Background: This study explores the impact of gender and sexuality…

Question Answered step-by-step Background: This study explores the impact of gender and sexuality… Background:This study explores the impact of gender and sexuality awareness training on perinatal health care providers’ (HCPs’) knowledge, attitudes, and intended behavior toward childbearing individuals identifying as lesbian, gay, bisexual, transgender, and/or queer (LGBTQ).Method:A nonrandom convenience sample of HCPs (n = 187) comprised an experimental group (n = 99) who attended grand rounds trainings covering gender and sexuality topics and a control group (n = 88) who attended sessions on other unrelated topics. All participants completed a pre-posttraining questionnaire to assess changes in knowledge, attitudes, and intended behavior toward LGBTQ patients.Results:Participants in the experimental group demonstrated significant improvement in knowledge, misconception, prejudice, sensitive language, and normativity regarding LGBTQ pregnant patients from pretest to posttest.Conclusion:These findings suggest that a 40-minute gender and sexuality training can immediately improve HCPs’ knowledge, attitudes, and intended behavior toward LGBTQ childbearing patients. [J Contin Educ Nurs. 2019;50(7):303-312.]MoreFull TextTranslateTop of FormBottom of FormOf the 10 million adults who identify as lesbian, gay, bisexual, transgender, and/or queer (LGBTQ; Table 1) in the United States, approximately 3.7 million are parents (Mallon, 2017). LGBTQ parents have long been the subject of social and legal discrimination, facing barriers to adoption or to acceptance of a partner as family in medical settings (Lim, Brown, & Justin Kim, 2014). Although the most discriminatory legal barriers were removed when the U.S. Supreme Court ruled in favor of marriage equality, significant barriers to quality health care for LGBTQ patients still persist. From 2 decades of health services research, five main characteristics have been tied to lower quality health care delivery to LGBTQ patients:Misinformation or lack of information received in degree programs (Dubin et al., 2018).Misconceptions about the type of care needed by LGBTQ patients (Streed & Makadon, 2017).Religious or ideological prejudice against LGBTQ people (Streed & Makadon, 2017).Use of insensitive or discriminatory language (Bonvicini & Perlin, 2003).A heteronormative world view (Table 1; Röndahl, Bruhner, & Lindhe, 2009).To address this problem, Healthcare Equality Index (Human Rights Campaign Foundation, 2014)-informed grand rounds trainings (GRTs) were created to equip perinatal health care providers (HCPs) with knowledge and preparedness to improve health care delivery to childbearing LGBTQ patients (McCann & Brown, 2018).Although many studies have surveyed LGBTQ provider perceptions of treatment, most have lacked a perinatal focus, proper controls, and a pretest-posttest format (Kelley, Chou, Dibble, & Robertson, 2008). However, one study possessing many of these elements demonstrated that an educational intervention can change diverse HCPs’ knowledge, attitudes, and intended behavior toward patients identifying as LGBTQ (Lim et al., 2014). Here, a similar research design was used to study the effects of LGBTQ-specific education on the knowledge, attitudes, and intended behaviors of perinatal HCPs toward patients identifying as LGBTQ.MethodThis study used a quasi-experimental design to identify changes in HCPs knowledge, attitudes, and intended behavior in providing perinatal care to LGBTQ patients before and after a 40-minute training (Table 2). Participants were recruited from seven different hospitals in two cities in the midwestern and northeastern United States. One presentation per hospital resulted in a total of seven GRTs that were offered to reach the desired number of participants in both the control and experimental groups. Approval for the study was obtained from each university’s institutional review board. Participating hospitals were chosen because they offered weekly perinatal GRTs and were city hospitals with labor and delivery units staffed by residents, students, and midwives. The GRT series format has served as an effective and highly valued method for providing continuing education to perinatal HCPs (Lannon, 2005). Callahan et al. (2015) successfully used GRTs to raise awareness about LGBTQ patients and their health disparities. The current study addressed whether adding LGBTQ awareness training to perinatal grand rounds could be similarly useful in educating perinatal HCPs about caring for the childbearing LGBTQ community (Makadon, 2011).A nonrandomized convenience sample recruited perinatal HCPs (obstetricians, nurse-midwives, nurse practitioners, RNs, and physician assistants) delivering antepartum, intrapartum, and/or postpartum care in the acute care setting. The experimental group (n = 99) received a LGBTQ-focused GRT, whereas the control group (n = 88) received a GRT about topics other than LGBTQ awareness.Although attendance varied, all GRTs were open to medical students, nursing students, residents, physicians, nurses, nurse practitioners, and midwives (Table 3). Because both the control and experimental groups comprised perinatal HCPs at university-affiliated hospitals, the demographics and educational preparation were similar, and the comparability of the groups was assessed and reported in the findings for the study. Most participants (n = 121; 67%) had never or rarely received LGBTQ-focused continuing education, 25% (n = 45) had occasionally received LGBTQ training, and only 4% (n = 7) had frequently received such training. Although not the main point of this research, perinatal HCPs’ apparent lack of prior LGBTQ-focused continuing education should be noted.The training intervention was designed to be incorporated into a GRT series (Table 2). Although the content varied between control and experimental educational presentations, both followed the same general hour-long format with 40 minutes designated for the presentation: explanation by presenter of institutional review board-approved informed consent form followed by participant review; pretest administration; educational presentation; question-and-answer review session; and posttest administration. Pretest and posttest components (Table 4) were used to measure changes in knowledge, attitudes, and intended behavior of HCPs toward LGBTQ patients. Responses of the experimental group were compared with the control group.Experimental group participants received a 40-minute LGBTQ-focused interactive GRT developed and led by the first author (Table 2). Training included a lecture, case studies, and videos to address gender identity, sexual orientation, and how cisnormativity and heteronormativity can negatively influence patient care (Human Rights Campaign Foundation, 2014; Pérez & Luquis, 2014). In addition, challenges faced by patients identifying as LGBTQ during perinatal care were emphasized. During the training session, participants had opportunities to engage in interactive discussions to develop methods for inclusive care while practicing usage of recommended terminology and concrete communication techniques (Pan & Moore, 2017).The control group participants experienced a regularly scheduled GRT addressing topics ranging from long acting reversible contraception to human trafficking. The same pretest and posttest were administered in the same way for both groups. Control group data provided evidence that changes in knowledge, attitudes, and intended behavior from pretest to posttest were not due to experimental artifacts, including the passage of time, regression to the mean, or to the completion of testing twice within the same session (Campbell & Stanley, 2015).Instrument: Pre- and Posttest SurveysPre- and posttest surveys (Table 4) for both groups were the same, except for demographic questions unique to the pretest and evaluative questions unique to the post-test. Responses were numerically based on a 5-item Likert scale with the following continuum: strongly disagree, disagree, unsure, agree, and strongly agree. To create the instrument, two previously developed instruments were modified (with permission) and combined to create the final 25-item survey (Kelley et al., 2008; Penn Understanding Sexuality in Healthcare, 2014). Before its use in the current study, the final survey was submitted to an expert panel of obstetricians, statisticians, nurse-midwives, nurse practitioners, and medical researchers, who deemed it suitable for use in testing the intended population.The pretest included seven demographic questions (Table 4). The pretest and posttest (Table 4) shared 25 statements assessing knowledge (eight statements), attitudes (nine statements), and intended behavior (eight statements). Knowledge construct statements measured participants’ understanding of sex assigned at birth, gender expression, gender identity, and sexual orientation. Attitude construct statements were focused on beliefs, judgments, and concerns about perinatal care for the childbearing LGBTQ patient population. Intended behavior was assessed by exploring participants’ plans for delivering inclusive care to this population.Data CollectionThe consent form was read aloud and distributed to participants prior to their receipt of a paper version of pre-test and posttest surveys. To link participants’ pretest and posttest responses, participants were asked to write the last four digits of their cell phone numbers on the tops of pre-tests and posttests (Kelley et al., 2008).Data AnalysisThe two independent variables in this study were time and training. Each contained two levels. Time was used to define whether the questionnaire was administered before or after the lecture (pretest or posttest). Training referred to whether participants received the LGBTQ-focused lecture or the unrelated lecture (the experimental and control groups, respectively). To analyze the data, a 2×2 repeated-measures ANOVA was performed, with repeated-measures on the first factor of time.Rather than assessing pretest and posttest differences as individual items, a principal component analysis (PCA) was performed to simplify the analysis (Jolliffe & Cadima, 2016). Based on factor loadings for this PCA, responses to items assessing knowledge, attitudes, and behavior were aggregated into seven subscales as follows: commitment to LGBTQ care, LGBTQ prejudice, sensitive language, misconception, heteronormative and cisnormative assumptions, knowledge, and assessment of care equivalence.ResultsThe total sample was 187, divided into experimental (n = 99) and control (n = 88) groups. There were more self-identified women (83.4%) than men (16.6%), and the ages of perinatal HCPs ranged from 20 to 69. Because six of 187 participants lacked gender identity data, the valid percentage for the gender identity parameter was based on n = 181 (Table 3). Some attendees at the GRTs did not complete the pre-posttest and this exact number is unknown, as attendance rosters were not kept. For this study, results were reported on the 187 participants who completed the study pre-posttests in their entirety. There were 117 participants from a northeastern U.S. city and 70 from a midwestern location. Chi-square analyses found no significant differences between the experimental and control groups.Participants were asked about sexual orientation and gender identity, as these variables were the central issues of this study. There were 135 (72%) participants who self-identified as heterosexual, 17 (9%) who identified as an ally, 10 (6.5%) as lesbian, four (2%) as bisexual, four (2%) as gay, two (2%) as queer, one (0.5%) as transgender, one (0.5%) as other, and zero as asexual; thirteen respondents did not answer. Because the focus of this study was to assess whether an LGBTQ-focused training would improve the knowledge, attitudes, and intended behavior of perinatal HCPs regarding their LGBTQ childbearing patients, the analysis did not focus on gains observed for any subgroup of LGBTQ-identified participants. Furthermore, the number (n value) was less than 20 for each subgroup and was thus too small to allow any conclusions to be made about the impact of LGBTQ training for LGBTQ-identified participants (Table 3).Pretest and Posttest Scores: Knowledge, Attitudes, and BehaviorData analysis of posttest scores yielded statistically significant time and training interactions in five of the seven identified subscales. These interactions suggested notable immediate improvement in knowledge, misconception, prejudice, sensitive language, and normativity subscales for experimental group participants (Table 5).KnowledgeThe knowledge factor assessed the presence of critical knowledge regarding childbearing LGBTQ populations. Control condition participants did not increase in knowledge from pretest to posttest [F (1,150) = 0, p > .05], whereas experimental condition participants exhibited a notable increase in knowledge [F (1,150) = 105.56, p < .05]. Therefore, LGBTQ training was associated with a statistically significant increase in provider knowledge.MisconceptionMisconception assessed the lack of understanding in regard to caring for patients who identify as LGBTQ. Analysis of simple effects revealed a decrease in misconception from pretest to posttest for experimental condition participants [F (1,149) = 26.02, p < .05] but not for control condition participants [F (1,149) = 2.59, p > .05]. Therefore, the results demonstrate with statistical significance that LGBTQ training may decrease misconception.PrejudiceThe prejudice subscale assessed negative attitudes toward LGBTQ patient populations. Analysis of simple effects demonstrated that experimental group responses exhibited a trend of decreasing prejudicial attitudes from pretest to posttest [F (1,149) = 3.01, p = .08], whereas control participants actually experienced an increase in prejudice over time [F (1149) = 9.63, p = .002]. Therefore, there is evidence of a significant effect of training on LGBTQ prejudice.Sensitive LanguageThe sensitive language subscale assessed participants’ use or intention to use sensitive language. Although the level of sensitive language usage for both participant groups increased from pretest to posttest [F (1,155) = 14.1, p < .05], experimental group participants exhibited an increase of greater magnitude [F (1,155) = 63.38, p < .05]. Therefore, there is evidence of attainment of a higher level of sensitive language usage after the LGBTQ training intervention than after the control intervention.NormativityNormativity measured beliefs that patients should be assumed to be heterosexual and cisgender. Higher values indicated greater proclivity toward these assumptions. Control group scores did not decrease from pretest to post-test on cisnormativity and heteronormativity [F (1,155) = 2.53, p > .05]. Conversely, experimental group participants exhibited an overall decrease in normativity [F (1,155) = 28.26, p < .05]. Therefore, there is statistically significant evidence that LGBTQ-focused training decreased participant assumptions toward this patient group.DiscussionThe significant change in knowledge exhibited by the experimental group demonstrates that LGBTQ-focused training is effective in communicating general knowledge with regard to LGBTQ patient issues, while also revealing HCP-based shortcomings in health care delivery to LGBTQ patients. Furthermore, attitude statement scores suggest that some participants, regardless of condition, possess heteronormative and cisnormative attitudes that influence their approach to care. The decrease in LGBTQ prejudice and misconceptions from pretest to post-test exhibited by the experimental group supports not only the effectiveness of education, but also that education may prompt HCPs to self-reflect on their attitudes toward LGBTQ patients. Indeed, because intended behavior demonstrated a statistical shift toward inclusivity, LGBTQ training may strongly influence perinatal HCP intent to use thoughtful, sensitive, all-inclusive language.How Does the Nursing Professional Apply This Information to Practice?Education is necessary in order to improve the knowledge, attitudes, and future behavior of perinatal HCPs (Röndahl et al., 2009; Spidsberg, 2007). Furthermore, evidence suggests that perinatal HCPs would feel more competent at fostering clinical relationships with their patients after receiving training focused on LGBTQ inclusion (Ekundayo et al., 2013; Lannon, 2005; Porter & Krinsky, 2014; Reis et al., 2008). Such training could address how language must be inclusive of all pregnant individuals. Understanding the need to be mindful of word choice is a step toward minimizing heterosexism and cissexism in perinatal health care. As an example, to be more LGBTQ inclusive, experimental group participants learned how to change their line of questioning starting with the initial prenatal visit. Makadon (2011) suggested starting every visit with, "So tell me about yourself." Similarly, this researcher's training prompted perinatal care providers to start new patient visits with an open-ended question, such as "It will help me to provide you with the best care possible if I know a bit more about your pregnancy. Tell me about this pregnancy." This opening takes provider assumptions out of the equation and allows for a deeper understanding of the patient based on actual facts, rather than on a heterosexist or cissexist assumption. More "Practical Recommendations for Practice" are shown in Table 6.LimitationsThe relatively small sample size and demographics of the sample of participants limits this study's general applicability. Importantly, due to self-selection and resulting nonrandom assignment of participants to experimental and control groups, a sampling bias existed that was related to voluntary participation in the LGBTQ presentation. Additionally, the relatively short time interval between pretest and posttest administration may have biased participants' answers toward greater inclusiveness. The posttest measured only intended behavior, not actual behavioral change. More studies are needed to assess the long-term impact of an LGBTQ-focused educational intervention on health care delivery. Finally, this study demonstrates a need for qualitative research with HCPs' quotes about their opinions, change in practice, and difficulties. Quotes, interviews, and case examples will lead to new questions to address through quantitative methods.Future ResearchRepeating this study in both rural and urban areas across the country would increase generalizability of findings. Additionally, a larger sample size including a more diverse distribution of perinatal HCPs across spectra of gender, sexuality, and age would likely increase statistical power. Also, strategies could be used to decrease the number of participants lost by those who completed only the pretest or the posttest. Future research expounding on this study would move beyond participant posttest responses of behavioral intent to include a longitudinal examination of the long-term effectiveness of gender and sexuality-based educational interventions on patient experiences and outcomes.ConclusionHCPs exhibit a gap in knowledge related to perinatal care of LGBTQ patients. This study suggests that bridging the knowledge gap using LGBTQ-specific education can yield immediate improvements toward inclusivity, as realized by changes in knowledge, attitudes, and intended behavior. Thus, an inclusive vision of LGBTQ perinatal care is well within reach, and educational interventions are one effective method of achieving that vision.ReferencesBonvicini K.A., Perlin M.J. (2003). The same but different: Clinician-patient communication with gay and lesbian patients. Patient Education and Counseling, 51, 115-122. 10.1016/S0738-3991(02)00189-1Callahan E.J., Sitkin N., Ton H., Eidson-Ton W.S., Weckstein J., LQuestions1)When was this article published?SELECT AN ANSWER2020201920172)Use point-form to list TWO characteristics linked to lower quality care experienced by LGBTQ patients:3)The population is the group that the researchers want to study. Who is the target population of this study? SELECT AN ANSWERnurses who identify as LGBTQchildbearing LGBTQ patients perinatal HCPs (health care providers)4)What is the aim or objective of this study?SELECT AN ANSWERTo study the effect of LGBTQ-specific education on the knowledge, attitudes, and intended behavior of health care providers towards LGBTQ patients.To study the effect of LGBTQ-specific education on health care providers who identify as LGBTQ.To study the effect of LGBTQ-specific education on the knowledge, attitudes, and intended behavior of perinatal health care providers towards childbearing LGBTQ patients.  5)Why is this study considered "quasi-experimental"?  Select all that apply. SELECT ALL THAT APPLYIt involves pretest-posttest, a common quasi-experimental study It lacks randomization (i.e. participants were not randomly assigned to the experimental or control group)It lacks a control group 6)How many participants were in the experimental group? SELECT AN ANSWERn = 187n = 88 n = 99  Health Science Science Nursing RPN S121 Share QuestionEmailCopy link Comments (0)