Teaching and Learning in Nursing 16 (2021) 116
120

Contents lists available at ScienceDirect

Teaching and Learning in Nursing

journal homepage: www.journals.elsevier.com/
teaching-and-learning-in-nursing

Incorporating health care concepts addressing the needs of the lesbian,

gay, bisexual, and transgender population in an associate of science in
nursing curriculum: Are faculty prepared?
Tracey Hodges, Ed.D, RN*, Sherry Seibenhener, DNP, RN, Diane Young, PhD, RN
Troy University, Montgomery, AL, USA

A R T I C L E I N F O A B S T R A C T

Article History: Background: The deficiency in knowledge and cultural awareness among nurse educators regarding LGBTQ
Accepted 21 November 2020 individuals potentiates inequitable and improper care that results in poor health outcomes.
Keywords:
Method: Using a descriptive design, this pilot study aimed to determine ASN faculty preparedness to teach
LGBTQ LGBTQ related healthcare with an online survey questionnaire through Qualtrics.
Culture Results: Thirty to forty percent of respondents indicated a lack of understanding, knowledge, and preparation
Competence necessary to incorporate culturally competent and fact-based LGBTQ education into their ASN program
Ethical curricula.
Inclusive Conclusion: Acquisition of understanding, competence, and skill in caring for LGBTQ individuals suggests a
Nursing education paradigm shift in nursing education is needed, starting with transforming nursing curricula to include
concepts specific to the LGBTQ population.
© 2020 Organization for Associate Degree Nursing. Published by Elsevier Inc. All rights reserved.

Introduction
The Lesbian, Gay, Bisexual, Transgender, and Queer (LGBTQ) pop-
ulation is estimated to be around 10% of the population in the United
States (Walker et al., 2016). However, population statistics lack accu-
racy due to the exclusion of LGBTQ categories on census forms in the
United States and Canada (Healthy People, 2020). Issues facing the
LGBTQ community have surfaced in the media, through television
specials, autobiographies, and news broadcasts. Although there is
increased presence regarding the LGBTQ population in scholarly liter-
ature, and initial strides have been made with increasing LGBTQ
awareness among the general public, the media continues to report
transgender persons being harassed, assaulted and even murdered
(Brown et al., 2017).
A recurring theme noted in the media is the lack of quality health-
care specific to the LGBTQ community. While not specifically
addressed in Leininger’s Transcultural Nursing Theory, the LGBTQ
community fits nicely within this theory and within nursing given
“. . .the theory is known for its broad, holistic yet culture-specific focus
to discover meaningful care to diverse cultures. . .and with. . .this
knowledge gradually transforming health systems and changing nurs-
ing practices into relevant new ways of functioning” (Leininger, 2002,
*Corresponding author.
E-mail addresses: thodges@troy.edu (T. Hodges), sseibenhener@troy.edu
(S. Seibenhener), dyoung86534@troy.edu (D. Young).
p. 190). Consequently, the authors of this study intend for the informa-
tion put forth here to help inform that health care transformation.
After all, Leininger and McFarland (Leininger & McFarland, 2002)
purported nurses were the largest percentage of caregivers and Smiley
et al. (2018) agreed in the 2017 National Workforce Survey when they
indicated nursing continues as the largest healthcare profession. As
part of that profession, nurse educators have the potential to influence
both fellow faculty and nursing students to become the most influen-
tial health care providers with respect to providing safe, quality care to
the LGBTQ community. To do this, though, requires an increase in fac-
ulty knowledge of LGBTQ health care needs so they can better prepare
nursing students to provide culturally competent care that helps pre-
vent adverse outcomes for this population. Unfortunately, some nurses
and nurse educators do not regard the LGBTQ culture very highly, con-
tinuing to display negative attitudes, stereotypes and a lack of comfort
in providing care for the LGBTQ community (Carabez et al., 2015).
Additionally, Lim et al. (2014) stated “The negative attitudes of nursing
students toward LGBTQ people may be attributed in part. . .to the lim-
ited coverage of LGBTQ health issues in nursing education” (p. 25).
This lack of regard by nursing students, nurses and nurse educators
result in a lack of exposure to the LGBTQ culture, limiting the art of
understanding this culture’s specific principles, beliefs, and caring pat-
terns. Therefore, quality of care for the LGBTQ community could poten-
tially be affected. In order to have qualified, competent nursing care for
all populations, nurses need education and training specific to popula-
tions that have been marginalized. Foundational training should begin

https://doi.org/10.1016/j.teln.2020.11.005
1557-3087/© 2020 Organization for Associate Degree Nursing. Published by Elsevier Inc. All rights reserved.
 T. Hodges et al. / Teaching and Learning in Nursing 16 (2021) 116
120
with nursing education programs and continue throughout the nurs-
ing career. The primary objective of this study was to survey nursing
faculty’s preparation for addressing the needs of the LGBTQ popula-
tion.
Background
Access to health care is a fundamental human right that is regu-
larly denied due to discrimination of LGBTQ and gender non-con-
forming individuals (Fredriksen-Goldsen & Espinoza, 2014). Mirza
and Rooney (2018) agree stating, “Discrimination in health care set-
tings endangers LGBTQ people’s lives through delays or denials of
medically necessary care” ({ 2). The Institute of Medicine (IOM) con-
sensus report (Institute of Medicine, 2011) accentuated the lack of
science-based knowledge on health care concepts of the LGBTQ pop-
ulation. According to the U.S. Transgender Survey (2015), when
attempting to access healthcare services, transgender individuals fre-
quently experience discrimination through disrespect, harassment,
violence, and denial of service. Kates et al. (2018) agree with the U.S.
Transgender Survey, and add that rejection of family and community,
as well as a lack of insurance coverage, results in sub-standard care.
Often, LGBTQ individuals are hesitant in seeking healthcare needs
due to practitioners’ lack of knowledge about the LGBTQ population
and their specific healthcare needs (Roche & Keith, 2014). This defi-
ciency in knowledge and cultural awareness of LGBTQ individuals
pose challenges for obtaining care that often results in poor health
outcomes (Lim et al., 2015; McNiel & Elertson, 2018; Kates et al.,
2018). The Joint Commission (TJC) strongly advocates for best practi-
ces among hospital settings through provision of safe, high quality
healthcare. To facilitate adoption of their vision, TJC now requires
U.S. hospitals to create a more welcoming, safe, and inclusive envi-
ronment that contributes to improved health care quality for LGBTQ
patients and their families. For example, policies should ensure equal
visitation rights of same sex partners and evaluating the effect that
changes in policy for effective care are working (The Joint Commis-
sion, 2011). Likewise, the American Nurses Association (2018) states
“. . .nurses must deliver culturally congruent care and advocate for
lesbian, gay, bisexual, transgender, queer, or questioning (LGBTQ+)
populations” (p. 1). By doing so, nurses will contribute to the caring
and welcoming environment advocated by TJC and ultimately help
improve good health outcomes for their LGBTQ patients.
LGBTQ, stigmatization, and nursing care
A stigma is the process of marginalizing a group or class of indi-
viduals, specifically labeling or understanding them as different in
terms of stereotypes (Roche & Keith, 2014). Stigmatization of LGBTQ
individuals has been highlighted as a contributor to illnesses such as
sexually transmitted diseases, suicide, drug and/or alcohol abuse and
depression (Centers for Diseases Control & Prevention, 2014), and
undesirable health outcomes for the LGBTQ population (Zunner &
Grace, 2012; Roche & Keith, 2014). The National LGBTQ Survey
showed 28% of LGBTQ individuals reported they postponed medical
care due to fear of discrimination (Grant et al., 2011). Similarly, a
Canadian study found 21% of LGBTQ individuals reported avoiding
the emergency room due to fear of discrimination reflective of their
LGBTQ status (Bauer et al., 2013). Such postponements and avoidan-
ces increase poor health outcomes for this population.
Nursing education and LGBTQ curriculum
Culture is learned values, beliefs, norms, and practices of a partic-
ular group that guides thinking, decisions, and actions in a patterned
way (Shen, 2015). A study by Shen (2015) highlighted the lack of cul-
turally appropriate care techniques for the LGBTQ population in
117
nursing program curricula. Lim et al. (2015) put forth that
“. . .negative attitudes of nursing students toward LGBTQ people may
be attributed in part to a lack of experience with this population and
to the limited coverage of LGBTQ health issues in nursing education”
(p. 25). As a result, providing culturally appropriate health care for
LGBTQ individuals may prove to be a challenge for many nurses.
Incorporating published standards of care for LGBTQ individuals is
critical to bridge the education gap that hinders the delivery of cul-
turally competent care for LGBTQ individuals (The World Professional
Association for Transgender Health, 2001; The Georgia Voice, 2011;
U.S. Department of Health and Human Services, 2014; The Joint Com-
mission, 2011; American Nurses Association, 2018).
Nurse educators play an integral role in increasing cultural aware-
ness in nurse graduates by incorporating culturally responsive peda-
gogy with an emphasis on both individual and organizational
cultural competence (Utley-Smith, 2017). Despite this role, studies
show 2.12 to 5 to be the average number of hours nursing programs
dedicate to discussing LGBTQ health issues, but the research does not
address a recommended number of hours to give to this topic (Lim
et al., 2015). Furthermore, BSN nursing students also imply nurse
educators do not demonstrate forward thinking regarding, nor have
the knowledge to teach, cultural awareness for the LGBTQ population
(Cornelius & Garrick, 2015). Given this overall environment, the aim
of this study was to gauge ASN faculty preparedness to teach LGBTQ
health care.
Methods
Using a descriptive design, this pilot study aimed to determine
ASN faculty preparedness to teach LGBTQ related healthcare. The Pri-
mary Investigators (PIs) for the study received University Institu-
tional Review Board (IRB) approval prior to initiating the study. The
PIs completed an internet search for Associate of Science in Nursing
(ASN) programs in five southeastern states. Fifty-eight programs
were identified as sources for nursing faculty participants in the ini-
tial step of the study. Each school’s website was reviewed to obtain
contact information for program administrators. The study survey
was administered using Qualtrics, an online survey platform. Admin-
istrators (directors, deans and chairs) of ASN programs in Alabama,
Georgia, Florida, Mississippi and Tennessee received an email con-
taining the study’s aim, a link to the survey, and a request that they
share the survey with all faculty in their ASN program. The survey
contained a consent form advising respondents that participation in
the survey was voluntary, all survey responses would remain anony-
mous, and each participant had the option to leave the survey at any
time should they become uncomfortable with the survey questions.
Respondents did not receive compensation for survey participation.
After sending the first e-mail, three follow-up emails were sent to
encourage nursing administrators to share the survey. Data collection
occurred between September 1 and November 30, 2017.
For this study, the PIs selected (with permission for use) a survey
questionnaire developed by Lim et al. (2015). The original question-
naire was developed from a literature review on LGBTQ health in
nursing, medicine, social work, and other allied health professions
regarding LGBTQ health knowledge and experience in teaching
LQBTQ health material, and comfort in incorporating LGBTQ concepts
into nursing curricula.
Completing the survey questionnaire took less than 15 minutes.
The questionnaire consists of 12 Likert scale questions with six possi-
ble responses for each question and two open-ended questions.
Depending on the Likert scale question, the available responses
ranged from number one (never, limited, not comfortable, not ready,
not important, not necessary, or non-existent) to number six (do not
know). Within that range, it was left to each participant to select their
responses based on their interpretation of the available responses
118 T. Hodges et al. / Teaching and Learning in Nursing 16 (2021) 116
120

(e.g., seldom, regularly, often, and frequently). The first open-ended Table 1
question asked about teaching strategies the participant or school Demographic characteristics of survey respondents.

used to integrate LGBTQ topics into the curriculum. The second Characteristic n %
requested that respondents provide any additional comments
Age (n = 28)
regarding inclusion of LGBTQ topics in their nursing programs. These
26 years 1 3.6
two questions yielded a total of 28 comments. 30+ years 27 96.4
Lim et al. (2015) sent the questionnaire to a panel of four content Race (n = 28)
experts, comprised of nurses, researchers and clinicians, to determine White/Caucasian (non-Hispanic) 20 71.4
Black/African American 5 17.8
instrument accuracy, relevance and content validity. A content valid-
Native American 1 3.6
ity index (CVI) and item-level CVI (I-CVI) calculation (from ratings of Hispanic 1 3.6
the content experts to adjust for chance agreement) demonstrated the Other 1 3.6
questionnaire had a 0.95 I-CVI, which exceeded the 0.78 considered to Asian 0 0
be evidence of content validity (Polit & Beck, 2012). Pacific Islander 0 0
Arabic/Middle Eastern 0 0
Sex (n = 28)
Sample Female 26 92.8
Male 1 3.6
The sample for this study was a non-probability convenience sam- Decline to answer 1 3.6
ple of all nursing faculty employed in 58 ASN programs located in five Transgender (male to female) 0 0
Transgender (female to male) 0 0
southeastern states (Alabama, Georgia, Florida, Mississippi and Ten- Intersex 0 0
nessee). Participants were included in data collection regardless of Other 0 0
education level, sex, ethnicity or age. Fifty-eight ASN Program nurse Sexual orientation (n = 27)
administrators received an email containing the survey link and were Other 23 85.2
Decline to answer 4 14.8
asked to disseminate the link to ASN nursing faculty in their respec-
Do not know 0 0
tive programs. Participation in the study was voluntary. However, Bisexual 0 0
since the total number of faculty who received the link is unknown, Lesbian 0 0
a survey response rate could not be determined. Additionally, the Queer 0 0
authors excluded incomplete survey questionnaire submissions leav- Gay 0 0
Years of teaching experience (n = 28)
ing 28 completed surveys (n=28) for evaluation. The majority (96%) < 1 year 2 7.1
of participants were over 30 years of age. Seventy one percent of the 1
5 years 11 39.3
sample were Caucasian with the remaining 29% representing African 6
10 years 6 21.4
Americans, Native Americans, Hispanic, and other. Although females > 10 years 9 32.2
Academic degree (n = 28) 22 78.6
compromised 93% and males 4% of the participants, this is typical of
Master’s degree 4 14.3
nurse educator demographics (National League of Nursing, 2015). DNP 2 7.1
The majority (39%) for years of teaching experience was between one EdD 0 0
and five. See Table 1 for further demographic information regarding PhD 0 0
study participants. DNS 0 0
Baccalaureate degree 0 0
Employment status (n = 28)
Results Full time 27 96.4
Adjunct 1 3.6
Primary findings Part time 0 0

Results for the question on faculty awareness of LGBTQ health-

related issues showed 17.86% were frequently aware; 25% regularly
aware; 14.29% often aware; and 42.86% seldom aware. Responses to
the question on perceived knowledge of LGBTQ health care issues
demonstrated 3.57% had full knowledge; 14.82% moderate knowl-
edge; 35.71% adequate knowledge; 35.71% somewhat limited knowl-
edge; and 10.71% limited knowledge. When asked how often they
read LGBTQ health-related articles in professional journals in the last
two years, 3.57% responded frequently; 7.14% often; 25% regularly;
35.71% seldom; and 28.57% never.
A separate question asked participants to rate how often they had
taught 13 different LGBTQ health-related topics in the last two years
(see Table 2). The most frequently taught topics were: (a) approaches
to reduce HIV/STI risks among LGBTQ people, (b) exposure to HIV
and STIs in the LGBTQ communities of color, (c) LGBTQ youth issues,
and (d) violence and hate crimes. The least taught topics were: (a)
obesity; (b) limited access to early detection programs; (c) inadequate
access to health insurance; and (d) high rates of tobacco, alcohol, and
drug use.
Participants were also asked to rate their readiness to include
LGBTQ health in nursing courses. Of the 28 respondents, 25% were
fully ready; 14.29% moderately ready; 25% adequately ready; 28.57%
somewhat ready; and 3.57% not ready. When asked to rate their com-
fort level in discussing LGBTQ issues in their courses, 25% responded
fully comfortable; 14.29% moderately comfortable; 25% adequately
comfortable; and 35.71% somewhat comfortable.
With regard to the question concerning how often health-related
LGBTQ issues were raised for discussion in faculty (e.g., curriculum)
meetings, 64.29% responded never; 17.86% occasionally; 14.29%
sometimes; and 3.57% did not know. Eighty-six percent of respond-
ents estimated the number of hours their ASN program devoted to
teaching health-related LGBTQ issues in the classroom. Sixty-two
percent reported 1
2 h, 29% 3
4 h, and 9% reported 10 h dedicated
to discussing LGBTQ care. The mean reported time was 2.78 h (n = 21;
SD = 2.67), with a range of one to ten hours.
Participant comments
Of the 28 comments generated by the survey, nineteen comments
concerned strategies to promote the integration of LGBTQ health into
the curriculum and returned two broad themes: curriculum and fac-
ulty. Comments were further categorized by actions seen as either
promoting or hindering the integration of LGBTQ health topics into
the curriculum, with 21% (n=6) of the respondents commenting on
one or both of these categorizations.
Actions considered as promoting LGBTQ health topics included
combining the topic with other similar topics, highlighting it as
 T. Hodges et al. / Teaching and Learning in Nursing 16 (2021) 116
120 119

Table 2
Frequency of LGBT health-related topics taught in the last two years.

Baseline characteristic 1 2 3 4 5 6
Never Seldom Regularly Often Frequently Do not know

n % n % n % n % n % n %

LGBT youth Issues (i.e. suicide, bullying and homelessness) 14 50 6 21.43 4 14.29 0 0.00 3 10.71 1 3.57
Limited access to early detection programs among LGBT persons 15 53.57 9 32.14 2 7.14 0 0.00 1 3.57 1 3.57
Exposure to HIV and other sexually transmitted infections (STIs), 5 17.86 15 53.57 3 10.71 1 3.57 3 10.71 1 3.57
particularly among LGBT communities of color
Approaches to reduce HIV/STI risk among LGBT people 7 25.00 12 42.86 4 14.29 1 3.57 3 10.71 1 3.57
Obesity among LGBT persons 19 66.67 6 22.22 1 3.70 0 0.00 1 3.70 1 3.70
Inadequate access to health insurance among LGBT clients 14 50.00 7 25.00 5 17.86 1 3.57 0 0.00 1 3.57
Need for referral to appropriate social services for LGBT clients 11 39.29 8 28.57 5 17.86 2 7.14 1 3.57 1 3.57
Shortage of health care providers who are knowledgeable and culturally 11 39.29 11 39.29 4 14.29 1 3.57 0 0.00 1 3.57
competent in LGBT health
High rate of tobacco, alcohol and drug use among LGBT clients 14 50.00 9 32.14 2 7.14 1 3.57 1 3.57 1 3.57
Homophobia 9 32.14 8 28.57 7 25.00 0 0.00 2 7.14 2 7.14
Minority stress among LGBT persons 12 42.86 7 25.00 6 21.43 1 3.57 1 3.57 1 3.57
Violence and hate crimes against LGBT people 10 35.71 7 25.00 6 21.43 1 3.57 3 10.71 1 3.57
Need for research into LGBT health concerns 12 42.86 8 28.57 7 25.00 0 0.00 0 0.00 1 3.57
Legend: HIV = Human Immunodeficiency Virus LGBT = lesbian, gay, bisexual, transgender; STI = sexually transmitted infection.

cultural competence, and adopting textbooks that include LGBTQ
health. The major action considered to hinder introduction of LGBTQ
health topics was a lack of formal direction given to faculty for incor-
porating LGBTQ topics into the curriculum.
Of all respondents, only two reported receiving formal training on
LGBTQ health care integration into the nursing curriculum and one of
those said, “I took a four-hour faculty continuing education course
(safe zone) to learn how to talk to students who may need assistance.
I now have the safe zone card on my door.”
Discussion
The primary finding in this pilot study is nursing faculty were not
adequately prepared to teach about caring for LGBTQ people. Consis-
tently, 30
40% of respondents indicated a lack of understanding,
knowledge, and preparation necessary to incorporate culturally com-
petent and fact-based LGBTQ education into their ASN program cur-
ricula. Furthermore, only 7% (n=2) of respondents reported any
formal training regarding care for, or issues of, the LGBTQ individual.
To that end, the authors encourage ASN programs to advocate for the
LGBTQ individual by completing formalized education on the LGBTQ
population, evaluating textbooks to ensure they include LGBTQ con-
tent, and then incorporating LGBTQ issues and healthcare concerns
into their curricula. This can be accomplished through establishing a
workgroup with members of the community who identify as LGBTQ
to help with nursing school curriculum revisions that are discussed
and proposed through program Curriculum Committees and dis-
cussed in faculty meetings for program adoption. Taking a structured,
methodical approach to including LGBTQ content allows all faculty
the opportunity to articulate thoughts and concerns of how to best
meet the educational needs of the student, and make a difference
in the educational efforts regarding LGBTQ health in their nursing
program.
Furthermore, since this focus of nursing education research is rel-
atively new, the PIs recommend continued research at every level to
improve the LGBTQ health care body of knowledge. Research can
inform policies aimed at decreasing systemic biases, facilitate bridg-
ing the gap between education and training and the delivery of care
relative to health disparities in the LGBTQ population, and improve
health care for the LGBTQ community over all. Ultimately, “Habits of
self-awareness and reflection, ongoing professional development,
and implementation of best practices are. . .” (Mitchell et al., 2016,
p. 33) critical to improving access to health care and health outcomes
(Jennings et al., 2019) for the LGBTQ population, and this could start
in the classroom with nurse educators in an effort to prepare students
for clinical practice.
Limitations
An identified study limitation is the small convenience sample.
Invited participants were ASN faculty solely. Invitations to nurse edu-
cators across all nursing programs would deliver more robust data.
Since the study was conducted in one geographic region, generaliz-
ability is limited. A potential for bias exists as the deans of each pro-
gram were asked to forward the survey to their respective faculty,
(which allowed the deans to determine who actually received the
survey). Furthermore, the language (seldom, frequently, moderate,
etc.) used on the survey questionnaire was left to interpretation by
each participant (where individual interpretation could have poten-
tially skewed the results as well). Given these considerations, replica-
tion of this study with a larger sample size across all geographical
regions of the United States, a longer data collection period, and
more specific definitions for qualifiers would help determine if the
findings are generalizable to ASN, and other faculty as a whole.
Implications for nursing
Adequate education for nursing students is essential to ensuring
the provision of care that is knowledgeable, safe, and culturally
aware. Acquisition of understanding experience, and skill in caring
for LGBTQ individuals requires a paradigm shift in nursing education,
starting with each program exploring their teaching practices to
identify any bias in order to increase cultural awareness. Case studies
involving LGBTQ individuals can be written to address care needs
upon entering the hospital. Through case studies, students can reflect
on personal biases and feelings. Although biases and prejudices are
human nature, nurses being cognizant of their own feelings and
beliefs can promote a more positive effect on patient care (Potter
et al., 2021; Zunner & Grace, 2012). Simulation exercises can be des-
ignated to address nursing assessment techniques and individual
health care needs detailed in the in the most recent Standards of Care
for the Health of Transsexual, Transgender, and Gender Nonconforming
People (The Georgia Voice, 2011). Community clinical experiences
that include LGBTQ individuals receiving health screenings can facili-
tate interactions with the LGBTQ community. An opportunity for stu-
dents to discuss and reflect after these experiences will be
imperative for transferring knowledge learned into future clinical
settings. Through implementing LGBTQ specific learning activities
120 T. Hodges et al. / Teaching and Learning in Nursing 16 (2021) 116
120
nurse educators can better prepare their nursing students to provide
safe, culturally aware, quality care to individuals within the LGBTQ
community.
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