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


Abstract and Figures

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.
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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 31:323329, 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:
Journal of Professional Nursing, Vol 31, No. 4 (July/August), 2015: pp 323329 323
© 2015 Elsevier Inc. All rights reserved.
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?
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.
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
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.
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.
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
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 sameor 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)
Years in nursing
05 87 (32.46)
610 58 (21.64)
1119 43 (16.04)
20 80 (29.85)
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)
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.
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 havefor many, many years. Everybodyin
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 thatone 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
comfortableworking 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)
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)
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
heterosexualnurses 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 mistreatmentand
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 backsum, anyone with a trans iden-
tityand 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
One response seems to illustrate a theme of
exoticizingof 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, soyou 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 fairmore
training should be provided and have the issues
addressed and that way we can feel comfortableI
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
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 issuesby We just educate one anotheror
You learn on the fly.
One nurse described herself as the token lesbianwho
taught queer healthto peers in nursing school. Later as
a staff nurse, she taught her co-workers because she was
passionateabout 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
the surface because this is something that's really omitted in
our organization. Andyou 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'tthere's
other issues in our organization.. so thank you.
This study is the first to explore the training of nurses on
LGBT issues in a large sample, using structured
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 sameas a rationale for not learning about
LGBT health issues. Others may be microaggressions,
slights, and stereotypical comments that may seem to be
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 snickeringand 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 meccafor 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.
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 (
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
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.
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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... According to existing research, healthcare workers have negative attitudes toward LG individuals; homophobia is common; they are hesitant to care; they feel helpless; and their expertise and equipment are inadequate. 11,12 In addition, it is reported that reasons such as being married, considering homosexuality as a disease, not having any LG family members, friends, or relatives, and not providing care to these individuals before are related to homophobia. 1 The study aims to determine the attitudes, homophobia, and empathy levels of healthcare professionals toward LG individuals. ...
... According to studies evaluating healthcare professionals' views and behaviors toward LG individuals, nurses, in particular, exhibit positive attitudes and behaviors. In these studies, it was determined that nurses do not care about differences like sexual orientation and gender identity and focus only on their work 20 ; they know that they cannot change them and that they should accept them as they are; 12,21 and they are open to the idea of giving care to them and feel comfortable doing so. 12,21 Furthermore, in a study by Cicero et al. (2016), it was reported that a transgender man was teased by emergency department staff because he appeared masculine but had a female name on his identity, but the nurse there had a very good attitude toward him, the only thing she was interested in was his physical well-being, and this made him feel comfortable. ...
... In these studies, it was determined that nurses do not care about differences like sexual orientation and gender identity and focus only on their work 20 ; they know that they cannot change them and that they should accept them as they are; 12,21 and they are open to the idea of giving care to them and feel comfortable doing so. 12,21 Furthermore, in a study by Cicero et al. (2016), it was reported that a transgender man was teased by emergency department staff because he appeared masculine but had a female name on his identity, but the nurse there had a very good attitude toward him, the only thing she was interested in was his physical well-being, and this made him feel comfortable. 22 On the other hand, studies indicating that healthcare professionals have negative attitudes and behaviors toward LG individuals emphasize that healthcare professionals make sarcastic comments, discriminate against LG individuals, and fear and feel ashamed of them. ...
This study aimed to determine the attitudes, homophobia, and empathy levels of healthcare professionals toward Lesbian and Gay individuals. This descriptive and cross-sectional study’s population consisted of healthcare workers working in hospitals in Turkey between April 2022 and August 2022. Using snowball method, 678 healthcare professionals who consented to participate in the study were recruited for the study. The data were collected using a questionnaire developed by the researchers, the Attitudes Toward Lesbians and Gays Scale (ATLGS), the Hudson and Ricketts Homophobia Scale (HRHS), and the Toronto Empathy Scale (TES).79.4% of the participants reported that caring for Lesbian and Gay (LG) individuals is no different from caring for heterosexual individuals. Low homophobia levels, work experience, and the existence of gay friends were identified as factors significantly influencing healthcare professionals’ positive attitudes toward LG. Healthcare professionals have partially positive attitudes about LG individuals and partially homophobic attitudes, and their empathetic abilities influence their attitudes toward them.
... As the largest part of the health care profession, nurses should play an important role in addressing the needs of LGBTQ+ older adults, as there are many strategies, and at the same time, they should work to promote an age-friendly health care system, including for LGBTQ+ older adults (Caceres, 2019). The study revealed that most nurses had no education or training in LGBT health issues, which causes gaps in the nurses' knowledge and can negatively affect patient care (Carabez et al., 2015). Caceres (2019) states that nursing and care providers need to know the appropriate terminology, which is the basis for effective communication and building trust with LGBTQ patients; they need to understand that LGBTQ+ older adults are not a homogeneous group; there are significant differences in health care needs within the LGBTQ+ community, e.g. ...
... Education of healthcare professionals, especially nursing and care providers, is crucial to improve the status of LGBTQ+ older adults in the healthcare system (Eickhoff, 2021). Eickhoff (2021) notes that there is a need for expanded LGBTQ+ health education and education about LGBTQ+ content in medical schools, although LGBTQ+ nursing education for older adults needs to begin in high schools and nursing and care provider programs (Carabez et al., 2015). Nursing care providers want to provide an open space for sexual and gender diverse communities, but they do not have the knowledge to do so (Kortes-Miller, Wilson, and Stinchcombe, 2019). ...
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The proportion of older adults (65+) is increasing rapidly. Therefore, caring for older adults must be a priority of our society, in order for them to have a dignified life in old age. LGBTQ+ older adults are a heterogeneous, growing subset of the ageing population, with many challenges and needs. Old age is a vulnerable period for all populations, and LGBTQ+ older adults are even more vulnerable in this period. They face discrimination and stress in finding a safe and inclusive environment. Our research used the descriptive method - a scientific literature review. The selection of articles was made according to the following inclusion criteria: accessibility, scientificity, content relevance, and topicality. The issue of LGBTQ+ older adults in search of a suitable living environment through a qualitative content analysis of eight articles was addressed. We find that it is important for this population group to feel accepted, safe and connected to the community in their living environment. Studies still point to discrimination and stigma being experienced by LGBTQ+ people, especially in the institutional environment, which affects physical and mental health. In the future, we must ensure that employees involved in the long-term care of older adults have sufficient knowledge about this vulnerable group of the population. A safe and inclusive environment for LGBTQ+ older adults must be promoted, where they can be accepted and feel connected to the community during their ageing.
... 9,10 Thus, it is crucial to educate nurses who have this perspective and can eliminate health inequality in SM. 11 However, nurses still do not feel comfortable in caring for SM individuals due to the lack of awareness about SM individuals in their education and training. 12 Thus, it is necessary to revise the nursing education system to change their perspective toward SM individuals. To achieve this goal, the important step is to understand the attitudes of nurse educators about SM in the society in which they are raised. ...
... The application of communication platforms in teaching and training of trans-affirmative care for healthcare providers is inadequate, as gender-diverse issues are not part of required courses in school education and formal training programme in healthcare facilities. [40][41][42][43] Besides, a holistic understanding of being trans is currently expected from professionals and from trans people themselves. 44 In this research, a self-introduction page with personal photo and stories of trans speakers and an interactive message function were applied, which not only provided the HIV screeners a sense of group belonging but also aroused their interest to actively provide different aspects of open-ended questions for trans speakers. ...
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Background Human immunodeficiency virus (HIV) screeners have limited experience of interacting with trans people. The application of communication platforms between them to empower HIV screeners’ trans-related cultural competence remains unknown. Objective This study aims to qualitatively explore the follow-up interviews of HIV screeners regarding their opinions on the feasibility of an online platform group discussion and web page to enhance communication between them and trans people and to explore their perspectives on how these components enhanced their promotion of cultural competence. Methods This study was conducted between October 2020 and June 2021. Purposive and snowball sampling were applied to recruit 6 trans persons and 11 HIV screeners. Six online platform group discussions were held on weekday evenings, each group meeting for 60 min, 360 min in total within 3 months, via a video chat room of Google Meet; this was supplemented by a closed web page. The major results were presented through content analysis of the HIV screeners’ follow-up interviews. Results The HIV screeners identified the facilitators of participating in the communication platforms, which included a reminder message, easy-to-use interface, visible–audible and readable interaction, recalled and reviewable content and group belonging; the barriers included time and space limitation, device restrictions and operation problem. Two categories of trans-related cultural competence – trans awareness and action taken – were revealed, from which five major themes emerged: provoked to ask questions, improved cognition, reflection, trans-sensitive communication and self-enhancement. Conclusion The results revealed that the communication platforms could facilitate the mutual and vivid discussion between HIV screeners and trans people and empower the trans-related cultural competence of HIV screeners. The highly feasible intervention design of this research can be applied to digital training courses related to gender diversity issues.
... From two U.S.-based nationwide surveys, 80.6% of endocrinologists and 82.5% emergency physicians expressed never receiving training for transgender care although 80% and 88% respectively have treated a transgender patient [18,19]. Similarly, 79% of nurses in a study who practice in San Francisco reported that they have not received LGBTQ + training from their organizations [20]. ...
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Background: Health disparities experienced by LGBTQ + individuals have been partially attributed to health professionals’ lack of cultural competence to work with them. Cultural competence, the intricate integration of knowledge, skills, attitudes, and behaviors that improve cross-cultural communication and interpersonal relationships, has been used as a training framework to enhance interactions between LGBTQ + patients and health professionals. Despite multiple published LGBTQ + cultural competency trainings, there has been no quantitative appraisal and synthesis of them. This systematic review assessed articles evaluating the design and effectiveness of these trainings and examined the magnitude of their effect on cultural competence outcomes. Methods: Included studies quantitatively examined the effectiveness of LGBTQ + cultural competency trainings for health professionals across all disciplines in various healthcare settings. 2,069 citations were retrieved from five electronic databases with 44 articles meeting inclusion criteria. The risk of bias in the included studies was assessed by two authors utilizing the Joanna Briggs Institute critical appraisal checklists. Data extracted included study design, country/region, sample characteristic, training setting, theoretical framework, training topic, modality, duration, trainer, training target, measurement instrument, effect size and key findings. This review followed the PRISMA statement and checklist to ensure proper reporting. Results: 75% of the studies were published between 2017 and 2023. Four study designs were used: randomized controlled trial (n = 1), quasi-experimental pretest–posttest without control (n = 39), posttest only with control (n = 1) and posttest only without control (n = 3). Training modalities were multiple modalities with (n = 9) and without simulation (n = 25); single modality with simulation (n = 1); and with didactic lectures (n = 9). Trainings averaged 3.2 h. Ten studies employed LGBTQ + trainers. The training sessions resulted in statistically significant improvements in the following cultural competence constructs: (1) knowledge of LGBTQ + culture and health (n = 28, effect size range = 0.28 – 1.49), (2) skills to work with LGBTQ + clients (n = 8, effect size range = 0.12 – 1.12), (3) attitudes toward LGBTQ + individuals (n = 14, effect size range = 0.19 – 1.03), and (4) behaviors toward LGBTQ + affirming practices (n = 7, effect size range = 0.51 – 1.11). Conclusions: The findings of this review highlight the potential of LGBTQ + cultural competency training to enhance cultural competence constructs, including (1) knowledge of LGBTQ + culture and health, (2) skills to work with LGBTQ + clients, (3) attitudes toward LGBTQ + individuals, and (4) behaviors toward LGBTQ + affirming practices, through an interdisciplinary and multi-modal approach. Despite the promising results of LGBTQ + cultural competency training in improving health professionals’ cultural competence, there are limitations in study designs, sample sizes, theoretical framing, and the absence of longitudinal assessments and patient-reported outcomes, which call for more rigorous research. Moreover, the increasing number of state and federal policies that restrict LGBTQ + health services highlight the urgency of equipping health professionals with culturally responsive training. Organizations and health systems must prioritize organizational-level changes that support LGBTQ + inclusive practices to provide access to safe and affirming healthcare services for LGBTQ + individuals.
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Background Children and adolescents undergoing umbilical cord blood transplantation (UCBT) are faced with severe fatigue and a decline in quality of life (QoL) during the inpatient period. Objective To investigate the effect of a structured exercise intervention on fatigue, QoL and clinical outcomes among children and adolescents during UCBT. Methods In this randomized controlled trial, participants (n = 48) were randomized to a control group (CG: usual care) or an intervention group (IG: a structured exercise intervention). Fatigue and QoL were assessed at hospital admission, 14 days after UCBT, and at discharge using linear mixed model analysis. In addition, engraftment kinetics, supportive treatment, transplant-related complications, and hospital length of stay were derived from medical records. Results 4 patients completed the study, the IG participated in an average of 2.12 (1.36-2.8) sessions with a duration of 24 (16-34) min weekly, and the total rate of adherence to the training program was 70.59%. For fatigue and QoL, there was a significant effect of time in the control group, with the total score of fatigue decreased from T1 to T2 (73.9vs 60.9, P = .001) and T1 to T3 (73.9vs 65.6, P = .049), and the QoL scores decreased from T1 to T2 (73.9vs 66.1, P = .043). The hospital length of stay was less in the intervention group ( P = .034). Conclusion Our randomized study indicated that structured exercise interventions might exert a protective effect by attenuating the decline in fatigue and QoL, and shortening duration of hospitalization.
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Introduction The LGBTQ+ community is often discriminated against and stigmatized resulting in greater psychological and emotional stress compared to heterosexual and cisgender people. Consequently, poorer mental health is often observed in this community. To alleviate these disparities, mental health professionals need to be culturally competent. Therefore, LGBTQ+ cultural competency was explored in a sample of Irish mental health professional students. Methods A questionnaire was circulated among Irish students in mental health programmes. Out of approximately 700 students, 66 competed the survey, of which 23 identified as LGBTQ+. Results In terms of cultural competency, participants reported significantly higher attitudinal awareness compared to basic knowledge and clinical preparedness. Further, cultural competency was lower for transgender clients. LGBTQ+ patient education significantly predicted cultural competency when controlling for demographic variables. Three themes were generated from the open answers: experiences of cultural competency training, affirmative but uninformed, and recommendations for implementing training. Conclusion To provide adequate, affirmative care, cultural competency training should be a mandatory component of all mental health professional programmes.
People who identify as lesbian, gay, bisexual, transgender, queer/questioning, intersex, asexual, two-spirit, or other minority sexual and gender identities (LGBTQIA2+) often avoid seeking healthcare due to social discrimination and stigma. Clinical education in LGBTQIA2+-affirming care is essential but often lacking across disciplines. Provider acceptance, awareness of personal biases, and understanding of microaggressions affecting LGBTQIA2+ people can improve access, outcomes, and survival for this population. Expertise in caring for LGBTQIA2+ people in rural and suburban communities, for people who are transgender, and for people who have undergone or are in the process of undergoing gender-affirming surgeries is essential to offer best-practice healthcare.
Introduction Providing culturally responsive, patient-centered care is crucial for ensuring safe and positive health care experiences for individuals with diverse gender identities and sexual orientations. Doing so requires adequate training and knowledge of the health professionals involved in those health care experiences. Review of Literature Individuals identifying as lesbian, gay, bisexual, transgender, queer, intersex, asexual, and other related identities (LGBTQIA+) experience significant barriers to health and positive health care experiences. In physical therapy, research has identified that individuals who identify as LGBTQIA+ experience discrimination, discomfort, and lack of practitioner knowledge about health needs. The aim of this study was to determine how, and to what extent, content related to LGBTQIA+ individuals is included in Australian physical therapy curricula as well as perceived barriers to inclusion. Subjects Physical therapy program directors (PDs) as of January 2022 for all Australian universities that deliver physical therapy programs (n = 24). Methods A Qualtrics survey was emailed to PDs to collect quantitative and qualitative data regarding the inclusion and mode of delivery of LGBTQIA+ content, as well as the perceived importance, and barriers to inclusion, of LGBTQIA+ curricula. Results Twenty-four (100%) universities (PD or proxy) responded to the survey. More than 62% (15/24) of PDs reported that their programs included LGBTQIA+ content with 88% (21/24), indicating that LGBTQIA+ content is relevant to the physical therapy curriculum. Time devoted to LGBTQIA+ content ranged from 0 to 6 (median 2–4) hours across any year, delivered primarily in general or foundational courses (37%). Perceived lack of trained faculty (14/22; 64%) and time (13/22; 59%) were barriers to the integration of LGBTQIA+ specific content into the curriculum. Discussion Our results indicate that the physical therapy curriculum may be contributing to ongoing negative experiences of individuals identifying as LGBTQIA+ with physical therapy encounters. Although most (87%) physical therapy program leaders in Australia believe that LGBTQIA+ specific content is relevant to the training of new graduates, content is included in only 62% of curricula. Perceived barriers to inclusion of LGBTQIA+ specific curriculum were a lack of time and appropriately trained faculty. Externally developed content is available to address limited expertise within programs, but faculty may require guidance on how to overcome perceived lack of time (ie, space in the curriculum). Conclusion Most Australian physical therapy programs include LGBTQIA+ content to a limited extent in their curricula, indicating a lack of perceived importance relative to other topics. In this way, Australian universities are maintaining the pervasive heteronormativity of the physical therapy profession and are complicit in the ongoing health disparities between the LGBTQIA+ and heteronormative communities.
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In this article the author reviews research evidence on the prevalence of mental disorders in lesbians, gay men, and bisexuals (LGBs) and shows, using meta-analyses, that LGBs have a higher prevalence of mental disorders than heterosexuals. The author offers a conceptual framework for understanding this excess in prevalence of disorder in terms of minority stress— explaining that stigma, prejudice, and discrimination create a hostile and stressful social environment that causes mental health problems. The model describes stress processes, including the experience of prejudice events, expectations of rejection, hiding and concealing, internalized homophobia, and ameliorative coping processes. This conceptual framework is the basis for the review of research evidence, suggestions for future research directions, and exploration of public policy implications.
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Nurses work with diverse populations, but the nursing literature lacks research, theoretical frameworks, or practice guidelines regarding lesbian, gay, bisexual, and transgender (LGBT) health. Through diverse teaching strategies, students explored issues related to LGBT patients, families, and nurses using a cultural humility lens. Diverse teaching strategies included readings, a 2-hour presentation on LGBT health issues, and an assignment to conduct a scripted interview with two nurse key informants, based on the Health Care Equality Index (HEI). Students completed an online LGBT awareness preinterview survey, completed interviews, and completed a postinterview survey. Students showed a significant increase in knowledge about sexual orientation and gender identity and research and interview methods from pretest to posttest. The diverse teaching strategies involved in this assignment can enhance student knowledge, attitudes, and skills related to LGBT health care needs and increase appreciation of nursing research. [J Nurs Educ. 2015;54(x):xxx-xxx.]. Copyright 2014, SLACK Incorporated.
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IOM (Institute of Medicine). 2011. The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding. Washington, DC: The National Academies Press. A review and report assessing the state of the science on the health status of lesbian, gay, bisexual, and transgender populations; identifying research gaps and opportunities; and outline of a research agenda that will assist NIH in enhancing its research efforts in this area.
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Informed by critical feminist and queer studies approaches, this article explores nurses' perceptions of practice with patients who identify as lesbian, gay, bisexual, transgender, or queer (LGBTQ). Qualitative in-depth, semi-structured interviews with 12 nurses in Halifax, Nova Scotia, illuminate a range of approaches to practice. Most commonly, participants argued that differences such as sexual orientation and gender identity do not matter: Everyone should be treated as a unique individual. Participants seemed anxious to avoid discriminating or stereotyping by avoiding making any assumptions. They were concerned not to offend patients through their language or actions. When social difference was taken into account, the focus was often restricted to sexual health, though some participants showed complex understandings of oppression and marginalization. Distinguishing between generalizations and stereotypes may assist nurses in their efforts to recognize social differences without harming LGBTQ patients.
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A growing body of literature suggests that lesbian, gay, bisexual, and transgender (LGBT) persons have significant health disparities as compared to heterosexuals. Although the reasons for this are complex and multifactorial, one area of research has examined the real or perceived negative attitudes of health-care providers. This integrative review critically appraises and synthesizes data from 17 articles regarding nurses' attitudes towards LGBT patients. Every study analyzed showed some evidence of negative attitudes. However, the literature revealed major limitations, including a paucity of well-designed studies; a dearth of qualitative studies; inconsistent use of validated, reliable instruments; and a lack of measures examining attitudes towards lesbian, bisexual, and transgender persons. Increased knowledge in this area could lead to interventions to improve nurses' cultural competency; resource allocation to nursing research, education, and services related to LGBT health; and inclusion of more LGBT content in nursing curricula.
AIM This article assesses the knowledge of faculty in baccalaureate nursing programs and their readiness to teach about lesbian, gay, bisexual, and transgender (LGBT) health. BACKGROUND Although health disparities affecting the LGBT population are increasingly acknowledged in the literature, a dearth of information exists on how LGBT health is integrated in nursing programs. METHOD A survey was sent to a nonprobability purposive sample of nursing school administrative leaders (N = 739); they were asked to share the link with their faculty. More than 1,000 faculty completed the survey. RESULTS The knowledge, experience, and readiness for teaching LGBT health among baccalaureate faculty are limited. LGBT faculty reported greater awareness, knowledge, and readiness compared with heterosexual faculty. The estimated median time devoted to teaching LGBT health was 2.12 hours. CONCLUSION Findings will help inform the design of faculty development programs and guide them in aligning the curricula with current LGBT health priorities.
: To provide culturally competent care, we need to know who our patients are. The health care needs of people who are lesbian, gay, bisexual, or transgender (LGBT) have received significant attention from policymakers in the last several years. Recent reports from the Institute of Medicine, Healthy People 2020, and the Agency for Healthcare Research and Quality have all highlighted the need for such long-overdue attention. The health care disparities that affect this population are closely tied to sexual and social stigma. Furthermore, LGBT people aren't all alike; an understanding of the various subgroups and demographic factors is vital to providing patient-centered care. This article explores LGBT health issues and health care disparities, and offers recommendations for best practices based on current evidence and standards of care.
Homosexual populations have unique and specific cultures, psychosocial characteristics, health issues, and health care disparities that are currently ignored or insufficiently addressed in nursing education. To understand the reasons for these omissions, this descriptive study explores the attitudes of nurse educators (N = 1,282) toward homosexuality and the extent to which demographic, educational, and occupational factors are related to their attitudes. Responding to a direct online survey solicitation, self-selected participants completed the Attitudes Toward Lesbians and Gay Men Scale (ATLG) and a supplementary data questionnaire. Results indicate that the majority of participants have positive attitudes toward homosexuality, which is consistent with prior findings. Most participants believe it is important to teach nursing students about homosexuality, but they consider themselves unprepared to teach this content. Effects of various demographic and occupational factors on participants' ATLG scores and implications of the findings for nursing education and nursing health care policy are discussed. [J Nurs Educ. 2013;52(xx):xxx-xxx.].
Studies have reported that homosexual patients fear they will not receive adequate care if they openly show their sexual orientation, for example, when introducing their partner. The aims of this study were to investigate the emotions of nursing staff and nursing students, and possible relations to cultural background and gender, towards homosexual patients; whether nursing staff and nursing students would choose to refrain from nursing homosexual patients, if the option existed; and, if so, how they express their wish to refrain from nursing this group of patients. All participants received verbal and written information before the study started. Returning a completed questionnaire indicated a participant's tacit consent. Approval was obtained from the heads of departments and persons in charge of nursing and nursing assistant programmes. The study had a descriptive, comparative design, and an Affect Adjective Checklist (AAC) and specially designed Nursing Behaviour Questionnaire (NBQ) were used. The participants included nurses and assistant nurses from an infectious disease clinic, and students enrolled in a university nursing programme and upper secondary assistant nurses’ training, all in central Sweden. The findings showed that both professional nursing staff (response rate 67%, n = 57), and students (response rate 62%, n = 165), expressed emotions of homophobic anger, homophobic guilt and delight. Groups with a cultural background other than Swedish expressed more homophobia. No gender differences were indicated for homophobic emotions. In the professional group, 36% would refrain from nursing for homosexual patients if given the option. The corresponding figure for the students was 9%. The limitations were that the sample was small and not randomly selected, and as participation was anonymous no follow-up could be done. It was concluded that the emotional factors of homosexual anger and homosexual guilt might be of value in helping to explain and predict attitudes towards homosexuals.
The concept of heterosexism is used in a variety of ways in healthcare literature. The lack of consensus of the term makes identifying when and how it impacts the health care of lesbian, gay, and bisexual people difficult. A lack of clarity of the concept could also hinder effectiveness of education, awareness, and research tool development efforts. The purpose of this concept analysis is to offer a synthesized definition of the term heterosexism, including its relation to and distinction from related concepts like homophobia and heteronormativity. The authors use Walker and Avant's eight-step concept analysis method: select a concept, determine the aim of analysis, identify all uses of the concept, determine defining attributes, construct a model case, construct additional cases, identify antecedents and consequences, and define empirical referents. The results of the analysis reveal focus areas for future research, tool development, and suggestions for improvements in nursing clinical practice.