The call for increased health promotion must address access to mental health care (Bockting, Miner, Romine, Hamilton, & Coleman, 2013; National Institutes of Health Sexual and Gender Minority Research [NIH SGM-RCC], 2016). Within the lesbian, gay, bisexual, and transgender (LGBT) community, transgender individuals experience the most health disparities (Lim, 2013). Devaluation, social isolation, and limited understanding of their life experiences are factors compromising the well-being of transgender individuals (Bockting et al. 2013). Budge, Rossman, and Howard (2014) examined the relationships between social support, coping, depression, and anxiety in transgender individuals. A direct, inverse relationship between social support and anxiety was reported with individuals with high social support using more effective coping and experiencing less anxiety, compared with individuals who reported low social support, ineffective coping, and increased anxiety. The Institute of Medicine (IOM, 2011) called for an increased awareness and action in the development of mental health interventions for transgender individuals (Bariola et al. 2011), which was reinforced by the NIH SGM-RCC (2016).
A significant stressor faced by transgender individuals is access to respectful, competent care (Grant et al., 2011; IOM, 2011; The Joint Commission, 2011; Roller, Sedlak, & Draucker, 2015). Their experiences in clinical settings often include discrimination and stigma (Xavier, Honnold, & Bradford, 2007), which are strongly associated with risk factors for mental illness (Hotton, Garofalo, Kuhns, & Johnson, 2013). The psychological well-being of transgender individuals must be incorporated within nursing curricula to prepare knowledgeable, culturally sensitive practitioners (Brennan, Barnsteiner, Siantz, Cotter, & Everett, 2012; Carabez et al., 2015; Díaz, Maruca, Gonzalez, Stockmann, & Hoyt, 2017; Eliason, Dibble, & DeJoseph, 2010; Lim, Brown, & Jones, 2013; Lim, Brown, & Kim, 2014; Lim & Hsu, 2016). The Essentials of Baccalaureate Education for Professional Nursing Practice (American Association of Colleges of Nursing, 2008) outlined the clinical experience expectations for undergraduate nursing curricula, addressing the need for graduates to be skilled in communication with clients and the health care team. Graduates are expected to competently conduct a comprehensive assessment and to address health disparities.
Nursing research is limited concerning the inclusion of LGBT content in nursing education. Lim and Hsu (2016) reviewed 12 studies to examine nursing participants' attitudes about LGBT individuals. Findings revealed that half of the studies indicated that participants held negative attitudes toward LGBT individuals, which may have an adverse effect on the care provided. Walsh and Hendrickson (2015) surveyed 113 nursing programs for the inclusion of LGBT education using a 12-question, Web-based questionnaire. Of the 21 respondents, 10 (47.6%) addressed transgender individuals and 15 (71.4%) reported spending an average of 1.6 hours on LGBT content, suggesting that more content related to transgender health needs may support students' ability to provide competent care. Strong and Folse (2015) implemented their educational intervention to promote students' ability to care for LGBT clients. Attitudes and knowledge level were evaluated in a convenience sample of 58 participants. A statistically significant increase in positive attitudes and knowledge level was found postintervention. These findings also suggest that education may promote students' ability to care for LGBT individuals.
Simulation is becoming an educational strategy for teaching participants the mental health nursing skills (Brown, 2015; Maruca et al., in press). Through mental health simulation, students can conduct a holistic assessment and evaluate their therapeutic communication in a safe learning environment. However, a review of the literature indicates that simulation to educate nursing students about the mental health needs of transgender clients has not been used.
For the purposes of this research, mental health nursing was explored based on interpersonal relations theory (Peplau, 1991). The nurse–client relationship (NCR) is the center of all nursing activity and is defined as an interpersonal situation where the difficulties of everyday living arise (Peplau, 1991). The purpose of the NCR is to help the client understand the presenting problem. The nursing process is implemented through the NCR, which includes therapeutic communication and self-awareness (Peplau, 1991).
The purpose of this study was to explore undergraduate nursing students' experiences caring for the mental health needs of a transgender client through simulation. The client is a high-fidelity human simulation (HFHS) that mimics reality. Research questions for this study included: (a) What are the experiences of students while caring for the mental health needs of transgender clients through simulation? (b) How do students provide care to address the mental health needs of transgender clients through simulation? (c) How do students describe their self-awareness following simulation?
A focus group method (Krueger & Casey, 2014) was used for data generation. Institutional review board approval was obtained, and all participants consented. Each student had participated in the HFHS as part of the Adult Health II clinical course prior to this study. The simulation was conducted and designed according to best practice in simulation (INACSL Committee, 2016). Students were informed of the study during their Adult Health II classes. The primary investigator was not the faculty on record for the course. Participation in this study was completely voluntary and had no effect on student evaluation. Each student participated in one focus group within 1 month following participation in the simulation. Group size was maintained between five and eight participants. A semistructured interview guide was created based on the study aims. Interview questions included:
- How would you describe your experience caring for the mental health needs of a simulated transgender client?
- How did you use the nursing process to provide care?
- How would you describe your relationship with the simulated client?
- How do you describe your self-awareness following this simulation?
Each focus group was audio recorded and lasted approximately 60 minutes. Group dynamics were documented through a sociogram and field notes. Participants' descriptions were confirmed through member checking (Lincoln & Guba, 1985). Data saturation was achieved after three focus groups were conducted.
Setting and Participants
Each focus group took place in a conference room at the university where the HFPS experience occurred. Criterion sampling (Patton, 2014) yielded a total of 20 first-semester senior nursing students who were enrolled in the mental health course and received instruction concerning therapeutic communication, the NCR, and anxiety in the didactic course prior to the simulation. The objectives of the mental health transgender simulation were to identify symptoms of anxiety, manage anxiety, and utilize therapeutic communication in a culturally sensitive manner. An HFPS manikin was used for this simulation, which enables dialogue between the student and simulated client. This also provides students with the opportunity to establish therapeutic communication to assess anxiety levels while providing safe care. The simulated transgender manikin, Taylor, presented with severe migraines, anxiety, and feelings of isolation. His speech was rapid and disjointed. When participants communicated therapeutically, Taylor's anxiety was alleviated, as indicated by normal vital signs and subjective data. When interventions did not include therapeutic communication, Taylor's anxiety escalated, as indicated by his rapid, disjointed speech and elevated vital signs.
Content analysis is a systematic method of analyzing communication to make replicable and valid inferences from texts (Krippendorf, 2012). Analysis of focus group data was guided by the purpose of the study with the goal of exploring variations in participant perceptions (Krueger & Casey, 2014). Qualitative content analysis as described by Krippendorff (2012) was applied to interpret and describe participants' experiences.
Analysis began with verbatim transcription of the audio recording of each focus group. Following full transcription of the data, each transcript was read in its entirety several times to gain an overall sense of the descriptions. Meaning units were identified and condensed. The condensed meaning units were then abstracted into codes based on interpersonal relations theory (Peplau, 1991), maintaining the core meaning of participant experiences. Codes with similar meanings were grouped into categories based on the characteristics of their content. Comparisons were continuously made between emerging categories and the text as a whole to determine variations in meaning and clearly distinguish each category. Comparisons were made across categories to determine their unique characteristics and to generate subcategories for varied experiences within each category. To maintain trustworthiness, the authors discussed the text, meaning units, codes and categories continuously throughout the interpretation process (Munhall, 2012). In the final step, coded data were synthesized until the final structure emerged. The categories and their content were viewed as a whole, with the central ideas clearly described.
The sample included 20 students. Most of the participants (90%) were female and Caucasian (80%) and between the ages of 20 and 29 years (85%). None of the students identified as transgender. Three of the students described knowing friends and family members who identified as transgender.
Three Emerging Themes
The three categories that emerged were limited experience addressing mental health needs, intervening with client anxiety with the subcategory of prioritizing care and collaboration, and therapeutic NCR with the subcategory of therapeutic communication.
Limited Experience Addressing Mental Health Needs
Students' uncertainty in providing mental health care for any client was increased due to their uncertainty about the particular mental health needs of transgender individuals. Although the students received instruction, they felt unprepared to address the simulated individual's mental health needs: “This one woke up the aspect of me having a hard time helping…trying to do mental health assessment because prior to that it was all medical health.” Students without clinical experience felt uncertain: “Especially if you've never had a transgender client and maybe you don't know really how to go about it…but you've never had a transgender patient and you don't know their specific needs because every patient is different.” Students felt increased anxiety due to their uncertainty: “There was more awkward silence and we were trying to say things…. But when I was standing there, I was like, ‘What do I do?’ I started [feeling] anxious.”
Through simulation, students gained increased awareness of the daily struggles transgender individuals face and believed that understanding their needs was essential: “I picked up on the isolation. Not having someone to talk to. There wasn't a community for that person. He had a hard time communicating with his family.” Another student stated, “We were told that he was a transgender male so immediately I thought that this person most likely has been through a lot.”
Intervening With Client Anxiety
Prioritizing care. Students initially conducted a physical assessment. Once priority of care was clarified, they conducted a mental status assessment and determined that the client had severe anxiety, low self-esteem, and limited social support. Safety and anxiety reduction became their priorities of care. Students also described managing their own anxiety and understood that it affected the client.
Collaboration. Students collaborated with one another to provide care: “We were like ‘You're gonna do this. You're gonna do this’ and we all went in doing it from a physical aspect. As we were talking and listening to the client, you could almost see a shift where ‘that's not the focus, it's the psychological that's the focus.’” They felt comforted having a partner: “Alone, I don't think I would have gotten the same result.”
Students established a therapeutic NCR to meet the client's needs. Physical presence, rapport, and trust were considered essential: “He felt like he was being judged by everybody, and he had had really low self-esteem…so he automatically assumed that you were going to judge him too. So you had to work a little bit harder to gain a relationship and a level of trust with [him].”
Therapeutic Communication. Students described verbal and nonverbal communication, including offering self, silence, empathy, and active listening: “We got quite a bit of information with just therapeutic communication. So as far as nursing process, I feel like we started with therapeutic communication and body language and discovered some safety issues and were trying to get resources.” Students believed that therapeutic interaction was compromised by the manikin's lack of nonverbal communication. “I felt like I could not complete a full mental status assessment because I can't measure the affect. I can't measure nonverbal. I feel like I'm being inquisitive because of asking a whole bunch of questions. So, I was getting anxious because I was not using therapeutic communication because I have to ask all these questions.” Students used silence, but were unsure whether their use of this technique would be perceived accurately.
Students described simulation as an effective strategy for teaching mental health nursing skills. Results supported previous studies addressing the integration of mental health needs of transgender individuals into nursing curricula (Brennan et al., 2012; Carabez et al., 2015; Lim et al., 2014; NIH SGM-RCC, 2016). As reported in previous research (Lim & Hsu, 2016; Strong & Folse, 2015; Walsh & Hendrickson, 2015), students believed that an understanding of transgender individuals' mental health needs was essential for quality care. Participants perceived transgender individuals as a vulnerable community that faces significant health disparities, supporting the literature (Bockting et al., 2013; Budge et al., 2014; Grant et al., 2011; Hotton et al., 2013; IOM, 2011; The Joint Commission, 2011; Roller et al., 2015). Consistent with the American Association of Colleges of Nursing (2008), comprehensive assessment and collaboration were described as essential for client safety and quality care. Students remained self-aware, utilized therapeutic communication, and generated client-centered goals, which supports work by Peplau (1991). Despite their uncertainty, students felt more confident, as reported by Brown (2015).
Participants' experiences caring for the mental health needs of transgender individuals through simulation were explored. Simulation allowed students to assess clients and evaluate therapeutic communication in a safe learning environment. Further understanding of mental health care needs of transgender clients is essential for the promotion of their well-being.
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