A Abstract Background:Thehealthoflesbian,gay,bisexual, transgender, and/or queer (LGBTQ) people is a national health priority. A barrier to...
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A Abstract Background: The health of lesbian, gay, bisexual,  transgender,

and/or queer (LGBTQ) people is a national health priority. A barrier to culturally congruent LGBTQ care is the lack of knowledge about LGBTQ people. LG-BTQ people face significant health disparities. This study established an understanding of the knowledge and  attitudes of RNs about LGBTQ people and the impact  of an educational intervention. Method: RNs received a 1-hour educational intervention. Pre- and post-tests  were administered to establish baseline knowledge  and attitude, as well as effectiveness.  Results: A statistically significant impact on the nurses' knowledge  of LGBTQ health (p < .0001) happened after the inter-vention. Qualitative responses from nurses showed an overwhelming desire to have LGBTQ education for their nursing practice. Conclusion: Implications for practice include implementing LGBTQ cultural competence into initial and ongoing educational training for RNs within health care organizations and improved nursing care of LGBTQ people. [J Contin Educ Nurs. 2020;51(8):359
Lesbian,  gay,  bisexual,  transgender,  and  queer  (LGBTQ) people face significant health disparities  in the United States (Traynor, 2016). The National Institutes of Health (NIH) declared LGBTQ communi-ties a health disparity population in 2016 and included  LGBTQ health in  Healthy People 2020 (Perez-Stable,  2016). Evidence indicates that LGBTQ people have less  access to health care and carry a higher burden of certain diseases such as HIV/AIDS, depression, and cancer (Perez-Stable, 2016). What causes these health disparities and barriers to care is not fully understood, and the NIH has called for more research to understand these challenges  better. Previous research conducted by the NIH has shown that LGBTQ people living in communities with high lev-els of prejudice toward LGBTQ people have a shorter life expectancy of up to 12 years on average, when compared with those living in more accepting communities (Perez-Stable, 2016). An area of research priority that was high-lighted by the NIH for LGBTQ health is understanding the knowledge and attitudes of health care providers about LGBTQ health. Within nursing curricula and research, heterosexual  bias exists that diminishes culturally competent LGBTQ nursing care (Strong & Folse, 2015). Research and con-tent published on LGBTQ health was almost nonexistent in the top 10 nursing journals between 2005-2009, with only 0.16% of nursing articles including content about  the subject of LGBTQ health during this time frame.  (Lim et al., 2015; Strong & Folser, 2015). In the United States, approximately 3.5% or 9 million people identify  as LGBTQ (Gates, 2017). The Department of Health  and Human Services found that the LGBTQ population is at an increased risk of suicide, depression, HIV infec-tion, sexually transmitted diseases, obesity, and alcohol  and drug abuse (Traynor, 2016). LGBTQ people do not have unique health disparities; instead, generations of sys-tematic discrimination, stigmatization, and marginaliza-tion created them. One of the most substantial barriers  to culturally congruent LGBTQ care is the lack of knowl-edge about LGBTQ people and possible negative attitudes among nurses and other health care providers (Strong & Folse, 2015). Without knowing LGBTQ people and their care, nurses are unable to deliver culturally competent care to this population. UNDERSTANDING LGBTQ The term  LGBTQ is an acronym for lesbian, gay, bi-sexual, transgender, and queer. The "LGB" of the acronym refers to sexual orientation. The "T" refers to transgen-der or gender-nonconforming people, whereas the "Q"  can represent either a person's sexuality or gender iden-tity (American Psychological Association [APA], 2017).  Identity and sexual orientation are not the same things. However, both reflect "gender norm transgression" and  share an intertwined social and political history (APA,  2017). Lesbian ("L") is a woman who is physically, romanti-cally, or emotionally attracted to another woman.  Gay ("G") is a term used to describe men who are attracted  to other men; however, some women wish to identify as a "gay woman."  Bisexual ("B") describes a person who has  attractions to people of the same or opposite gender. Bi-sexual people experience these attractions in different de-grees throughout their lifetime, and many bisexual people describe this as a spectrum.  Transgender ("T") is an um-brella term used for those whose gender identity and/or  their gender expression differs from their assigned sex at  birth. The "Q" in LGBTQ can be used by someone who identifies themselves as queer or as questioning. Queer is a term that is seeing a resurgence among LGBTQ youth and adolescence. They use it when they feel their identity is more than being lesbian, gay, bisexual, or transgender, or when they feel that there is not a term to adequately  describe their sexual or gender identity.  Questioning can  used when a person is questioning their sexuality or gen-der identity (APA, 2017). LITERATURE Review Cultural Competence  Cultural competence arose as a critical concept in the lit-erature. The researcher included and considered the follow-ing terms as a variation of cultural competence:  culturally congruent care, cultural safety, and transcultural nursing care.The classic work of Campinha-Bacote's theory of cultur-al competence provides the foundation for this study. In her process of cultural competence, Campinha-Bacote discussed several key constructs of cultural competence: awareness, knowledge, skill, encounters, and desire (Campinha-Ba-cote, 2002). If one of these critical constructs is missing  from the journey to cultural competence, nurses will not be able to deliver care that is culturally congruent with the populations served. With the scarcity of LGBTQ content in nursing education and curricula, faculty are unable to provide nurses with the baseline knowledge to care and  interact with LGBTQ people. Without this knowledge,  nursing can perpetuate the health disparities faced by this population. For nursing to create a culturally competent  workforce, LGBTQ content must be incorporated into  nursing education programs. Knowledge and Attitude Perhaps the most significant barrier to LGBTQ cultur-ally competent care is the lack of provider knowledge. The invisibility of LGBTQ nursing research is evident in that from 2005 to 2009, only eight of 5,000 articles published by the top 10 nursing journals focused on LGBTQ health (Lim et al., 2015; Strong & Folse, 2015). To break it down further, of those eight articles, six were qualitative studies and two were quantitative research, mostly authored out-side of the United States (Johnson et al., 2012). New evidence on LGBTQ health research in nursing  from 2009 to 2017 shows slow growth on the topic. Re-searchers found that from 2009 to 2017, 0.19% (or 33 ar-ticles) of literature in the top 20 nursing journals focused on sexual minority health (Jackman et al., 2019). This  dearth of information on LGBTQ in top nursing research journals sends a message that the topics of LGBTQ health are not crucial to nursing research or that they represent a "niche" topic that many nurses do not need to know (Jack-man et al., 2019). Much of the available nursing research on LGBTQ health focuses on lesbian and gay populations, with limited discussion and insight into transgender and gender-nonconforming populations. Another limitation  to the available nursing research on LGBTQ health is that much of the research focuses on HIV and AIDS, despite a small percentage of the LGBTQ population living with HIV or AIDS (Johnson et al., 2012).In the nursing education realm, 79% of nurse educa-tors felt that LGBTQ health and issues are important to teach students; however, another study found that 72% of nurse educators surveyed felt that they were not prepared to teach about LGBTQ issues (Carabez et al., 2015a). LGBTQ content must be incorporated into the class-room and clinical education for nursing students, such as ingrained in simulations, case studies, nursing care plans, test questions, and elective courses (Lim & Borski, 2015). Universities and nursing schools recruit and retain diverse faculty that are openly LGBTQ to bring multicultural  perspectives and education into the classroom and clinical setting (Lim & Borski, 2015). In the literature, limited studies have evaluated the ef-fectiveness of the improvement of knowledge and attitudes regarding LGBTQ care after an educational intervention. One  study (Strong & Folse, 2015) that examined nurs-ing students had statistically significant increases in mean scores after their educational intervention on LGBTQ  health for nursing students. For further research, this study should be expanded to examine current practicing nurses and the impact of such interventions longitudinally. Another study (Gendron et al., 2013) that examined  the effects of cultural competence training on health care professionals about LGBTQ people  found that the par-ticipants reported feeling more knowledgeable and cultur-ally competent about LGBTQ issues after the interven-tion; however, they are unsure whether it had any impact on deep-seated beliefs about the LGBTQ population.  Another limitation that they discuss in their study under-stands that people will respond in a socially desired man-ner because they knew that the intervention's purpose was to impact their views (Gendron et al., 2013). This type of bias could potentially affect the reliability and validity of the results. Communication One aspect of communication that is vital to the nurse-patient relationship and can affect the overall health of a patient is their ability to disclose sexual or gender identity comfortably. In one study, 79% of the sample disclosed  their sexual identity to their oncologist or provider treat-ing their cancer, and only 47% disclosed their identity to surgeons. More than half (52%) of the individuals in the study disclosed themselves after correcting heterosexual  assumptions of the provider, and less than 15% reported that their providers asked general questions that elicited  disclosure (Kamen et al., 2015). From the results of this  study, providers must create safe and inclusive spaces for LGBTQ patients so that they feel empowered to disclose their sexual identity. For LGBTQ older adults, communication and dis-closure play a more significant role. Approximately  89% of LGBTQ older adults in long-term care be-lieved that staff would discriminate against an LG-BTQ resident, and 53% believed that staff would  abuse or neglect a resident if they identified as LG-BTQ (Moone et al., 2016). Many believe that part  of the fear of disclosure by LGBTQ older adults and others is because medical providers believe that they  "treat everyone the same" and that they "do not ask  anyone about sexual orientation or gender identity"  (Moone et al., 2016). However, this type of communi-cation approach can lead to significant health disparities and poor outcomes, including significant feelings of isolation (Moone et al., 2016).When assessing a patient's sexual orientation or gen-der identity status, the nurse must be cognizant of their  body language and their responses to the patient. Some-times nurses or providers can have feelings or thoughts of discomfort, shock, embarrassment, and/or awkwardness  when patients disclosed their sexual or gender identity and sexual practices (Cahill et al., 2014; Moone et al., 2016). Nurses may feel uncomfortable in certain situations that may be foreign to them and that they have not encoun-tered previously. To help build rapport and communica-tion with the patient, nurses should own their discomfort with the patient, as this shows them that they are willing to "go there" (Cahill et al., 2014). Nurses, providers, and facilities must also ensure that  their facilities, forms, and policies communicate inclu-sivity to the LGBTQ population. In one study (Carabez et al., 2015b), nurses were interviewed about the use of  gender-inclusive forms. Their results highlighted that only 5% of respondents used gender-inclusive forms, 44% did not know about gender-inclusive forms, 37% did not  understand what a gender-inclusive form was, and 14%  confused gender with sexual orientation. Their study was conducted in the San Francisco Bay Area, which has one of the largest and most prominent LGBTQ communi-ties than any other U.S. geographical area (Carabez et al., 2015b). Method Methodological Type and Design descriptive correlational study with a cross-sectional design and pretest-posttest was used for this study. RNs  received a 1-hour educational intervention. Pre- and post-tests were administered to establish baseline knowledge  and attitude, as well as effectiveness. The study was ap-proved as exempt by the following Institutional Review  Boards: Allegheny Health Network, University of Pitts-burgh, Carlow University. Setting The population of the study was a convenience sample of employed RNs (N = 111) who worked in four different hospitals in the Pittsburgh metropolitan region. Procedures Recruitment of participants took place via flyers and  email correspondence from the nursing education depart-ments of each hospital. Each hospital had set up their date and time for the educational intervention. At the beginning of the education session, nurses re-ceived a packet containing informed consent documents a demographics survey, and the pretest containing the  three survey tools. After the educational intervention,  participants completed the posttest containing the three  survey tools for postintervention data. Intervention This project implemented an educational intervention to improve the attitudes and knowledge of nurses about  LGBTQ people. The intervention was titled "LGBTQ  Cultural Competence for Registered Nurses." The author delivered the presentation via a lecture to the attendees.  It comprised 28 slides organized into three sections: defi-nitions and  terminology, health disparities faced by the  population, and communication practices. The research  team created all this information through the information available from the Fenway Institute. The length of the in-tervention lasted approximately 60 minutes and included the pretest, intervention presentation, and the immediate posttest, as well as some time for questions and discussion. The educational intervention was delivered by the author, whose doctoral studies focus on LGBTQ nursing care and has taught on the subject to local nursing programs, health care organizations, and various national presentations. Instruments and Variables The knowledge and attitudes of the RNs were mea-sured utilizing three validated tools—the modified  Atti-tudes Toward Lesbians and Gay Men (ATLG) scale; the  Attitudes Toward Lesbian, Gay, Bisexual and Transgender Patients (ATLGBTP) scale; and the Knowledge of Les-bian, Gay, Bisexual, and Transgender People (KLGBT)  questionnaire. These tools had been modified by Strong  and Folse (2015), and permission was granted to use the tools. Strong and Folse (2015) validated these tools with undergraduate nursing students in their doctoral research study "Assessing undergraduate nursing students' knowl-edge, attitudes, and cultural competence in caring for les-bian, gay, bisexual, and transgender patients." The first tool, the modified ATLG, consists of a 9-item 5-point Likert scale. Participants responded to their at-titudes and cultural competence for LGBTQ people. The 5-point Likert scale consisted of 5 =  strongly agree, 4 =  agree, 3 = neutral,  2 = disagree,  and 1 = strongly disagree. Items within the scale gauged the participants' attitudes  on  whether they found LGBT people as "plain wrong,"  "disgusting," and a "natural expression of sexuality or  gender identity." The ATLG scale has been found to be  reliable in previous research studies, with a Cronbach's al-pha of > .85 among college samples. The reliability of the modified ATLG scale was established with a Cronbach's  alpha of .95 (Strong & Folse, 2015). The ATLGBTP scale was a 6-item 5-point Likert scale and allowed for the written elaboration of the research  participants. The scale assessed the participant's cultural  competence and attitudes towards LGBTQ people. An-other area of analysis was whether their nursing curricu-lum incorporated LGBTQ content into the curriculum.  Additionally, it provided two questions for a narrative re-sponse from the participants. This scale was also evaluated previously for the level of reliability that was established  in a previous research study by Strong and Folse (2015), with a Cronbach's alpha of .54. The low number of items on this scale could affect the reliability of the ATLGBTP; therefore, the results should be interpreted with caution. The KLGBT questionnaire is a 15-item true-or-false  questionnaire. The research team designed the question-naire in the research study by Strong and Folse (2015). Re-liability for this scale was established through the Kuder-Richardson Formula 20. The reliability coefficient for the KLGBT was an alpha of .54. With those results, results  from this scale should also be interpreted with caution. Data Analysis Descriptive statistics were used to analyze the demo-graphics of the study participants (mean, standard devia-tion, and range). These calculated the variables of age,  years of experience of the RN, education level, sexuality, exposure to LGBTQ individuals, and their reported scores on the attitude's subscales and knowledge scores. RESULTSDemographics The population of the study was a convenience sample of RNs (N = 112) who were actively employed as a registered staff nurse by four  different hospitals in the south-western Pennsylvania metropolitan region. There was one participant who completed only the demographic portion of the study packet and was not included in the final sta-tistical analysis. The age ranges of the sample were 18 to 24 years (n = 9, 8.04%), 25 to 39 years (n = 33, 29.46%), 40 to 54 years (n = 38, 33.93%), 55 to 64 years (n = 31, 27.68%), and 65 years and older (n = 1, 0.89%). The majority (44.64%) of the sample had more than 21 years of RN experience; other experience levels represented within the sample included 0 to 3 years (18.75%), 4 to 6 years  (9.82%), 7 to 10 years (11.61%), 11 to 15 years (7.14%), and 16 to 20 years (8.04%). Most of the sample size re-ported having a baccalaureate degree (40.18%) or a master's degree or higher in nursing (39.39%). Those with  an associate's degree or diploma in nursing comprised  20.54% of the respondents (Table 1).The sample population primarily identified as hetero-sexual (92.86%), less than 3% of the size as homosexual, less than 2% as bisexual, and 2% preferred not to answer. The reported sexual orientations in this study's sample  size were congruent with a national sampling done by the Gallup Poll showing 4.1% of Americans who identified as LGBTQ (Gates, 2017) (Table 1).Respondents also reported varying levels of personally knowing someone who identifies as LGBTQ. Many had a friend (73.87%), family member (42.34%), or coworkers (63.96%) who identified as LGBTQ, and less than 2% of respondents did not personally know anyone (Table 2).Attitudes Baseline attitudes were established with the pretest,  with a post-test comparison for effectiveness. A two-sample t test was performed to measure the difference and impact of the  pretest-posttest scores. Individual scores ranged  from 1 (strongly negative) to 5 (strongly positive) for each of the subscales, with mean scores showing a somewhat posi-tive attitude toward LGBT people and feelings of cultural competence (Table 3).The first research question was to establish the base-line attitudes of RNs about LGBTQ people. The mean  scores of the participants show a somewhat positive atti-tude (3.86) toward LGBTQ people, as well as a feeling of cultural competence. The second research question was to evaluate the im-pact of an educational intervention on their attitudes. For this study, a result was statistically significant when the p value was less than .05. There was a slight increase in the mean attitudes between pretest and posttest.  However, none of them were statistically significant  (p = .30). KnowledgeThe 15-item true-or-false test was administered before and immediately after the intervention. The knowledge  portion of the posttest had an 88% completion rate (n = 98 of 111.).The participants had a strong baseline knowledge about LGBTQ health (M = 14.18, SD = 1.16). After the inter-vention, their knowledge levels increased to 14.76 (SD = 0.70) and showed a statistically significant increase in their knowledge from the educational intervention (p < .0001) (Table 4).ResponsesIn addition to the quantitative findings, RN par-ticipants wrote one take-away message from the educational intervention. Only one written comment  was perceived as unfavorable by the research team:  "We are moving further away from the Bible every  day."Other responses that the nurses had about the educa-tional intervention and their awareness of LGBTQ in-clude:•    Necessary to get past personal bias first.•      How to respectfully ask patients personal questions about their sexual orientation and gender identity.•        Importance of learning about the sensitivity and health  care needs of LGBTQ patients.Many of the participants echoed these comments.  Themes  that arose from their narrative comments in-clude gaining a new awareness for the importance of  sensitive patient communication, understanding the dif-ference between gender and sexuality, the need for nurs-ing and health  care to provide more education, as well  as the necessity of understanding our own biases. Many of the participants also included that they wish they had received education about LGBTQ people in either nurs-ing school or their nursing orientation DISCUSSION The purpose of this study was to examine the base-line knowledge and attitudes and level of cultural com-petence among RNs in a metropolitan area and the  impact of an educational intervention. Cultural com-petence consists of five constructs: cultural awareness,  cultural knowledge, cultural skill, cultural encounters, and cultural desire (Campinha-Bacote, 2002). There is a direct relationship between the level of competence  of health care providers and their ability to provide  culturally responsive health care services (Camphinha-Bacote, 2002). The study highlighted the effectiveness of an educa-tional intervention on knowledge. To further assess the  impact of the intervention on the attitudes of RNs, longi-tudinal research is warranted. Although the study did not have a statistically significant effect on attitude, perhaps  providing nurses with the cultural awareness and knowl-edge of LGBTQ people can help to improve their skills  and care of LGBTQ people. Another concept for discus-sion is that nurses might see it is necessary to change their actions to deliver culturally competent care but not their beliefs (Wyckoff, 2019). Further research is warranted to examine the gap between nurses' behaviors and their at-titudes toward LGBTQ people. The study identified that most respondents had person-al encounters with LGBTQ people (e.g., coworkers, fami-lies, friends), with less than 2% of the study population  not having an encounter with someone who identified as LGBTQ. Regional and national studies would be benefi-cial to further examine the relationship between a person's attitude about LGBTQ people and their encounters with that population. LIMITATIONSThe study focused on the knowledge, attitude, and  cultural competence of RNs in a metropolitan region in  southwestern Pennsylvania using a convenience sample.  The findings added to the body of literature about the  need for educational interventions. The study had a to-tal of 111 participants complete the pretest, with 100%  completion of the attitudes portion of the posttest and  88% completion rate on the knowledge portion of the  posttest. However, the use of a convenience sample limits the generalizability of the findings from the study. The use of a cross-sectional research design also does not allow for longitudinal measurement and study of changes in knowl-edge, attitudes, and cultural competence over time. With voluntary participation, nurses who had a more favorable attitude on LGBTQ people might have been more likely to consider participating in the study and engaging in the educational intervention, which may have influenced the findings of the study. The metropolitan area where the  study was conducted could allow for regional variances  among the participants regarding knowledge and attitude, which could have also influenced the study's results. CONCLUSIONSThe results of this study added to the body of literature about the need for educational interventions and the role of the provider's attitude and knowledge and LGBTQ  health. The outcomes of this study show that although  nursing has somewhat positive attitudes about LGBTQ people, further research is warranted for the generaliz-ability of such findings. Through an educational inter-vention, nurses were able to gain more knowledge about LGBTQ people so that they could better provide them with culturally competent care in the clinical setting.  The study has furthered the understanding of LGBTQ  cultural competency within nursing and the healthcare  setting.Nurses are the guardians of public and individual  health in our society. Providing care with dignity and  respect are central tenets to the nursing profession. As  our society continues to diversify, nursing education and practice must prepare current and future nurses to deliver culturally congruent health care to diverse and complex patient populations. This study has shown that nurses  desire to learn about LGBTQ people and want to pro-vide them with culturally competent care. Incorporating LGBTQ content into nursing curriculums, programs,  and research will help to create a culturally competent  nursing workforce capable of providing quality care to LGBTQ people
 
 
Answer the multiple-choice and short-answer questions at the bottom of each page.
 
(1.) The researcher uses Campinha-Bacote's definition of cultural competence or culturally congruent care. According to the researcher, why are nursing faculty unable to provide baseline knowledge about caring for the LGBTQ population to nursing students?
 
(2.) Why is this lack of knowledge harmful to the LGBTQ population?
 
(3.) What are some limitations in the existing literature about LGBTQ health and care?
SELECT ALL THAT APPLY
·  too much emphasis on HIV and AIDS (even though there's only a small percentage of LGBTQ people living with HIV or AIDS)
·  limited research about the number of LGBTQ nursing faculty 
·  limited research about transgender and gender-nonconforming populations
(4) In addition to more knowledge about the LGBTQ population, what is another element that health providers and facilities should ensure in order to provide culturally congruent LGBTQ care?
 
(5.) How did the researcher collect data? In other words, what method or research design did they use? Please refer to the "Qualitative and Quantitative Research Designs" document on Blackboard. 
SELECT AN ANSWER
·  qualitative, case study research 
·  quantitative, experimental 
·  qualitative, narrative research 
·  quantitative, pretest-posttest 
(6.) What are the three instruments or survey tools used to measure the nurse's attitudes and knowledge about LGBTQ people? Please provide the complete names of the survey tools.


 
 
(9.) The researcher recommends a longitudinal study to measure the impact of an educational intervention on attitudes of RNs toward the LGBTQ population. Why do you think they recommend that? 
 

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