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Health Care Needs of the Population : Call for a Paradigm S hift in Nursing Curriculum Sherry L Roper, PhD, MSN, RN.

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  1. Health Care Needs of the Population: Call for a Paradigm Shift in Nursing CurriculumSherry L Roper, PhD, MSN, RN This continuing nursing education activity was approved by the Northeast Multi-State Division, an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation 1 Contact Hour

  2. Disclosure This educational activity does not include any content that relates to the products and/or services of a commercial interest that would create a conflict of interest. • There is no commercial support being received for this event.

  3. At the conclusion of this presentation the participant will: • Identify 3 health disparities faced by LGBT people. • Describe 3 effects of stigma and/or discrimination on health outcomes of LGBT individuals. • Propose 3 strategies for incorporating LGBT health related content into the nursing curriculum.

  4. What’s in An Acronym • LGBT stands for lesbian, gay, bisexual, and transgender. • Includes 11 different groups. • Represents a diverse group of 10 million American adults (4.1% of population). • Encompassing all races and ethnicities, religions, and social classes. • Meant to be inclusive and respectful term representative of all sexualities. • Other forms of reference for gender and sexualities: • LGBTQ • LGBTQQIP2SAA • (Gates, 2017; Office of Disease Prevention and Health Promotion [ODPHP], 2014)

  5. What’s in An Acronym B T G A sexual orientation that describes a woman who is emotionally and sexually attracted to other women. Describes a person whose gender identity and assigned sex at birth do not correspond. Sometimes abbreviated as trans. L A sexual orientation that describes a person who is emotionally and sexually attracted to people of their own gender. It can be used regardless of gender identity, but is more commonly used to describe men. A sexual orientation that describes a person who is emotionally and sexually attracted to people of their own gender and people of other genders. (National LGBT Health Education Center, 2016)

  6. What’s in An Acronym For the purpose of this presentation the LGBT population is combined as a single entity. However, it should be understood that each entity is a distinct, subcultural group with its own specific health care needs.

  7. Terminology Gender Identity Group we self identify with. Man/male Woman/female Neither Another Gender Sexual Orientation: Who we are romantic and sexual attracted to (lesbian, gay, bisexual). Biological Sex Sex we were born with (male, female, intersex) (National LGBT Health Education Center, 2016)

  8. Terminology: Sexual Orientation vs Gender Identity Everyone has a sexual orientation and gender identity (National LGBT Health Education Center, 2016)

  9. True or False Transgender is a sexual orientation? • False: • Sexual orientation is how a person describes their physical and emotional attraction to others (romantic and sexual attraction) • Transgender refers to people who have a gender identity that is different than their birth sex.

  10. True or False Our biological sex determines our gender identity? False. Biological sex (male, female or intersex) is the sex we were born. Our gender identify is determined by an intense sense of belonging to a particular gender.

  11. LGBT Health Disparities • LGBT individuals face health disparities linked to societal stigma, discrimination, and a lack of access to culturally-competent health care. • The Institute of Medicine [IOM] (2011) has identified the LGBT population as health disparate and underserved.

  12. Stigma & Discrimination • Share the disturbing effects of stigma and/or discrimination • For example: In a 2017 study of 857 LGBT adults: • 25% reported experiencing discrimination in the last year • 18% avoided doctors’ office • 11% experienced harsh or abusive language from the healthcare provider • In a 2015 national survey of 10,528 LGBTQ students between the ages of 13 and 21 • 57.6 % felt unsafe at school • 31.8% missed at least one day of school in the last month because they felt unsafe or uncomfortable • 71.5% avoided school functions due to feeling unsafe or uncomfortable • In a 2013 study of 1,197 LGBT adults: • 39% were rejected by a family member or friend • 30% were threatened or physically attacked • 21% were treated unfairly by an employer Findings indicate that LGBT individuals are more likely to alter the way they live out of fear of discrimination. • (Bogart, Revenson, Whitfield, & France, 2014; GLSEN, 2015; Lim, Brown, Kim & Min, 2014; Pew Research Center, 2013; Singh & Durso, 2017)

  13. Stigma & Discrimination In 2015 20% of hate crimes were bias motivated towards sexual orientation (LGB) or gender identify (transgender or non-conforming). 32.8 percent of sexual orientation hate crimes occurred in or near residences/homes; 25.3 percent happened on highways/roads/alleys/streets/sidewalks; 6.0 percent transpired at schools/colleges. 33.3 percent of gender identify hate crimes occurred on highways/roads/alleys/streets/sidewalks; 6.1 percent occurred at schools/colleges ; and 4.4 percent happened in churches/synagogues/temples/mosques (US Department of Justice, 2015)

  14. Stigma & Discrimination • Inequalities that influence health • The Institute of Medicine [IOM] has identified the LGBT population as health disparate and underserved.

  15. LGBT Health Disparities: Poverty Decrease in Legal Equality = Higher Rates of Poverty Lack of Anti-Discrimination Protection = (Movement Advancement Project, 2017)

  16. LGBT Health Disparities: Homeless Among Homeless Youth: • 40% identify as LGBT (represent a total of 7% of the entire homeless population) • 43% of clients served by drop-in centers are LGBT • 30% of street outreach clients are LGBT • 30% of clients utilizing housing programs are LGBT • Difficulty locating shelters that accept them • Transgender are more likely to be turned away & experiences the worse health outcomes • Lack of nondiscrimination protections • Family rejection due to sexual orientation and gender identity the most frequently cited factor contributing to LGBT homelessness (Durso & Gates, 2012)

  17. LGBT Health Disparities: Lack of Access to Culturally Competent Health Care • Lack of access • Shortage of knowledgeable and cultural competent health care providers • A 2011 IOM report found that “LGBT individuals face barriers to equitable health care that can have a profound impact on their overall well-being” (IOM, p. 297, 2011)

  18. LGBT Health Disparities: Lack of Access to Culturally Competent Health Care • In a 2010 national survey only 22% of LGBT seniors reported feeling safe in being open about their sexual orientation in long term care facilities. • LGBT seniors experienced discriminating actions by staff 89% of the time. • A 73-year-old male reported “Due to my financial situation, I will have to share a room with another man. The thought of going back into a closet is making me ill. Frankly, I’m afraid of telling anyone that I’m gay” (NSCLC, p. 14, 2010). • In a similar 2013 study of 2,560 LGBT older adults 13% reported having been denied health care or provided substandard care. (Fredriksen-Goldsen et al., 2013; National Senior Citizens Law Center [NSCLC], 2010)

  19. True or False Nurses may describe themselves as culturally competent, but still may hold negative stereotypes about the LGBT population. • True: • Nurses may describe themselves as culturally competent, but still may hold negative stereotypes about the LGBT population. • Evidence suggests that negative attitudes towards the LGBT population may preclude the delivery of culturally competent care and elevate the risk for a variety of negative health problems.

  20. True or False Historically, nursing students have expressed negativity, attitudes of avoidance, phobia, and misconceptions towards the care of LGBT individuals. True: Historically, nursing students have expressed negativity, attitudes of avoidance, phobia, and misconceptions towards the care of LGBT individuals.

  21. Nurse’s Attitudes • In an integrative review of 17 articles regarding nurses' attitudes towards LGBT patients every study analyzed revealed evidence of negative attitudes. • In a study of practicing 268 nurses in San Francisco 80% reported a lack of knowledge in providing care to LGBT individuals. • Researchers concluded that gaps in knowledge and discomfort may adversely affect patient care. (Carabez, Pellegrini, Mankovitz, Eliason, Ciano, & Scott, 2015; Dorsen, 2012)

  22. Nursing Student’s Attitudes • Positive correlation between negative attitudes and a lack of willingness to care for LGBT persons identified. • In fifty percent of studies (6 out of 12 studies) nursing students expressed a negative attitude towards LGBT individuals. • Evidence suggests that negative attitudes towards the LGBT population may preclude the delivery of culturally competent care and elevate the risk for a variety of negative health problems. (Lim & Hsu, 2016)

  23. Effects of Stigma & Discrimination on Health • A lack of understanding regarding cultural and linguistic norms regarding sexual orientation and identify • Adverse mental health • Adverse physical health • Unhealthy risk behaviors • Failure to access care

  24. Effects of Stigma & Discrimination on Health Compared to peer counterparts LGBT youth: • Have higher rates of suicidal ideation and suicide attempts (at least one attempt) • At a greater risk for homelessness • Experience harassment, victimization, and violence including sexual assault • More likely to experience posttraumatic stress disorder (PTSD) • Have a current major depressive episode • At higher risk of HIV and STDs • (IOM, 2011; Healthy People, 2020; Keuroghlian, Shtasel, & Bassuk, 2014; Russel & Fish, 2016)

  25. Effects of Stigma & Discrimination on Health Compared to heterosexual counterparts LGBT adults: • Higher risk for poor mental health issues: • Depression • Anxiety • Suicidal ideation • Psychological distress • Greater risk for harassment, victimization, and violence including rape and physical assault • (Bostwick, Boyd, Hughes, & McCade, 2010; Kidd, Howison, Piling, Ross, & McKenzie, 2016; Mereish, Cleirgh, & Bradford, 2014; Carter, Van der Deen, Wilson, & Blakely, 2012; Walters, Chen, & Breiding, 2013)

  26. Effects of Stigma & Discrimination on Health Compared to heterosexual counterparts LGBT adults: • Higher rates of smoking (30% vs 20% of general population) • Higher rates of substance abuse • A higher risk of HIV and STDs • Less likely to participate in preventive services • Higher rates of cancer • Cardiovascular disease • (CDC, 2013; Grant, Mottet, Tanis, Harrison, Herman, & Keisling, 2011)

  27. Effects of Stigma & Discrimination on Health Notable differences among LGBT adult groups: • Transgender experience higher rates of victimization and suicide attempts. • Gay, bisexual and transgender women have a higher risk of HIV and STDs (especially among communities of color) • Lesbians are less likely to access preventive services for cancer (pap tests and mammogram). • Transgender men face barriers in receiving pap tests. (CDC, 2012, 2013)

  28. Effects of Stigma & Discrimination on Health Compared to heterosexual counterparts LGBT elders: • Greater risk of having poorer health outcomes due to issues of: • Isolation • Lack of support system • Lack of social services • History of inadequate preventive screenings, treatments, and other health care services • Increasing number of people over age 50 with HIV/AIDS • Higher mortality rates due to fear of discrimination (Orel, 2014)

  29. Health Care Needs Meeting the needs of the LGBT population begins with the establishment of a welcoming and inclusive environment. Which requires a cultural competent healthcare workforce. As nurse educators are we preparing nurses to provide culturally competent LGBT care?

  30. Cultural Competency • Students reported that nurse educators were not proactive • Eighty percent of San Francisco Bay nurses reported no education or training • Nearly 40% of BSN students (n=112) reported feeling unprepared • Only 28% of the students felt gender identity and sexual orientation mattered to patients. • A survey of 190 nursing students in the Southwest indicated significant knowledge deficits in the care of LGBT individuals. • A national survey of BSN programs 69% of faculty respondents (n 1,231) reported that they never or seldom teach LGBT health topics. (Carabez, Pellegrini, Mankovitz, Eliason, Ciano, & Scott, 2015; Cornelius & Carrick, 2015; Lim et al., 2015)

  31. Gaps in the Curriculum • Barriers to nursing faculty incorporating concepts into the curriculum include: • Alack of awareness • Homophobic and/or negative attitudes • Lack of knowledge regarding LGBT culture • Mounting evidence indicates that nursing education lacks curricular offerings on LGBT health. • Lack of curricular offerings serves as a barrier towards achieving a LGBT culturally competent nursing workforce.

  32. Calls for Change • In a study assessing the knowledge of faculty (n = 1,121)in BSN programs and their readiness to teach about lesbian, gay, bisexual, and transgender (LGBT) health 75% of the respondents identified the need for reviewing the curriculum to identify gaps in LGBT health topics and in aligning curricula with national LGBT health priorities. • Evidence indicates a need for faculty to assist the student in understanding patient’s sensitivity to attitudes conveyed by health care providers and resulting health implications. • Evidence demonstrates that the inclusion of LGBT related content into curricula effectively decreases prejudice and improves attitudes, knowledge, skills, and behaviors of healthcare workers towards this population. • (Lim, Johnson, & Eliason, 2015)

  33. Curriculum Solutions • An integrative review of current evidence in determining the best practice for improving the cultural competence of undergraduate nursing students towards the LGBT population identified three main categories: • Formal education such as lectures and prescribed assignments, • Contact with members of a LGBT cultural group • Interactive experiences • Analysis of findings indicate that all 3 categories of methods improved aspects of cultural competencewith no single activity being superior. (Orgel, 2017)

  34. Curriculum Solutions: Formal Education Incorporate LGBT with similar topics: • Fundamentals • Communication • Care plans • Health Assessment • Utilize non-heterosexist forms - adding options beyond "male" and "female" to the gender question. • Routinely discuss sexual orientation and gender identity across the lifespan • Geriatrics • Long term care needs (room assignments; use of appropriate pronouns) • End of life discriminatory issues for LGBT • OB/Pediatrics • Include discussions regarding gay or lesbian childbearing family • Risk factors facing LGBT youth • Adulthood • Identify the special needs of LGBT individuals in relation to adverse health outcomes

  35. Curriculum Solutions: Formal Education • Mental Health • Identify the special needs of LGBT individuals in relation to adverse mental health outcomes • Community Health: • Promote LGBT topics on social justice, vulnerability issues, and cultural competence • Ethics • Code of Ethics and duty in care of LGBT individuals • Examine personal biases • In general: • Include visuals/pictures that represent the variety of sexual orientations, identifies, and families into lecture content. • Invite members from an LGBT organizations to present on a topic. • Incorporate documentaries with debriefings: • Transgender HBO Biograph Special: https://video.search.yahoo.com/yhs/search?fr=yhs-mozilla-002&hsimp=yhs-002&hspart=mozilla&p=transgender+movie#id=1&vid=a3d069c5834c9571d9e833e8b5ab344c&action=click • To Treat Me, You have to Know Who I am: https://www.youtube.com/watch?v=NUhvJgxgAac • Invisible: The State of LGBT Health: https://vimeo.com/120083815 • “Gen Silent” by Stu Maddux. film on the life of a 60-year-old transgender:http://gensilent.com/.

  36. Curriculum Solutions: Contact • Incorporate forms (health history or physical assessment) that are non-heterosexist. • Collaborate with LGBT community agencies to plan clinical experiences. • Include appropriate assessment(s) of sexual orientation and gender identity.

  37. Curriculum Solutions: Interactive Experiences • Real-life scenarios • Use a standardized LGBT patient in simulation • LGBT-specific unfolding case studies • Role playing • Activities to examine person bias and potential LGBT phobic attitudes

  38. Curriculum Solutions: Interactive Experiences Are your attitudes toward LGBT people based upon experience or preconceptions? Do you fully embrace LGBT people as equal and valuable members of the community? Do your personal feelings prevent you from accepting and respecting LGBT people? Are you as accepting of LGBT people as you are of people from different racial, ethnic or religious backgrounds? How might your attitudes help or hinder your ability to provide cultural competent care for LGBT people? What can you do educate yourself about LGBT issues and improve your attitude with regard to LGBT people? Adapted from Frazer, Roche, & Mirzayi (2011)

  39. Conclusion • A lack of understanding regarding LGBT cultural and linguistic norms and mores regarding sexual orientation has been directly linked to a myriad of negative health outcomes. • The Institute of Medicine has identified the LGBT population as health disparate and underserved. • A variety of conditions have been identified as root causes of these disparities including societal stigma, discrimination, and a lack of access to culturally-competent health care. • The inclusion of LGBT related content into curricula is one strategy to address such disparities.

  40. Questions

  41. References • Bogart, L. M., Revenson, T. A., Whitfield, K. E., & France, C. R. (2014). Introduction to the special section on lesbian, gay, bisexual, and transgender (LGBT) health disparities: Where we are and where we're going. Annals of Behavioral Medicine, 47(1), 1-4. doi:10.1007/s12160-013-9574-7\ • Bostwick W.B., Boyd, C.J, Hughes, T.L., McCabe, S.E. (2010). Sexual orientation and the prevalence of mood and anxiety disorders in the United States. American Journal of Public Health,;100, 468–475. doi:  10.2105/AJPH.2008.152942 • Carter, K. N., Van der Deen, F. S., Wilson, N., & Blakely, T. (2012). Smoking uptake is associated with increased psychological distress: Results of a national longitudinal study. Tobacco Control, 23, 33-38. doi:10.1136/tobaccocontrol-2012-050614 • Carabez, R., Pellegrini, M., Mankovitz, A., Eliason, M.J., & Dariotis, W.M. (2015). Nursing students’ perceptions of their knowledge of lesbian, gay, bisexual, and transgender issues: Effectiveness of a multi-purpose assignment in a public health nursing class. The Journal of Nursing Education, 54(1), 50-53. • Carter, K. N., Van der Deen, F. S., Wilson, N., & Blakely, T. (2012). Smoking uptake is associated with increased psychological distress: Results of a national longitudinal study. Tobacco Control, 23, 33-38. doi:10.1136/tobaccocontrol-2012-050614

  42. Centers for Disease Control and Prevention. (2014). Lesbian, gay, bisexual, and transgender health. Retrieved from https://www.cdc.gov/lgbthealth/ • Centers for Disease Control and Prevention. (2013). HIV/AIDS: HIV among gay and bisexual men. Retrieved from http://www.cdc.gov/hiv/ risk/gender/msm/facts/index.html#refb • Centers for Disease Control and Prevention. (2012). Lesbian, gay, bisexual, and transgender health. Retrieved from https://www.cdc.gov/lgbthealth/ • Cornelius, J.B. & Carrick, J. (2015). A survey of nursing students’ knowledge of and attitude toward LGBT health care concerns. Nursing Education Perspectives, 36(3), 176-178. doi: 10.5480/13-1223 • Dorsen, C. (2012). An integrative review of nurse attitudes towards lesbian, gay, bisexual, and transgender patients. Canadian Journal of NursingResearch, 44, 18-43. Retrieved from http://docserver.ingentaconnect.com/deliver/connect/mcgill/08445621/v44n3/s3. pdf?expires=1492808393&id=90499671&titleid=6601&accname=Guest+User&checksum=30E7332EE76BF503FB2777A367D510A2 • Durso, L.E., & Gates, G.J. (2012). Serving our youth: Findings from a national survey of service providers working with lesbian, gay, bisexual, and transgender Youth who are Homeless or At Risk of Becoming Homeless. Los Angeles: The Williams Institute with True Colors Fund and The Palette Fund.

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  44. Grant, J. M., Mottet, L. A., Tanis, J., Harrison, J., Herman, J. L., & Keisling, M. (2011). Injustice at every turn: A report of the National Transgender Discrimination Survey. Washington, DC: National Center for Transgender Equality and National Gay and Lesbian Task Force. • Healthy People 2020 [Internet]. Lesbian, gay, bisexual, and transgender health. Washington, DC: U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. Retrieved from https://www.healthypeople.gov/2020/topics-objectives/topic/lesbian-gay-bisexual-and-transgender-health • Institute of Medicine. (2011). The health of lesbian, gay, bisexual, and transgender people: Building a foundation for better understanding. Retrieved from http://www.nationalacademies.org/hmd/Reports/2011/The-Health-of-Lesbian-Gay-Bisexual-and- Transgender-People.aspx • Keuroghlian, A.S., Shtasel, D., Bassuk, E.L. (2014). Out on the street: A public health and policy agenda for lesbian, gay, bisexual, and transgender youth who are homeless. Am J Orthopsychiatry, 84(1), 66-72. doi:  10.1037/h0098852 • Kidd, S.A. , Howison, M., Pilling, M., Ross, L.E., & McKenzie, K. (2016). Severe mental illness among LGBT populations: A scoping review. Psychiatric Services, 67(7), 779-783. Doi.org/10/1176/appi.ps201500209 • Lim, F.A. Brown, D.V., Kim, S.M.J. (2014) Addressing health care disparities in the lesbian, gay, bisexual, and transgender population: A review of best practices. Am J Nurs ,114(6), 24-35. doi: 10.1097/01.NAJ.0000450423.89759.36

  45. Lim, F, Johnson, M., Eliason, M. (2015). A national survey of faculty knowledge, experience, and readiness for teaching lesbian, gay, bisexual and transgender (LGBT) health in baccalaureate nursing programs. Nursing Education Perspective, 36(3),144-152. doi: 10.5480/14-1355 • Lim, F. A., & Hsu, R. (2016). Nursing students' attitudes toward lesbian, gay, bisexual, and transgender persons: An integrative review. Nursing Education Perspectives, 37(3), 144. doi:10.1097/01.NEP.0000000000000004 • Lim, F. & Levitt, N. (2011). Lesbian, gay, bisexual, and transgender health: Is nursing still in the closet? American Journal of Nursing, 111(11), 11. doi: 10.1097/01.NAJ.0000407277.79136.91 • Mereish, E.H., Cleirgh, C.O. & Bradford, J.B. (2014). Interrelationships between LBGT-based victimization, suicide, and substance use problems in a diverse sample of sexual and gender minorities. Psychology, Health & Medicine, 19(1), 1-13. http://dx.doi.org/10.1080/13548506.2013.780129 • Movement Advancement Project. (2017). Equity maps. Retrieved from http://lgbtmap.org/equality-maps • National LGBT Health Education Center. (2016). Providing quality care ot lesbian, gay, bisexual, and transgender patients: An introduction for staff training. Boston: MA. A Program of the Fenway Institute.

  46. National Senior Citizens Law Center. (2010). LGBT Older adults in long-term care facilities. Retrieved from http://www.lgbtagingcenter.org/resources/pdfs/NSCLC_ LGBT _report.pdf • Office of Disease Prevention and Health Promotion. (2014). Lesbian, gay, bisexsual, and transgender health. Retrieved from https://www.healthypeople.gov/2020/topics-objectives/topic/lesbian-gay-bisexual-and-transgender-health • Office of Disease Prevention and Health Promotion. (2014). Lesbian, gay, bisexsual, and transgender health. Retrieved from https://www.healthypeople.gov/2020/topics-objectives/topic/lesbian-gay- bisexual-and-transgender-health • Orel, N.A. (2014). Investigating the needs and concerns of lesbian, gay, bisexual, and transgender older adults: The use of qualitative and quantitative methodology. J Homosex. 6(1), 53-78. doi:  10.1080/00918369.2013.835236 • Orgel, H. (2017). Improving LGBT cultural competence in nursing students: An integrative review. ABNF Journal, 28(1), 14-18. • Pew Research Center. (2013). A survey of LGBT Americans. Retrieved from http://www.pewsocialtrends.org/2013/06/13/a-survey-of-lgbt-americans/ • Russell, S.T. & Fish, J.N. (2016). Mental health in lesbian, gay, bisexual, and transgender (LGBT) youth. Annu Rev Clin Psychol, 12, 465-87. doi: 10.1146/annurev-clinpsy-021815-093153

  47. Singh, S., & Durso, L. E. (2017). Widespread discrimination continues to shape LGBT peopl’s lives in both subtle and significant ways. Center for American Progress. Retrieved from https://www.americanprogress.org/issues/lgbt/news/2017/05/02/429529/widespread-discrimination-continues-shape-lgbt-peoples-lives-subtle-significant-ways/ • US Department of Justine. (2015). 2015 Hate crime statistics. Retrieved from https://ucr.fbi.gov/hate-crime/2015 • Walters, M. L., Chen, J., & Breiding, M. J. (2013). The National Intimate Partner and Sexual Violence Survey: 2010 findings on victimization by sexual orientation. Retrieved from http://www.cdc.gov/ViolencePreven tion/pdf/NISVS_SOfindings.pdf • Whitehead, J., Shaver, J., & Stephenson, R. (2016). Outness, stigma, and primary health care utilization among rural LGBT populations. PLOS One, 11(1). doi.org/10.1371/journal.pone.0146139

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