Ms. Rowe is a nurse practitioner and primary care provider at the VA Southern Nevada Healthcare System in Las Vegas. Dr. Ng and Dr. O’Keefe are assistant professors of nursing at the University of Alabama in Huntsville.
Author disclosures The authors report no actual or potential conflicts of interest with regard to this article.
Disclaimer The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies.
Another community partnership of importance for the nurse leader to develop is an alliance with local universities to train nursing students in cultural competencies in transgender care at VA facilities. The U.S. population continues to diversify in race and ethnicity and cultural influences; therefore, nurses must be prepared in cultural competencies in order to provide quality care that reduces health disparities.53
Under federal law, the VHA has a data sharing agreement with the DoD. Despite the repeal of the "Don't Ask, Don't Tell" federal law, which cleared the way for transgender persons to openly serve in the military, many transgender persons may remain fearful of reprisals, such as judgment, denial of care, or loss of benefits if gender identity is disclosed.54 Given the bureaucratic structure of the VHA, the implementation of cultural changes at the system level will require a collaborative effort between multidisciplinary teams and community partnerships to transform the VA environment over time. The authors believe that on this issue, external forces must guide and lead changes within the VA system in order to develop sustainable and trusting relationships with transgender veterans.
The fourth solution is implementation of policies that "empower patients or families in all aspects of the health care process."42 Again, the nurse leader is trained and prepared to advocate for a policy that implements a Patient Bill of Rights that explicitly guarantees health care and prohibits discrimination of gender-minority veterans. This change would foster trust and confidence from transgender individuals. A study found that 83% of providers and 83% of lesbian, gay, bisexual, and transgender veterans believe that this policy change would make the VHA environment more welcoming.48 Providing transgender-affirming materials and language on standard forms also would eliminate barriers, promote patient-centered care, and empower transgender patients by creating an environment that is more inclusive of everyone.48
Conclusion
The nurse leader is well positioned to implement the QSEN framework to integrate research, practice, and policy to create a more inclusive, patient-centered health care system for transgender veterans. By using the essential principles of doctoral education for advanced nursing practice, the nurse leader is prepared to advocate for changing the organization at the systems level. The nurse leader also is equipped to direct the implementation of patient-centered transgender care initiatives by ensuring the integration of the nursing organization as a partner in strategic planning as well as the development of solutions.
The VHA Blueprint of Excellence envisions organization and collaboration to promote new relationships that serve and benefit veterans. The DNP preparation allows the nurse leader to demonstrate the ability to collaborate with VHA stakeholders and develop alliances within and outside the organization by advocating for policy changes that will be transformational in improving health care delivery and patient outcomes to vulnerable transgender veteran populations. The IOM has tasked nurse executives with creating a health care infrastructure of doctorally prepared nurses to provide patient care that is increasingly growing more complex. With an increasing number of veterans using services, VHA has prioritized an expansion in the number of doctorally prepared nurses.55
As the largest integrated health care system in the U.S., the VHA provides an ideal setting for initiating these organizational changes as a result of having developed an integrated infrastructure to collect evidence-based data at the regional (network) and state facilities and make comparisons with national benchmarks. Therefore, changes are less difficult to disseminate throughout the hierarchy of the VHA. Consequently, the VHA has been a leader in the U.S. for equity in the health care arena and provides a model for international health care systems. Finally, these changes address an urgent need to reduce health disparities, morbidity, and mortality by improving quality care and health care delivery to a vulnerable transgender population.
