During the Obama Administration, the U.S. Department of Health and Human Services (DHHS, 2013) continued its concerted effort to improve the health and well-being of all Americans, including lesbian, gay, bisexual, and transgender (LGBT) Americans. It is estimated that up to 10% of the American population identify as LGBT (Grant et al., 2011). The major health care concerns of LGBT individuals are depression, heart disease, cancer, obesity, and sexually transmitted diseases. Both the Institute of Medicine (2011) and Healthy People 2020 (2016) have addressed health disparities that affect the LGBT community, with the most significant being the lack of culturally knowledgeable health care providers to provide care.
Given that nurses are the largest number of and most trusted health care providers (Riffkin, 2014), one priority question is: Are schools of nursing preparing nurses to be proficient in providing care to LGBT individuals? This study aimed to examine how LGBT health care content is integrated into the curricula of North Carolina schools of nursing and to examine the existence of specific LGBT policies. Adequate integration of LGBT health care content into nursing school curricula will help prepare nurses to become competent in addressing the health care needs of sexual minorities.
Gaps of LGBT Content in Nursing Curricula
The CINAHL®, PubMed®, and MEDLINE® databases were searched using the keywords of nursing schools, nursing curriculum, and LGBT health care in the research published from 2009 to 2016 pertaining to LGBT content in nursing curriculum. Based on the literature review by Eliason, Dibble, and DeJoseph (2010), which addressed the lack of LGBT content in nursing literature, the year 2009 was chosen as the beginning time period for the search.
Findings from the search showed that nursing students were not knowledgeable about providing LGBT health care, that they had less than positive attitudes about providing this care (Rondahl, 2009; Cornelius & Carrick, 2015), and that few nursing programs had integrated LGBT content in the curriculum (Brennan, Barnsteiner, Siantz, Cotter, & Evertett, 2012).
In one review of the literature, Brennan, Barnsteiner, Siantz, Cotter, and Evertett (2012) found that gaps existed in the discussion of LGBT and intersex content in nursing curriculum. The authors underscored the importance of expanding nursing students' definition of diversity before addressing attitudes and competency to provide care. In another study, Lim and Bernstein (2012) provided recommendations on how health care content for aging LGBT individuals could be integrated into a baccalaureate course. The authors recommended that faculty begin by conducting a review of the curriculum to identify gaps and opportunities for course development and health teaching. Carabez, Pellegrini, Mankovitz, Eliason, and Dariotis (2015) examined the effectiveness of a multipurpose assignment in a public health class on nursing students' perceptions of LGBT knowledge. After participating in course readings, the students showed an increase in knowledge pertaining to sexual orientation and gender identity. Cornelius and Whitaker-Brown (2015) found that undergraduate nursing students' LGBT health care knowledge increased, but their attitudes did not improve after a brief educational program. The authors noted that more time might be needed to change nursing students' attitudes toward sexual minorities. Conversely, Strong and Folse (2015) found that knowledge and attitudes increased after a brief 45-minute educational intervention, which focused on definitions, LGBT health disparities, cultural competence, and transgender-specific health care.
In other studies, faculty partnerships resulted in the integration of LGBT content in the curriculum at John Hopkins University (McDowell & Bower, 2015) and in a health assessment course for family nurse practitioners at the University of California at San Francisco (Rowniak & Selix, 2016). In the latter study, no formal outcome measures were evaluated but students provided positive feedback about the experience.
To the authors' knowledge, only one study has examined faculty's readiness to teach LGBT health care content. Lim, Johnson, and Eliason (2015) conducted a national survey of faculty's readiness for teaching LGBT content. The authors found that 75% of faculty indicated that LGBT health care topics were basically nonexistent in the nursing curriculum. The median time devoted to teaching this content was 2.12 hours. The respondents reported that articles on LGBT health care were seldom or never read in professional nursing journals. One limitation of the study by Lim et al. (2015) was that it addressed faculty at Bachelor of Science in Nursing (BSN) programs only.
If LGBT health is taught through the broader lens of health promotion and prevention, the curriculum would better prepare future nurses to provide quality care to sexual minorities (Lim, Brown, & Jones, 2013). But before we can begin to integrate LGBT health care content into schools of nursing, we need to examine the current state of knowledge and identify if gaps exist within nursing curriculum. The findings from this study could add to the literature on how nursing programs from all three educational levels are addressing this content in the curriculum.
The design of this study was exploratory descriptive. The university's institutional review board approved the study.
The researchers developed a survey after a literature search did not identify one for the study's purpose. The literature on LGBT health care issues in nursing and medicine informed the development of the 10-item questionnaire. The questionnaire was meant to represent salient features of LGBT content in nursing. Three LGBT health and nursing curriculum content experts were sent the survey to review for relevancy and accuracy. Using a 4-point Likert scale (1 = not relevant, 2 = somewhat relevant, 3 = quite relevant, 4 = highly relevant), all reviewers agreed that the content was highly relevant, resulting in a content validity index score of 1.00. Nine of the 10 questions allowed participants to respond to general information about their nursing program and LGBT content. Specific information sought included specific course LGBT health care content was covered; hours are devoted to teaching LGBT health care content; elective courses on LGBT health care in the nursing curricula; and the nature of policies regarding students caring for LGBT patients. The last question allowed respondents to answer an open-ended question about the nature of school policies regarding nursing students caring for LGBT patients in clinical practice.
The 10-item questionnaire with an accompanying cover letter was mailed to 70 deans and directors at the address found on the North Carolina Board of Nursing Web site. The schools consisted of 49 Associate Degree of Nursing (ADN), 2 diploma, and 19 BSN degree programs. To increase the response rate, a second mailing was sent to those who had not responded within 4 weeks of the first mailing. Returned surveys provided evidence of implied consent. Data were analyzed using descriptive statistics for differences among ADN, diploma, and BSN programs using SPSS® version 21 software.
Of the 70 schools surveyed, 41 surveys were returned (58% response rate). Participants represented deans and directors from ADN (n = 27, 56%), diploma (n = 2, 100%), and BSN (n = 12, 63%) degree programs. The programs had been in existence for 1 to 100 years (average of 25.57 years). Student enrollment ranged from 50 to more than 600 students. The number of faculty teaching in the programs ranged from 9 to 150.
LGBT Health Care Content
The results revealed that 91% of the surveyed schools indicated they were teaching LGBT content. LGBT content was taught in all three types of programs. The majority of the LGBT course content was taught as an “other” course, which included Fundamentals of Nursing (n = 15, 37%), followed by Health Assessment (n = 13, 32%), and Health Diversity (n = 11, 27%). Additional courses identified were Medical–Surgical Nursing (n = 10, 24%), Psychiatric Nursing (n = 9, 22%), and Maternal–Child Nursing (n = 7, 17%). In ADN programs, LGBT health care content was taught primarily as other courses, followed by psychiatric nursing. With diploma programs, LGBT health care content was taught in Maternal–Child Nursing, Pediatrics, Medical–Surgical Nursing, and Psychiatric Nursing courses. In BSN programs, LGBT health care content was taught primarily in Psychiatric and Medical–Surgical courses. Of note, only one program, an ADN program, reported that they offered an LGBT elective health care course.
Seventy-eight percent (n = 32) of the programs reported that less than 5 hours was devoted to teaching LGBT health care. Seventeen percent (n = 7) reported teaching 6 to 10 hours, and only one program reported teaching 11 to 15 hours of LGBT health care content in their curriculum. The majority of the administrators (n = 35, 85%) responded that they did not have policies regarding students caring for LGBT patients. Many indicated that all patients should receive quality health care regardless of their gender, sexual orientation, or social and economic background.
This study was one of a few to include schools from three educational levels in an examination of how LGBT health care content is being taught in one state. The majority of the schools (91%) indicated they were teaching LGBT content. Consistent with previous research, the total time devoted primarily to this teaching this content was less than 5 hours (Lim et al., 2015). The fact that schools of nursing are teaching LGBT health care content is encouraging, but should more time should be devoted to teaching this content? Faculties find it difficult to maintain high NCLEX pass rates while integrating additional content and time to already full curricula. However, the lack of time teaching this content has resulted in LGBT individuals reporting they have to teach health care providers about their health care needs (Cornelius & Whitaker-Brown, 2016).
There is no evidence to support where LGBT health care content should be taught in the curriculum. It was not surprising that this content is being taught primarily in other courses, as identified by the respondents. LGBT health care content is being disseminated in elective or fundamental courses, where the code of nursing ethics is being discussed. In one study, McDowell and Bower (2015) used a Professional Development course and a Pharmacology course to integrate transgender health care into five baccalaureate courses in their curriculum.
One encouraging fact was that the majority of nursing programs in North Carolina (91%) are teaching LGBT health care content. LGBT content should be taught in courses where health assessment, health promotion, and disease prevention (common threads through all nursing courses) are discussed (Carabez et al., 2015; Lim et al., 2013). Without LGBT-focused education in nursing curricula, students will be unprepared to care for this diverse and often overlooked population.
An emphasis on the readiness of faculty to teach this content in the curriculum has been recommended because this could provide a strong foundation for cultural humility (Jeffreys & Dogan, 2012). Questions that remain unanswered by this study are: “How are nonresponding schools handling LGBT health care content in their curriculum?” and “Is the lack of failure to respond to the survey related to a lack of emphasis on LGBT health care content or a lack of readiness on the part of faculty to teach this content?” Additional research may be needed to answer these questions. Faculty can begin to guide curriculum changes by first reviewing national guidelines on LGBT health care issues. The questions will be answered by examining the curriculum to see who is teaching this information and what competencies are needed for nurses educators. Finally, the study should be replicated on a larger scale to see whether regional differences exist in the inclusion of LGBT content in nursing curricula.
The study had a few limitations. Although the board of nursing Web site consists of state-approved nursing programs only, the nonprobability sample represents deans and directors who responded to the survey. These administrators may have felt a responsibility to address LGBT health care content in the nursing curriculum. Also, because data on the geographic location of the schools were not analyzed, the authors cannot report on regional differences. Schools located near urban cities may be representative of LGBT health care content in the curriculum, whereas schools located in rural areas may not. Future research could examine the readiness of faculty across all educational levels in teaching LGBT content in the curriculum and how much time is needed to teach this content. One limitation, which was also a strength, was that the survey was conducted in one state. Another strength of this study is that more than half of the participants responded, representing a response rate of 58%, which is considered high (10% to 15% is the most common response rate) for mailed surveys (Fryrear, 2015).
Findings indicate that the majority of reported nursing schools in the state are teaching LGBT health care content in their curricula. Consistent with previous research, less than 5 hours is being devoted to teaching this content. Of importance, faculty will need to assess their readiness to teach this content. This may require workshops and sensitivity training to assist them in becoming comfortable and proficient in teaching LGBT health care content.
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