Government and Regulations
Native Americans Address LGBT Health Issues
IHS discusses the advancement of health needs for American Indian/Alaska Natives within the LGBT community.
Public Health Resources
Public health resources addressing transgender patient care advocacy, public policy, community education, standards of care, cultural competency, mental health, hormone therapy, surgical interventions, reproductive health, primary care, preventative care, and research are available. For example, WPATH is an international multidisciplinary organization that has published comprehensive SOC for transgender, transsexual, and gender-nonconforming people. The seventh version of the SOC contains evidence-based guidelines for treatment.39 Additional online resources for transgender health are available from the CDC, the Center of Excellence for Transgender Health at the University of California, San Francisco; Department of Family and Community Medicine; and the National Center for Transgender Equality.13,40,41
Patient-Centered Transgender Care
The QSEN framework outlines competencies that provide applicable solutions that help prepare organizations to deliver culturally competent, patient-centered transgender care. The first step to creating patient-centered transgender care is to "analyze factors that create barriers to patient-centered care."42 The magnitude of the barriers to providing patient-centered transgender care also must be identified and understood. An assessment of individual values, beliefs, and attitudes can help to identify cultural characteristics and eliminate stereotypes that impact health practices.43
The nurse leader should solicit support from stakeholders to assess barriers to providing patient-centered transgender care at the system level. Stakeholders would include staff directly involved in patient care, such as physicians, nurse practitioners, physician assistants, registered nurses, nurse managers, nurse educators, licensed practical nurses, medical support assistants, psychologists, dieticians, and social workers. Other ancillary stakeholders with an interest in creating a patient-centered environment with positive patient outcomes include the executive leadership team of the organization, which consists of the chief of staff, director, administrative officers, and nurse executive.
The nurse leader should consult with experts in transgender care and present evidence-based research showing how deficits in staff knowledge, skills, and cultural competence negatively impact the quality of care provided to transgender persons. National data on the consequential health disparities and negative impacts on patient outcomes also should be discussed and presented to all stakeholders. The nurse leader in collaboration with the VA Office of Research and Development is ideally suited to obtain institutional review board approval of a proposal to conduct a needs assessment survey of health care staff barriers to providing patient-centered transgender care. Thereafter, the nurse leader would analyze, extract, and synthesize the data and evaluate the resources and technology available to translate this research knowledge into a clinical practice setting at the system level.44
The second solution uses the results of the survey to develop staff competency training within the organization. The nurse leader can facilitate collaboration and team building to develop practice guidelines and SOC. Competency training will prepare the staff to assist in developing strategies to improve the quality of care for transgender persons. Educationconcerning existing evidence-based clinical guidelines and SOC as well as anecdotal evidence of the needs of transgender patients should be included in competency training.45 One approach to competency training would be to trainintegrated multidisciplinary teams with expertise in transgender care to promote wellness and disease prevention.9 The nurse leader should collaborate with multiple disciplines to facilitate the development of interdisciplinary teams from nursing, medicine, social work, pharmacy, primary care, mental health, women's health, and endocrinology to participate in the Specialty Care Access Network Extension of Community Healthcare outcomes (SCAN-ECHO) training. Training can be offered by videoconferencing over several months and provides cost-effective, efficient training of providers in patient-centered transgender care.46,47 After the SCAN-ECHO program is completed, trained nursing experts could then develop a cultural sensitivity training program for nursing organizations to be offered to educate health care staff on an annual basis.
The third solution addresses the QSEN competency to "Analyze institutional features of the facilities that support or pose barriers to patient-centered care."42 Many veterans do not perceive VA environments as welcoming. In a study by Sherman and colleagues, less than one-third of veterans believed the VA environment was welcoming to sexual or gender minorities, and sexual orientation or gender identity was disclosed by only about 25% of veterans.48 Many veterans in this study felt uncomfortable disclosing their gender or sexual orientation. The majority felt that providers should not routinely ask about sexual orientation or gender identity, and 24% said they were very or somewhat uncomfortable discussing the issue. In another study, 202 VA providers were asked if they viewed the VA as welcoming, and 32% said the VA was somewhat or very unwelcoming.48
The nurse leader is trained in the essentials of health care policy advocacy, which is central to nursing practice.49 Nursing as a profession values social justice and equality, which are linked to fewer health disparities and more stable health indicators.50 Therefore, nursing can ideally provide organizational leaders by developing a culture wherein stable, patient-centered relationships can develop and thrive.
Organizational Culture
Strategies must be deployed to create an organizational culture that is welcoming, respectful, and supportive of transgender patients and family preferences. VA should develop support groups for transgender veterans in VA facilities. Support groups are helpful in diminishing stress, improving self-esteem, building confidence, and improving social relationships.51 Additionally, VA should develop community-based partnerships with other organizations that already provide institutional care and support from HCPs who support transgender persons' right to self-determination.52 These partnerships can foster environmental influences over time and lead to the development of trusting relationships between transgender veterans and the VA organization.