“Never in all my years…:” Nurses’ Education about LGBT Health

Abstract

In spite of recent calls for patient-centered care and greater attention to the needs of lesbian, gay, bisexual, and transgender (LGBT) patients, nurses still lack basic education about LGBT patient care and, as a result, may have negative attitudes, endorse stereotypes, and/or feel uncomfortable providing care. This study reports on education/training of practicing nurses and explores some of the reasons for nurses reporting feelings of discomfort with LGBT patient care. Transcripts from structured interviews with 268 nurses in the San Francisco Bay Area revealed that 80% had no education or training on LGBT issues. Although most said they were comfortable with LGBT patient care, some of their comments indicated that they might not be providing culturally sensitive care. Implications for nursing education and for policies and procedures of health care institutions are addressed.
Copyright © 2015 Elsevier Inc. All rights reserved.

Full text

“NEVER IN ALL MYYEARS…”:NURSES'
EDUCATION ABOUT LGBT HEALTH
REBECCA CARABEZ, PHD, RN*, MARION PELLEGRINI, BSN, RN*,
ANDREA MANKOVITZ, BSN, RN*, MICKEY ELIASON, PHD†, MARK CIANO‡,AND
MEGAN SCOTT‡
In spite of recent calls for patient-centered care and greater attention to the needs of lesbian, gay,
bisexual, and transgender (LGBT) patients, nurses still lack basic education about LGBT patient
care and, as a result, may have negative attitudes, endorse stereotypes, and/or feel uncomfortable
providing care. This study reports on education/training of practicing nurses and explores some of
the reasons for nurses reporting feelings of discomfort with LGBT patient care. Transcripts from
structured interviews with 268 nurses in the San Francisco Bay Area revealed that 80% had no
education or training on LGBT issues. Although most said they were comfortable with LGBT
patient care, some of their comments indicated that they might not be providing culturally sensitive
care. Implications for nursing education and for policies and procedures of health care institutions
are addressed. (Index words: LGBT; Nursing curriculum; Diversity training; Health equity) J Prof
Nurs 31:323–329, 2015. © 2015 Elsevier Inc. All rights reserved.
NURSING, LIKE OTHER health and human service
professions, is affected by sociopolitical shifts in
society, although changes to the basic nursing educa-
tional curriculum are slow to initiate and difficult to
effect. This results in knowledge gaps for practicing
nurses that may adversely affect patient care. In recent
years, along with changing attitudes in society about
LGBT people, attitudes of nurses have slowly become
more positive (Dorsen, 2012). However, because nursing
curricula still contain very little information about LGBT
health topics (Lim, Johnson, & Eliason, in press), and
nursing scholarship still ignores research on LGBT
patients (Eliason, DeJoseph, & Dibble, 2010), it is likely
that practicing nurses lack cultural sensitivity to the
needs of LGBT patients. Nursing educators are not yet
sufficiently prepared to teach LGBT health issues (Sirota,
2013), and therefore, nursing practices and procedures
are still heterosexist (Morrison & Dinkel, 2012; Rondahl,
2011). That is, many practicing nurses may be unaware
that some patients (and some coworkers) are LGBT.
In general, nursing has been slower than other health
professions to address LGBT health (Eliason et al., 2010).
Only a handful of studies have examined the attitudes of
nurses, nursing students, and nurse educators (Blackwell,
2007; Dinkel, Patzel, McGuire, Rolfs, & Purcell, 2007;
Eliason, 1998; Eliason & Raheim, 2000; Eliason &
Randall, 1991; Rondahl, 2009; Rondahl, Innala, &
Carlsson, 2004; Schlub & Martsolf, 1999), and although
attitudes have shifted toward the positive in recent years,
there is still a small core of nurses with negative or
ambivalent attitudes, including some who would refuse
to care for LGBT patients if given a choice (Rondahl et al.,
2004). Although nurses may say that they are comfort-
able working with LGBT patients, they still express an
attitude that there is no need for training about these
issues because they “treat everyone the same”(Beagan,
Fredericks, & Goldberg, 2012).
LGBT Health
Significant health disparities for LGBT patients are
addressed in Healthy People 2020 and a recent Institute
on Medicine (IOM) Report on LGBT Health (IOM, 2011).
Among the most significant issues identified by the IOM
report are the following: LGBT youth are more likely to
be homeless and are two to three times more likely to
attempt suicide; LGBT populations have high rates of
tobacco, alcohol, and other drug use; lesbians are less
likely to get preventive services for cancer; lesbians and
bisexual women are more likely to be overweight or
obese; and gay men are at higher risk of HIV and other
sexually transmitted diseases, especially among
*Assistant Professor (Carabez), Nursing student at time of the study
(Pellegrini, Mankovitz), School of Nursing, San Francisco State University,
San Francisco, CA 94132.
†Associate Professor, Department of Health Education, SanFrancisco State
University, San Francisco, CA 94132.
‡Current SFSU graduate nursing student (Ciano, Scott), Student School of
Nursing, San Francisco State University, San Francisco, CA 94132.
Address correspondence to Dr. Carabez: Assistant Professor, School
of Nursing, San Francisco State University, 1600 Holloway Avenue,
Burk Hall 379, San Francisco, CA 94132. E-mail: rcarabez@sfsu.edu
8755-7223
Journal of Professional Nursing, Vol 31, No. 4 (July/August), 2015: pp 323–329 323
© 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.profnurs.2015.01.003

communities of color. Specific to transgender individuals,
the IOM report suggests a significantly higher prevalence
of HIV and sexually transmitted diseases, victimization,
mental health issues, and suicide, and less likelihood of
having health insurance than heterosexuals or lesbian,
gay, or bisexual individuals. All of these health issues are
thought to stem in part from the chronic stress resulting
from stigmatization (Meyer, 2013).
Two common assumptions that nurses make pose
barriers to quality care of LGBT patients: the idea that all
clients are heterosexual and that all people identify as
either male or female (Eliason, Dibble, DeJoseph, &
Chinn, 2009). Both assumptions by nurses can negatively
impact supportive interactions with clients and make
patients and their families invisible.
Improving Health Care Quality
The Joint Commission now urges U.S. hospitals to create
a more welcoming, safe, and inclusive environment that
contributes to improved health care quality for LGBT
patients and their families (Joint Commission, 2011). The
Health Care Equality Index (HEI), created in 2007 as a
joint program of the Human Rights Campaign and several
LGBT advocacy groups, is an on-line survey completed
by health care organizations to evaluate if they are
providing optimal care to LGBT patients. Organizations
that are LGBT welcoming and inclusive meet the Centers
for Medicare and Medicaid Services and Joint Commis-
sion requirements. The HEI provides a benchmark for
gauging progress in LGBT inclusion among health care
institutions, but has never before been applied to the
study of individual nurses.
In conclusion, the research on nurses' attitudes and
training about LGBT health issues is still sparse and often
limited to a few survey items and to studies with small
sample sizes. As regulatory bodies like the Joint
Commission and federal agencies begin to demand that
health care institutions become inclusive of LGBT
patients and their families, there is a need for more
nuanced studies of nurses' knowledge and attitudes to
drive curricular change. Metropolitan areas like the San
Francisco Bay Area typically have greater numbers of
openly LGBT people, and it might be assumed that nurses
would have more experience and knowledge in working
with LGBT populations. San Francisco County has a high
number of same-sex households (30 per 1000 house-
holds) in the United States, according to the 2010 census
(Gates & Cooke, 2010).
Purpose of the Study
Practicing nurses' prior education as well as current
knowledge and attitudes about working with LGBT
patients was assessed. Community/public health nursing
students conducted key informant interviews with
registered nurses. The study had two overarching
purposes: (a) to explore the effectiveness of having
students do structured interviews as a way to learn about
health care needs of LGBT patients and train students in
research methods (Carabez, Pellegrini, Mankovitz,
Eliason, & Dariotis, in press), and (b) to assess the
current state of the art of LGBT-sensitive nursing
practice. This article focuses on the latter. The primary
research question for this part of the study was: What is
the state of training/education and the comfort level of
nurses regarding LGBT health care needs?
Methods
Study Design
Because of the lack of information on this topic or
theoretical frameworks to organize our study, we chose a
needs assessment method with key informant interviews.
Highly structured interviews minimize the potential
impact of inexperienced interviewers and maximize the
use of time with busy professionals (Patton, 2002). The
great degree of structure with focused questions on
workplace experiences makes the data easier to analyze
and reduces human subjects' concerns. Yet, respondents
provided additional commentary on many questions that
allowed for qualitative analysis, making this a mixed-
methods study.
Procedures
The study was designated as exempt by the university
institutional review board (IRB). Nursing students (n=
119) enrolled in a Community/Public Health Nursing
Theory Course in baccalaureate- and entry-level graduate
programs (level 4 of 5) in a large urban university in the
San Francisco Bay Area were given an assignment to
interview a minimum of two nurses regarding care of
LGBT patients. Before recruitment, all students complet-
ed and submitted the on-line research training course
certificate from the National Institutes of Health. The
students recruited nurse key informants (n= 268)
through convenience sampling. The inclusion criteria
for the nurse key informant included the following: (a) a
registered nurse, (b) resides in the San Francisco Bay
Area, (c) 18 years and older, and (d) willing to discuss
health care needs of LGBT clients based on their
professional experience.
The students were provided instructions on interview
techniques and practiced in a classroom exercise before
conducting the actual interviews. Because this was a
learning experience for the student as a nurse researcher,
students were advised to read directly from the script and
not to digress to other topics. Student interviewers
provided instructions to the key informant nurses about
the questions in the interview and confidentiality of
patients and families, and obtained written informed
consent. All interviews were completed face-to-face and
audio recorded for accuracy. Interviews were conducted
in locations that ensured confidentiality and they took
approximately 1 hour to complete.
The key informant nurses were explicitly asked to not
state their names, the names of employers, or any
demographic information to ensure confidentiality.
Student interviewers transcribed the audio-recorded
interviews and uploaded the transcript to a compact
disc. The transcripts of the interviews were the raw data
324 CARABEZ ET AL

used for this study. The study resulted in more than 1000
pages of transcripts.
Interview Instrument
Key informant nurses were asked to state their initials
only, the date of interview, unit/department in which
they worked, principal responsibilities, types of patients
served, and length of time as a registered nurse. The
16-item scripted interview was based on the HEI that
addresses institutional policies to ensure quality health
care to lesbian, gay, bisexual, and transgender (LGBT)
patients and families. The four categories addressed in
HEI are patient nondiscrimination policies, visitation
policies for same-sex couples and same-sex parents for
their minor children, employment nondiscrimination
policies, and training in LGBT patient-centered care. In
addition, the HEI assesses the degree to which institu-
tions provide LGBT patient-centered care. This article
focuses only on the findings from the questions about
training and comfort level working with LGBT patients.
Analysis
All transcribed interviews were analyzed using content
analysis to identify emerging themes and patterns in the
interviews. Authors divided the transcripts and indepen-
dently identified initial themes. These emerging themes
were discussed and refined in research team meetings
until consensus was reached. Data were also reviewed for
frequency of common themes (quantitative data) and
unique insights that did not fit neatly into a theme.
Results
This article focuses on three questions from the HEI
related to education and comfort level: (a) Does your
organization provide training for key staff members in
LGBT patient-centered care? (b) Have you received
training or orientation regarding care of lesbian, gay,
bisexual, or transgender patients? (c) How prepared/
comfortable are nurses working with LGBT patients?
After reporting sample characteristics, the findings focus
on three themes: organizational training, comfort level,
and revelations sparked by the interviews.
Sample Characteristics
Of the 268 key informant nurses interviewed, nearly half
(46%) had 10 or more years of nursing experience. More
than 77% of the nurses worked in hospital settings, and
12% worked in community/public health settings. Ten
percent of the nurses held formal administrative posi-
tions. Nearly 80% of the nurses stated that they mostly
served adults, 12% served families, 8% served the
geriatric population, and fewer than 2% reported no
direct patient care. Most (71%) reported their job
description as providing direct patient care, whereas
28% described their responsibilities as mostly adminis-
trative. See Table 1 for details.
The full spectrum of nursing positions was represented,
including charge nurse, clinical nurse specialist, float nurse,
nurse practitioner, nursing instructor, health educator,
quality improvement, informatics, researcher, staff nurse,
travel nurse, case manager, clinic nurse, hospice, home
health, and public health nurse. No key informant
demographic information such as gender, age, race/
ethnicity, or sexual orientation was collected in the
interview. However, 28 (9.6%) of the nurses voluntarily
disclosed that they were gay, lesbian, bisexual, or
transgender.
Organizational Training
Nurse key informants were asked, “Does your organiza-
tion provide training for key staff members in LGBT
patient-centered care? Please describe.”Of the 268 nurses
interviewed, 79% stated that no LGBT patient-centered
care training was offered through their organization.
Much of the education described was based on everyone
being the “the same”or mentioned in a cultural
competency orientation. Most respondents simply an-
swered “no,”whereas others provided a little more
context for their answers, such as:
Never in all my years of nursing. 37 years in nursing
I've never been educated in that subject.
No. It is the same training as our regular patients.
Table 1. Key Informant Characteristics
Characteristic Total (N= 268)
n(%)
Years in nursing
0–5 87 (32.46)
6–10 58 (21.64)
11–19 43 (16.04)
≥20 80 (29.85)
Title
In hospital ⁎207 (77.24)
Out of hospital
†
33 (12.31)
Administrative 28 (10.45)
Patients served
Adults 210 (78.36)
Families 33 (12.31)
Geriatrics 21 (7.84)
No direct care 4 (1.49)
Responsibilities
Direct patient care 189 (70.52)
Administrative 76 (28.36)
Other 3 (1.12)
Place of employment
In hospital 176 (65.67)
Out of hospital 74 (27.61)
Unknown 18 (6.72)
Primary unit
In hospital 189 (70.52)
Out of hospital 76 (28.36)
Unknown 3 (1.12)
⁎Data include the following: charge nurse, clinical nurse specialist,
float nurse, nurse practitioner, nursing instructor/educator,
quality improvement, informatics, researcher, retired, staff
nurse, and travel nurse.
†
Data include the following: case manager, clinic nurse, hospice,
home health, and public health nurse.
325NURSES' EDUCATION ABOUT LGBT HEALTH

We talk about patient-centered care a lot, but
specifically for LGBT patients how to take care of
them I never had any in-service, or training unless I
learned in school or individually on my own.
I think we still have a lot more to prepare in getting
more training related to LGBT patient centered care.
No, I'm not aware that um they provide any training
for that, for particularly LGBT, um, patient centered
care. I know for other ethnicities and religions they
do, but not for LGBT.
A nurse working in public health was unique in being
employed at an agency with a serious commitment to
diversity training:
Yes I have…for many, many years. Everybody…in
the organization from the custodian up to the CEO.
Everybody is required to take this anti-discrimina-
tion course and it has to do with gender, race and
everybody gets the same course.
This nurse also stated:
And our organization is really very adamant about,
they tell you what they want is this is a diverse
population and you are going to be working with all
kinds of different people. And provide lots of all
training you could ever need.
Another nurse responded:
We had that…one presentation that I've been
referring to a couple of years ago and that I believe
that was the only presentation that we have had that
was only about that topic.
Many stated that they had received training or
orientation in diversity and cultural competency but
not specifically for LGBT patients. Several nurses
responded that there were assumptions about knowledge
because of the geographical location in the San Francisco
Bay Area, where there is a large and visible LGBT
population. However, one respondent reflected on his
lack of knowledge this way:
We received some in school; I wish we would have
gotten more. Even for me as I identify as gay, I think
there is a lot that I didn't know at first which is why
I asked for a rotation where I would be in a center
focused specifically more on transgender and
lesbian populations.
A few respondents who stated that their organization
did not provide training questioned the need for training
on LGBT issues, seeming to indicate that LGBT patient
care was about beliefs, and not related to specific
educational content.
No. What will we be trained for? I guess that's my
question, attitude, you can't teach attitude [laugh-
ter] attitude I think is within, uh, unless it's obvious
that your attitude is discriminatory then maybe
some ease will come up about training, but no.
I don't think it's a concern actually.
I almost feel like providing dedicated training in
dealing with LGBT community could be construed
as discrimination itself. I almost feel like asking
people or offering people specialized training in
dealing with gay people might be like, ‘Oh wait,
we're not supposed to treat anybody differently.
Why do you need special training for that?’
The last comment mirrors some of the arguments in
dominant discourses that construe LGBT civil rights as
“special rights”(Table 2) summarizes information
on respondents' training and comfort level regarding
LGBT patients.
Comfort Level
When asked how prepared/comfortable nurses are
working with LGBT patients, nearly 71% of the key
informants stated that they, or nurses in general, were
comfortable providing such care, whereas 12% stated
nurses or they personally were not comfortable providing
care. Another 17% did not answer or were not sure how
to answer the question. For example:
I feel fairly comfortable working with LGBT
patients. But, I don't know if I am necessarily
prepared or what issues are necessarily important to
them because I haven't been trained in that.
Some respondents linked discomfort with the lack of
training. The first quote is from one nurse who stated that
he had not received any training and that he was “never
comfortable”working with LGBT patients.
I honestly don't think many are prepared or
comfortable working with this population. I don't
think many of us are very well prepared to handle
the diversity of health concerns and issues that arise
from this community population.
I don't think they are very well prepared at all. I
didn't get any training on it, um, and I think you
Table 2. Training in LGBT Patient-Centered Care
Characteristic Total (N= 268)
n(%)
LGBT organizational training offered
Yes 56 (20.89)
No 212 (79.10)
LGBT training attended
Yes 70 (26.11)
No 198 (73.88)
Comfort level providing LGBT care
Not comfortable 33 (12.31)
Comfortable 189 (70.52)
Unclear answer 46 (17.16)
326 CARABEZ ET AL

know as a new grad nurse, if I came across an LGBT
situation where I didn't know how to handle it I
would be uncomfortable in my ability to provide
competent care because I haven't been trained in
you know what might be population-specific or
population-pertinent issues. You know, I think it
could definitely be an uncomfortable situation if
you're talking about transgendered patients in terms
of a sensitive way to deal with it, how do you
acknowledge it, how do you approach it, do you
approach it with a patient and under what context,
um, yeah I don't think they're well-prepared at all. I
know I would feel lost in that situation.
I believe it is assumed that the patients will be
heterosexual…nurses in general are not prepared
enough to work with LGBT patients. The education
nurses get in nursing school and the training nurses
receive at work does not address LGBT issues. Most
nurses have limited contact with LGBT patients or
families. I believe a lot of nurses are uncomfortable
working with a LGBT patient, especially if they live
in a city that has a very limited population of LGBT.
Nurses are accustomed to address a spouse of a
different sex, but not of the same sex.
Others made more general statements about discomfort:
I think the younger generation is not as open as the
older generation. My experience in watching how
the younger generation is much more flippant and
critical of people than the older generation which
kinda [sic] shocks me.
I have to say 90% of nursing care that I have
observed that are involved with LGBT patients have
been very receptive very open and the other 10% of
nurses will have some nurses mistreatment…and
they may be uncomfortable.
So I can't speak from a first hand basis on that, but
uh, I can speak in terms of, I know numerous times
where nurses would snicker and talk behind
patient's backs…um, anyone with a trans iden-
tity…and then its silly little things.
I don't think they are comfortable, very few are
comfortable. I think they may be more comfortable with
gay or lesbian but when you start talking transgender,
bisexual I think they're not that comfortable.
There's a climate of homophobia that's still in the
environment.
One response seems to illustrate a theme of
“exoticizing”of sexual orientation:
I feel comfortable, more comfortable than prepared,
quite honestly. But I, it doesn't bother me. I will,
you know, confess that I have sort of a perverse
fascination about, like, oh, so…you know…
Finally, some discomfort appeared to relate to
stereotypes. This respondent seemed to endorse myths
about gay men as oversexed and predatory:
uhm you know I would say like uhm I would repeat
that's just because we live in San Francisco and
we're very much comfortable that's where we live
and their capital and you know we're expose
everywhere and so we're very much comfortable,
as long as we keep it to on the professional level, as
long as the patients keep it on a professional level,
and not flirt with nurses or you know uhm speaking
in my terms as long as the gay patients do not hit on
me or ask me out or else I won't be comfortable
especially in inserting Foley catheters.
Student interviewer: “oh, are you having any issues
with that?”
Respondent: “okay, well yeah, because you know there
might be some kind of sexual stimulation, and I kind of
occasionally, I fear of that stimulation.”
Revelations Sparked by Interviews
The process of the interview seemed to alert many
participants to their lack of knowledge related to LGBT
health. A number of them (20% of the nurses; n= 55) at
the end of the interview voluntarily stated that they
wanted training or wished that more was available.
I feel there should be more training available….we
only do that once a year. And it's like 15 minutes
little video clip which is kind of not fair…more
training should be provided and have the issues
addressed and that way we can feel comfortable…I
don't think we are prepared…. so when we have a
patient coming in, its like a dilemma, you know,
you don't know how to address them. You don't
know how to start your conversation and they
already see the fear on your eyes. Most of the times,
patients can sense fear. They like Ok may be they
don't like me. Maybe they are scared to approach
me because I'm this way or that way. You know it's
not a good thing for the patient and the nurse.
One nurse reflected that there may have been a lecture
in nursing school when discussing HIV/AIDS and then
commented:
It's not enough training obviously”.“I don't think…
we're trained very well or many nurses out in the
hospital are trained very well.…I've have had zero
lectures dedicated to this topic. We have to change
our curriculum in order to discuss, to include this
discussion, especially given that we are living and
working in the bay area.
Nurses who stated they had no training described an
informal process of other co-workers educating each
other on “gay issues”by “We just educate one another”or
“You learn on the fly”.
One nurse described herself as the “token lesbian”who
taught “queer health”to peers in nursing school. Later as
a staff nurse, she taught her co-workers because she was
327NURSES' EDUCATION ABOUT LGBT HEALTH

“passionate”about nurses understanding patients and
communicating effectively. Other comments included:
I think nurses are not very prepared. This is
something that nurses need to know more about.
People my age, in the 50s, are not well trained. I am
fortunate to have worked here and be trained, but,
many of my counterparts are very naive and
judgmental and I don't want to mention the horrible
things I've heard people say about gay people or
about lesbians. It's appalling and I'm ashamed of it
and I want people to be educated and I want people
to respect the community of folks.
We've missed the boat on the LGBT and I'm hoping
that some of this research will lead to better education.
Finally, some nurses stated that the interview had
brought an awareness of the lack of training and hoped
that the student interviewers would do something about
this gap in training.
Nurse to student interviewer: “So you will advocate for
more education regarding LGBT!”and “It would be great to
have some kind of program or some kind of initiative or
somekindofpolicyouttherethatatleastbringsthisissueto
the surface because this is something that's really omitted in
our organization. And…you bringing this to my attention, I
feel like I should bring this to the nurses and at least have
something in place because, like I said, there isn't…there's
other issues in our organization….. so thank you.”
Discussion
This study is the first to explore the training of nurses on
LGBT issues in a large sample, using structured
interviews.EvenintheSanFranciscoBayArea,
practicing nurses reported having had very little educa-
tion about LGBT health care. Nearly 80% had no training
at all, and among those with some training, some
reported that they had only a single lecture in nursing
school or a broader diversity training that mentioned
LGBT issues very briefly. This lack of training is
important, as it appeared to translate into discomfort
working with LGBT patients for some of the nurses
interviewed. Nearly 30% reported some level of discom-
fort, often linked to their lack of education on LGBT
health issues. In addition, other respondents expressed
stereotypical beliefs about LGBT people. A number of
comments reflect hiding behind the mantra of “we treat
everyone the same”as a rationale for not learning about
LGBT health issues. Others may be microaggressions,
slights, and stereotypical comments that may seem to be
minor,butaddedupovertime,maycreatean
uncomfortable climate for LGBT patients and health
care workers. Comments that create “us and them”
situations such as setting up LGBT versus “regular”
patients, or inappropriate workplace behaviors such as
nurses “snickering”and “silly little things,”can take a
toll. These are issues that can be addressed in nursing
education and by in-service education.
The interviews provided an opportunity for nursing
students to network with registered nurses and ask direct
questions about care delivered to a specific vulnerable
population in a variety of health care settings. At least for
some of the nurses, the interview itself created an
awareness of their lack of knowledge, even if they did
not think that such training was necessary.
Limitations to the Study
The use of undergraduate students as interviewers is one
limitation. Student researchers had uneven interviewing
skills; some students digressed from the topic, and others
failed to use probes and elicit full information. No
demographic information was collected on the sample
such as gender, age, race/ethnicity because of the
requirements of the IRB and their concern with student
skills in obtaining this information and keeping it
confidential. There were significant time constraints.
The study was done as a one-semester assignment, so
everything had to be completed in a 16-week semester
period. Students reported some challenges in finding
nurses who were willing to talk to them about LGBT
issues, so the respondents are likely not representative of
the practicing nurse in the area. Finally, all participants
were drawn from one geographic region with a reputation
as being a “mecca”for LGBT people. The findings are even
more striking given the location, and it is possible that
even more negative attitudes and even less training might
be reported in samples in other parts of the United States.
Implications/Recommendations
Nursing curricula still contain very little information about
LGBT health topics (Lim et al., in press), so it is not
surprising that practicing nurses are still not culturally
sensitive to the needs of LGBT patients. In the next paper,
we will report on the questions about the health care needs
of LGBT people from practicing nurses' perspectives,
showing how little they know about these needs. LGBT
health care education needs to start in nursing schools and
programs, but research shows that nursing educators are
not yet well prepared to teach LGBT health issues (Sirota,
2013). Therefore, nursing practices and procedures are still
heterosexist (Morrison & Dinkel, 2012; Rondahl, 2011).
That is, many practicing nurses may be unaware that some
patients (and some coworkers) are LGBT, or they hold the
belief that there are no differences in patient care for LGBT
versus heterosexual patients. To move the field forward,
schools of nursing can
•use the Health Equality Index to assess their college/
school's inclusivity of LGBT issues
•incorporate culturally competent, patient-centered
training in nursing education curricula
•utilize case studies, assignments, readings, on-line
training modules, interactive webinars, and other
already existing educational materials from GLMA
(Health Care Professionals Advancing Equality), Fenway
Institute or Lavender Health (www.lavenderhealth.org)
328 CARABEZ ET AL

•provide links to Web sites and on-line films on LGBT
topics (e.g., the Family Acceptance Project; PFLAG)
•invite expert guest speakers to class for open discussions
about communication and LGBT health issues in
general or in relation to specific nursing specialties
•host panel discussions of LGBT patients sharing
their health care experiences
•utilize interactive experiences in providing LGBT
competent care in clinical simulation courses
•offer an LGBT health certificate or minor to create
nursing expertise
•have explicit discussions in clinical rotations about
dealing with discomfort stemming from working with
patients who are different from the nurse in some way.
Health care institutions also have a major role to play
in meeting new government standards of welcoming an
inclusive health care for all. Health care organizations can
•provide annual updates and ongoing training as new
policies and legislative mandates are passed. If
institutions are unable to develop these trainings,
several continuing education opportunities are now
available (e.g., Eliason et al., 2009 offers 21 hours of
CE; Lim, Brown, & Kim's, 2014 article in AJN offers
2.6 hours of CE).
•include LGBT health training in new employee
orientation
•actively recruit and hire openly LGBT employees
•whenever considering diversity initiatives, make
sure LGBT issues are included
•review and update policies, procedures, and written
forms to be inclusive.
Conclusion
Practicing nurses, even in the San Francisco Bay Area, rarely
have received any training or education on LGBT health
issues in school or in their current jobs. As a result, many feel
uncomfortable working with LGBT patients or do not
recognize what the health care needs of those clients may be.
There is a clear need for integrating LGBT education into
schools of nursing, nursing continuing education, and
institutional orientation and cultural diversity training.
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