master’s nursing students (84% women and 16% men, 65% aged 18 to 20 years) were enrolled. By race/ethnicity, students were Asian/Filipino/Pacific Islander (35%), White (35%), Latino (14%), African American (5%), mixed race (5%), and missing data (6%). Neither the university nor the school of nursing collect information on students’ sexual orientation or gender identity diversity, but this institution is known to be a welcoming and inclusive campus for LGBT students.
School of Nursing Community/Public Health Nursing Curriculum
Students complete the prelicensure nursing program in five (16-week) semesters. The Community/Public Health Nursing course is offered in the fourth semester and provides the foundation for community health nursing care of individuals, families, and communities. Coursework in prior semesters includes foundations of nursing, medical–surgical nursing, women’s health, and pediatric nursing. The objectives of the course are to describe the multiple roles of the community health nurse working with individuals, families, and aggregates within various communities; to analyze the impact of the sociocultural, economic, and political systems on the health status of individuals, families, and communities; and to identify populations at risk, using the levels of prevention framework. This assignment counted for 25% of students’ grades; students who chose not to participate were given an alternative and were informed that nonparticipation would not affect their grade. The study was approved by the university’s institutional review board.
Purpose of the Study and Course Assignment
Students explored issues in delivering care to LGBT patients and families and the experiences of LGBT nurses. Diverse teaching modalities included readings, a 2-hour presentation on LGBT health issues, and instruction on how to conduct a scripted interview with two nurse key informants based on the Health Care Equality Index (HEI). The HEI, created in 2007 by the Human Rights Campaign (2014), is an online survey completed by health care organizations to evaluate their policies addressing the care of LGBT patients. The purpose of the HEI is to ensure that LGBT Americans receive equitable, knowledgeable, sensitive, and welcoming health care, free from discrimination. The HEI addresses Core Four categories that include (a) Patient Non-Discrimination Policies, (b) Visitation Policies for same-sex couples and same-sex parents for their minor children, (c) Employment Non-Discrimination Policies and (d) Training in LGBT Patient-Centered Care (Human Rights Campaign, 2014). The scripted interview was based on these “Core Four” categories. Prior to conducting key informant interviews with two RNs, students completed a preinterview survey to assess their understanding of gender identity and sexual orientation terms, their own comfort level in providing care to LGBT patients and families, and awareness of the preparation received thus far in their educational experience in LGBT issues. After interviewing the nurses, students summarized the interviews for major themes and completed a postinterview survey. The postinterview survey gave students the opportunity to reassess their knowledge of LGBT health issues and helped them to consider what teaching strategies were the most helpful in preparing them for working with LGBT patients. The assignment served many purposes—in addition to teaching students about LGBT patient care via lectures and readings, students were required to conduct a structured interview with two RNs about LGBT patient care and agency policies and procedures. This assignment involved instruction on conducting qualitative research, effective interviewing skills, and learning to synthesize findings from the interviews into a short summary. In addition, the assignment required students to determine how much knowledge nurses in the field had about LGBT patient care and LGBT nurses’ issues in the discipline. The results of these structured interviews will be reported separately.
What is the baseline knowledge, awareness, and understanding level of fourth-semester nursing students regarding LGBT health care needs? Can a class assignment affect the knowledge, attitudes, and skills of LGBT health care needs in nursing students?
One hundred twenty-two students were enrolled in the class, including students from baccalaureate, generic master’s, and RN-to-baccalaureate nursing programs. Students provided informed consent before completing the online survey, and if no consent was given, the respondent could not proceed. All responses were anonymous and no identifiers such as name, student number, or e-mail address were solicited. All students were assured that participation in the pre- and postinterview surveys would not affect their grade in the course.
Students were evaluated prior to interviewing RN key informants and again after completing the interviews using surveys designed specifically for this study. The preinterview survey contained 14 questions, two of which were demographic in nature to ascertain age group and eligibility (i.e., current nursing students enrolled in the course). Likert scale questions evaluated baseline knowledge in LGBT terminology and issues. Questions focusing on students’ nursing education asked how much education they had received regarding caring for LGBT clients and knowledge about sexual orientation and gender identity (from 1 = not at all knowledgeable to 5 = expert). Comfort level was evaluated with a question on using appropriate pronouns for transgender clients. Students were asked whether they thought their personal, cultural, and religious beliefs and their own sexual and gender identities might impact their ability to provide nursing care. The 18 postinterview questions evaluated which specific assignment components best prepared students to support LGBT clients and allowed students to articulate key concepts learned through this project. Questions focused on the extent to which the interviews provided students with increased research and interviewing skills, as well as knowledge about LGBT clients’ and nurses’ issues.
The majority of students completed the preinterview and postinterview surveys (n = 112), for a response rate of 92% at postinterview survey. Most were between 26 and 35 years of age (49%; 30% were younger than 26 years and 21% were older than 35 years). Nearly 40% felt unprepared to provide nursing care to LGBT patients. More than one in 10 had religious values that might interfere with quality care.
Some students reported a lack of comfort in using a transgender client’s preferred pronoun: 5% were not comfortable; 18% were somewhat comfortable; 70% were comfortable; 5% were not sure; and 2% were missing data. When asked how much they thought gender identity and sexual orientation mattered to the patients and families that they served, 13% said not at all; 16% said very little; 42% said it mattered sometimes; 28% said it matters a lot; and 1% were missing data. On the pretest, 62% said they possessed the knowledge to work with LGBT clients, but 85% said their nursing education had not prepared them, suggesting that they had acquired knowledge from venues other than nursing education. Knowledge about sexual orientation and gender identity from preinterview to postinterview shifted, with the majority of students reporting that they were more knowledgeable after completing the assignment. Change in knowledge was more pronounced for gender identity (t = 19.3, p < 0.0001) than for sexual orientation (t = 4.14, p < 0.005).
The majority (74%) reported that the assignment made them more aware of LGBT issues. Students’ self-reflective comments regarding the usefulness of the assignment referenced their concern with the way LGBT patients and nurses are treated in health care settings. Students noted being made aware of their unconscious biases: “You can never assume anything about your patients,” and “I learned that most people either do not notice, or purposely ignore any discrimination.” Some students recognized that although the assignment better equipped them to address these issues, they still have much to learn: “Opening our minds and bringing awareness to a topic that only has its surface skimmed in the nursing course curriculum. I feel even more comfortable and equipped to deal with issues surrounding this topic,” and “[This] taught me that perceptions and thoughts on the LGBT community is vast and that there is A LOT of room for learning.” After this realization has been made, students can recognize that invisibility and silence often go hand-in-hand with vulnerability.
Many of the open-ended comments about the assignment include students developing consciousness about the need for greater education: “This assignment opened my eyes to an entire culture of patients that no one had taught us about so far in nursing school,” and “I hadn’t thought about the lack of education regarding LGBT issues in nursing school. Now this lack seems glaringly obvious. I think this assignment was valuable.” One student noted: “The LGBT articles…taught me about the nursing silence of LGBT issues in the workplace. This nursing silence was evident in one of my key informant interviews, and since I had read the articles before conducting the interviews, I could give it a name—‘nursing silence.’” These comments point to the potential ripple effect, as nursing students who have been educated regarding LGBT issues may bring this knowledge into the workplace.
Students also recognized the value of conducting original research as nurse-researchers: “Nurses have a great role as researcher[s] in order to improve [the] health of patients.” One respondent commented: “I learned about the power we can have as nurse researchers in order to create a positive change to the nursing field.” This assignment introduces students not only to the skills required to conduct original research, but it also teaches students “that nursing research is incredibly valuable.” The interviews also provided students with the collateral benefit of contacting and networking within the nursing community.
Students benefitted from a guided assignment in a Community/Public Health Nursing class to understand LGBT health care issues and practice skills in interviewing and conducting research. The assignment was near the end of the undergraduate curriculum, but this type of multipurpose assignment could be developed for any nursing class. Assignments that “break the silence” in nursing programs about LGBT issues and social justice open up students to ask questions and to explore health disparities related to sexual orientation and gender identity. Framing the project within the context of cultural humility may benefit student learning by emphasizing the ongoing process of such learning. The preinterview survey allowed students to explore the limits of their knowledge or sexual identity and orientation, perhaps for the first time. The interviews demonstrated the effects that knowledge (or lack) of LGBT issues can have on client care, as well as the value of conducting interviews to add information to the collective knowledge base. The postinterview survey and summaries allowed self-reflection, which is a key component of cultural humility pedagogy. Rounds et al. (2013) reported that LGBT patients desired health care providers who have basic knowledge about LGBT issues and better communication skills. Expert speakers in the classroom created a safe environment in which to ask questions and discuss communication needed to provide patient-centered care. Other skills addressed in this assignment included interviewing skills, synthesis, writing, and critical thinking.
In the setting of a metropolitan area with many hospitals and health care organizations, the primary challenge students reported was finding nurses who were comfortable talking about LGBT issues or taking on the role of key informants. This may reflect the comfort levels of both students as nurse researchers and of nurses as key informants, particularly about a topic for which they had no previous training. However, with thousands of nurses practicing within the immediate area, many of who have connections with the school’s nursing program, it was possible for students to locate respondents.
Nurse educators with little preparation in LGBT health care can use an assignment such as the one described in this article because it focuses on discovery learning. The authors recommend providing a step-by-step checklist and a grading rubric to help students successfully complete the assignment. The time spent to set up this assignment and the attendant guest lectures and readings was equivalent to creating a new course module (this includes obtaining university institutional review board approval). Managing the interviews required the instructor to write clear directions with a checklist and a specific grading rubric.
Even in a large metropolitan area, where many might assume that students already have been exposed to LGBT issues, the majority of nursing students lacked the language, knowledge, and skills needed to provide culturally sensitive care. This course project provided students with the three components of cultural humility: basic knowledge about LGBT health, self-reflection on attitudes of nurses toward LGBT patients and coworkers, and skills in interviewing about taboo topics. Students left the course with an enhanced awareness of the social justice issues involved in the exclusion and silencing of any group of people and enhanced their skills for culturally humble health care provision.
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