Nursing students Tayler Avant (left) and Mitchel Becher (right) and an actor, Michael Nash (center), recreate in the simulation lab a roleplay scenario where the learners must make their transgender patient feel comfortable after experiencing bias. The College of Nursing debuted the module to teach undergraduate students about LGBTQ+ patient population needs in spring 2020. (Photos by August Jennewein)
Simulation
A patient walks into a clinic. It’s his first visit, and he’s nervous. In the past, providers have been judgmental and unknowledgeable because he’s transgender. He’s also hopeful because the clinic has unusually progressive forms, which he printed out to fill in at home.
Need
Lesbian, gay, bisexual, transgender and queer individuals face worse health outcomes when compared to their heteronormative counterparts.
“It’s a vulnerable population that experiences health disparities,” says Natalie Murphy, associate teaching professor and associate dean for academic programs in the College of Nursing. “This population is often afraid to even go for help or care because they’ve experienced stigma from providers in the past.”
The University of Missouri–St. Louis faculty member had already started to do something to combat the problem by incorporating education on LGBTQ+ population needs into her graduate courses. Then, her colleague, Assistant Teaching Professor Tonya Haynes, approached Murphy about creating something similar for undergraduates – they settled on an interactive learning module designed to incorporate education and dialogue specific to the health care needs, barriers and clinical experiences often encountered by members of the LGBTQ+ community.
“We wanted to present knowledge through a different lens,” Haynes says. “Many of our students have family members or friends in the community, or they may be part of the community, but we wanted to create something specific to health care.”
Simulation
The patient feels a stab of anxiety when the receptionist calls out his deadname instead of his chosen name. He approaches the desk, explains and requests to be called by his preferred name. The receptionist is flustered but accommodating at first, then resistant to using anything but the patient’s legal name.
Education
When Associate Teaching Professor Alicia Hutchings started to research LGBTQ+ curriculums across the U.S., she was surprised to find very little.
“In general, nursing schools only spend about two hours working with the health care needs of this population,” she says. “Our feeling was that we wanted to add this missing component.”
Hutchings, Haynes and Murphy – along with Assistant Professor Sheila Grigsby and Assistant Teaching Professor Amanda Finley – created then debuted the module in spring 2020.
The group wanted to know if the module would work, so they engaged the College of Nursing’s research office to collaborate on the design of a study to run simultaneously to measure the undergraduates’ knowledge and attitudes before and after.
The three-part program was spread out over the semester and included an in-class portion, the simulation with a transgender patient and a panel with members of the LGBTQ+ community. The group knew students would have different levels of knowledge coming in, so starting with didactic instruction was key.
“It was something completely new,” alumna Dajae Post says. “At that point, I was a tech, but we didn’t interact much with patients that weren’t cisgender. I can’t prepare for something I didn’t know about.”
Simulation
Again, the clinic gets his name wrong. This time it’s the medical tech. He’s apologetic but blunderingly confused, then asks the patient to take off his shirt for vitals. The patient is uncomfortable. He feels anxious and beyond frustrated – this clinic was supposed to be better.
Maybe it would be best to leave now.
The second phase of the module builds upon didactic knowledge with a simulation designed by Haynes. It starts with a video created by Montgomery College in which a transgender patient experiences bias stereotype frustration coming into an appointment. Then, in groups, the students work through the scenario with an actor playing the role of the patient.
“Learning how to communicate with someone who is very upset is a difficult situation,” Grigsby says. “We’re able to simulate that in a controlled environment, and they walk away with skills that they can take into reality. Nurses are supposed to be advocates for their patients, and if we find a situation happening, we have to intervene and fix it and make it better for that patient and train the rest of the health care team.”
Afterward, the students debrief with an instructor, investigate the implications of their choices and discuss opportunities to engage differently with the patient during subsequent encounters.
The high rates of cancer in the LGBTQ+ community made the worst-case scenario – where the patient leaves without care – hit home hard for alumnus John Gass, who is now a nurse on the oncology floor at Christian Hospital.
“One of the big fears in the training simulation was alienating the patient,” he says. “The importance of trying to reach out stuck out to me. A lot of people in the LGBTQ+ community are apprehensive about going to health clinics or going to the hospital for fear of judgment. If you are sick and not getting regular checkups, it could be too late by the time you find out that there is a serious problem.”
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- From left: Aleah Alonzo, Danielle Berry, Assistant Teaching Professor Tonya Haynes, Mitchel Becher, Tayler Avant and Taylor Mayberry debrief after the simulation.
Simulation
The nurse enters the exam room after receiving an update from the tech. She apologizes to the patient for the name inaccuracies and experience thus far. The nurse also explains that the medical record system is unable to support certain gender inclusive language. She displays empathy and assures the patient that priority will be placed on enhanced staff training. The patient seems a bit relieved and allows the nurse to proceed with the assessment. The nurse updates the provider and agrees to coordinate team training on cultural competency.
Change
After participating in the simulation, the nursing students are given an opportunity to reflect on the experience and discuss the content, with rationale, that they would include in team training: gender identity and pronouns, welcoming signage and progressive language on intake forms and medical records.
BSN student Danielle Friz hopes to see records change even more dramatically.
“You need to consider individual circumstances that could impact someone’s care,” she says. “You can’t always assume female patients need birth control for pregnancy prevention if that’s not their sexual orientation. Typically, when I go to the doctor, I receive a medical form that’s for females. If I were not heterosexual, all those questions would not apply to me and extra questions would apply.”
Community
The final segment is a panel discussion that invites the students to connect with the stories and lives of LGBTQ+ community members.
“That was my aha moment,” Post says. “This is a real issue, and it’s something that needs to be focused on. Everybody has the right to proper health care. Your sexuality, your race, your gender – none of that should be relevant. You should have the resources and the opportunities available to everybody else.”
Afterward, Grigsby had the students complete two reflections, one about what they gained and one about what they’d like to learn more about.
“This should be something that’s taught across the board to everybody, not just medical professionals,” Post says. “Everybody should be aware of the challenges that people of different sexual orientations face. People should be educated on this all the time.”
Results
The module proved to have a powerful effect, showing statistically significant results, which the group went on to present to the Nuts & Bolts for Nurse Educators Conference in August.
This brought about a second awakening – for the organizers.
“The earlier we can start training students, the more we can focus on developing better relationships,” Finley says. “We’ll have a better chance, with any group, to keep them healthy instead of having to chase after an illness that develops because they don’t feel comfortable coming for care.”
Since then, the team has received a grant from Sigma Nursing Honor Society to design and implement modules that will fit throughout the entire nursing curriculum, beginning this fall with students in their first semesters.
But the students carry within themselves the real results: knowledge, empathy, communication and collaboration skills and more.
“You have to be an advocate for your patients and treat them with respect,” Gass says. “You never want them to feel like they can’t get care. If you can refer to a person by the correct pronoun, if you can establish a relationship with your patient, it makes your job easier. When you have questions to ask them, they’ll answer them a lot more honestly, give you a lot more information. It makes the process a lot easier, a lot safer and a lot better.”
This story was originally published in the fall 2020 issue of UMSL Magazine. If you have a story idea for UMSL Magazine, email magazine@umsl.edu.
