Much of the current nursing curricular models emphasize a binary classification of both sex and gender while erroneously conflating sex assigned at birth with gender identity. Historically, nursing education delivers information through a cis- and heteronormative lens to the student learner. The lack of provider preparation to underderstand diverse sexual and gender identities can result in inadequate health care delivery, lapses in communication and inaccurate assessment of risk factors. Additionally when LGBTQ+ individuals are mentioned in nursing curriculum, they’re commonly associated with content on sexually transmitted infections and mental health disorders. This compartmentalization of sexual and gender minorities can sustain harmful assumptions and stereotypes that constrain the LGBTQ+ community into a monolith, only to be defined by their deviation from an established cis- and heteronormative setpoint. It is critical for nurses to receive accurate and evidence based information to improve their social and contextual understanding of LGBTQ+ patients and the impact that present day health disparities have on their physical and emotional wellbeing.
This poster presentation, entitled “Enhancing Nursing Education Through LGBTQ+ Inclusive Curriculum” outlines a process model for integrating content regarding the care of LGBTQ+ communities across the lifespan into nursing curriculum. This specific model was co-created, co-led, and implemented at the Emory University Nell Hodgson Woodruff School of Nursing (NHWSN). In accordance with the NHWSN values of leadership and social responsibility as well as the objectives of Healthy People 2020, student leaders within NHWSN drafted a concept paper outlining the current gaps in the nursing curriculum, which included solutions to remedy these gaps alongside NHWSN leadership. Student nurses and future healthcare providers possess an ethical responsibility to educate themselves on the needs of all patient communities and work towards the elimination of health disparities. Because the vast majority of nursing curriculum includes little or no LGBTQ+ content, curriculum integration is an important first step to ensuring that all people receive quality, equitable healthcare.
The urgent need for curricular integration of LGBTQ+ content in nursing education is made evident by the stark health disparities faced by this population. LGBTQ+ patients encounter unique disparities in the healthcare setting as a result of a historically pathological understanding of their identities and behaviors (National LGBT Health Education Center: A Program of the Fenway Institute, 2012). Currently, LGBTQ+ individuals continue to experience both overt discrimination as well as unconscious bias during interactions with healthcare providers (Association of American Medical Colleges, 2014). The 2015 U.S Transgender Survey (USTS), the largest survey ever to examine the experiences of transgender Americans with 27,715 respondents, shed light on the lack of access to gender-affirming care, discrimination, and outright abuse that transgender individuals experience in the healthcare setting. According to the survey:
"In the year prior to completing the survey, one-third (33%) of those who saw a health care provider had at least one negative experience related to being transgender, such as being verbally harassed or refused treatment because of their gender identity. Additionally, nearly one-quarter (23%) of respondents reported that they did not seek the health care they needed in the year prior to completing the survey due to fear of being mistreated as a transgender person, and 33% did not go to a health care provider when needed because they could not afford it."
These results provide a snapshot of the inequity of our healthcare system and indicate the need for intervention at the educational level in order to equip future providers with the tools to adequately care for this patient population. Equity is one of the six aims put forth by the Institute of Medicine (IOM) in its 2001 report “Crossing the Quality Chasm: A New Health System for the 21st Century” and constitutes a foundational value in both nursing education and health care delivery. In order to meet the aim of providing equitable healthcare, defined as “care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status.” (IOM, 2001). Providers must be trained from the start of their education to address the unique and varied needs of all patient populations.
The clear need for curricular integration of LGBTQ+ content in nursing education inspired the writing of a content paper, which outlined the issues stated above and offered opportunities for inclusion across all aspects of the nursing curriculum. This content paper was then presented to NHWSN Deans and leadership in order to implement these changes through the initiation of student-led task force. Curricular integration can be divided into didactic and clinical learning modalities. Didactic information is presented in the classroom lectures and online learning modules where students receive the theoretical knowledge required to care for patients. In their content paper, student leaders at NHWSN emphasized both didactic and clinical-based learning methods were required for students to feel competent providing care for LGBTQ+ patients and their families. Through clinical integration, student nurses actively engage with patients to obtain social and medical histories that will inform their physical evaluation and guide the plan of care. These interactions can be simulated with standardized patients or obtained through clinical rotations at sites that specialize in LGBTQ+ patient care. Didactic teaching methods utilize written and computer-based exams for students to demonstrate their understanding of the theoretical knowledge delivered. Clinical integration methods utilize objective performance measures that outline evaluation criteria such as development of rapport, clinical reasoning skills and the ability to establish a plan of care with the patient. Ideal integration of LGBTQ+ health into nursing curriculum involves both didactic and clinical components of learning. For those wishing to promote LGBTQ+ health care topics, a needs assessment of the current state of curricular content can be an important first step, followed by the curricular mapping of both didactic and clinical content.
The promotion of a more inclusive classroom and clinical environment is not met without challenges. Some of these barriers include reluctancy amongst faculty to provide instruction on these topics due to a personal lack of familiarity and expertise. Others have expressed a need to adhere to content that will assuredly be included in licensing examinations. Additionally, it may be difficult for some to justify large curricular changes for the LGBTQ+ population, who they argue, constitute a small minority. An awareness of this resistance is need to successfully promote inclusivity of LGBTQ+ health in nursing education. Nursing education possess immense potential to influence how LGBTQ+ individuals navigate the clinical setting, obtain services and retain agency in achieving their healthcare goals. Ultimately, nursing education must continue to evolve alongside the dynamic nature of patient identities and behaviors. The delivery of equitable, patient-centered healthcare begins with the inclusion of sexual and gender minority health in health professions education as part of a holistic understanding of health and wellbeing.
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