Stacie N. Klima, EdD, RRT
sklima@ccbcmd.edu
From the Respiratory Care Therapy Department, School of Health Professions, Community College of Baltimore County, Baltimore, Maryland.
This intervention was designed to investigate the understanding and pedagogical application of affirmative and inclusive healthcare for transgender and gender non-conforming individuals by School of Health Profession (SHP) faculty. The intervention was a faculty workshop on affirmative and inclusive health care. Participants were recruited from the Community College of Baltimore County who teach specifically in the SHP. A total of 7 faculty participants attended both the workshop as well as the post-intervention individual interview. Guiding questions about the efficacy of the workshop and its potential lasting effects were utilized by the project manager to guide the study. Participant interviews were the primary source of qualitative data. Participant interviews were analyzed using in vivo coding and thematic analysis. Results indicated that the SHP faculty workshop on affirmative and inclusive healthcare improved participants’ knowledge of gender identity and affirming practices in healthcare and improved their understanding of how to apply this information to their course curriculum. The faculty workshop proved to be an effective tool for increasing the faculties’ understanding and pedagogical application of affirmative and inclusive healthcare. Implications for professional practice are to continue the implementation of the faculty training workshop.
The purpose of this project was to implement a faculty workshop on affirmative and inclusive health care to improve the pedagogical application of affirmative and inclusive healthcare for transgender and gender non-conforming individuals by faculty. The target audience for the study was full-time faculty members who actively teach in the School of Health Professions (SHP) at the Community College of Baltimore County (CCBC). This is because they are responsible for producing health profession graduates who are prepared to treat all patient populations, including transgender and gender non-conforming individuals. Therefore, the goal was to ensure faculty are educated on affirmative and inclusive healthcare. The organizational issue intended for investigation revolves around the future graduates of the SHP, and the health profession educators responsible for ensuring they become responsible and equitable members of the healthcare team. The focus of the intervention centers on a greater understanding of affirmative healthcare for transgender and gender non-conforming individuals at the bedside and beyond.
Although there is greater evidence of an increasing transgender and gender non-conforming patient population, with 5.1% of adults under 30 identifying as a gender minority, there is still a disparity in the effective education of medical professionals (Pew Research Center, 2022). According to Thompson et al. (2020), there are still several barriers that persist in education for health care professionals to treat this population of patients. Barriers include a lack of time with curriculum topics, less focus on sexuality education, religious beliefs of educators, and educators’ lack of understanding and comfort with teaching the topic (Walker et al., 2023). Even though medical professional students may feel comfortable treating transgender and gender non-conforming individuals, the lack of curricula that directly address gender-affirming health care leaves them ill-prepared to discuss gender-related topics. For example, there may be respect for an individual’s gender identity, but a deficit in understanding correct and affirming terminology leads to discussing gender identity with the patient when it is not appropriate, as well as the expectation that the patient must teach the healthcare practitioner about gender identity. This continues the cycle of healthcare disparities for transgender and gender non-conforming individuals and reinforces the microaggressions and trauma that they encounter in the healthcare arena.
The focus of the intervention centers on a greater understanding of affirming healthcare practices for transgender and gender non-conforming individuals at the bedside and beyond. According to Conlin et al. (2019), transgender and gender non-conforming individuals experience a plethora of discrimination, including harassment, physical violence, sexual assault, and negative mental health outcomes, which include a higher incidence of suicide. In addition to this, there are negative experiences with healthcare institutions, which include refusal of care, biases in healthcare, and fear of discrimination (Grant et al., 2021). According to Walker et al. (2023), medical mistrust and inadequate access to competent medical professionals further exacerbate the delay of care. This delay in care can convert a survivable condition that is easily treated into a terminal disease.
Graduates of the SHP are required to provide safe and equitable healthcare to all patients regardless of sexual orientation or gender identity. Therefore, healthcare educators in the SHP must ensure this training is taking place within their designated programs to fully prepare SHP graduates to be responsible and equitable healthcare providers to all patient populations post-graduation. Healthcare educators must educate health profession students about what microaggressions are and how they can impact patients. According to Nadal (2023), microaggressions are types of everyday discrimination that can be subtle or even well-intended and are frequently experienced by members of a minority group, in this case, transgender and gender non-conforming individuals. They tend to be more covert as compared to a direct assault and can occur in a multitude of settings, such as schools, workplaces, health institutions, etc. Microaggressions experienced by transgender and gender non-conforming individuals, whether intentional or not, include misgendering, incorrect pronoun use, and the use of one’s dead name (their chosen name versus a name given at birth that they no longer identify with). All of these can lead to a discounted sense of one’s identity and an avoidance of healthcare institutions altogether (Conlin et al., 2019). Avoiding health care treatment can lead to increased mortality for otherwise very treatable conditions. Therefore, it is imperative that, as part of their education, students of SHP have experience and education through the curriculum that specifically addresses affirmative and equitable healthcare.
The intervention was designed as a 1-day faculty workshop on affirmative and inclusive healthcare for transgender and gender non-conforming individuals after obtaining written approval to move forward from the Assistant Dean of SHP. Faculty recruitment targeted members of the SHP faculty pool who actively teach students in the various health profession programs at CCBC, with a final sample size of 7 SHP faculty members.
Interactions with faculty participants began during the recruitment phase for the intended intervention of a faculty workshop on affirmative and inclusive health care. During the intervention, the project manager led the faculty workshop by presenting a PowerPoint presentation on affirmative and inclusive health care. The main objectives of the PowerPoint presentation were to define key terms, understand the difference between gender identity versus sex at birth, identify affirming and inclusive practices, as well as identify strategies to provide affirmative and inclusive healthcare. The content of the PowerPoint also included information on implicit bias and Project Implicit so that participants can investigate their own bias. Following the content portion of the PowerPoint, faculty participants were shown a pre-recorded simulation video (Montgomery College, 2016). This video followed a transgender male patient and their encounter with the doctor’s office staff. After viewing the video, the faculty participants were led by the project manager through a debriefing session, which helped gain valuable insight into what participants thought and felt during their experience with the training. Following the conclusion of the workshop, lunch was provided, and participant interviews were scheduled to collect data regarding the effectiveness of the faculty training workshop.
Participant interviews were conducted after permission from the participant had been granted, and their designated identifier in the data was the letter P and their participant number (i.e., P1, P2, P3) to protect their identity. Interviews took place post-faculty training workshop to capture the thoughts and feelings about the intervention. The aim was to discover through participants’ words whether the intervention was successful, as well as what could be added to the intervention or improved upon. While words like empathy can have different meanings, this study accepted terms from the participants from their own perspectives.
The qualitative data collected from participant interviews were analyzed using the phases of Braun and Clarke’s (2006) thematic analysis, which includes 6 specific phases. The raw data were initially coded from the interview transcripts utilizing in vivo coding, and an example can be seen in Table 1. According to Manning (2017), in vivo coding is a coding strategy (within a data analysis process) that preserves and emphasizes the spoken word of the participants. This allows for the voice of the participants to be honored at the very inception of the data analysis and thereafter in the further development of categories and themes.
| Table 1. Sample Organization of Transcripts. | ||||||
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| Interview Transcript | Initial Codes | |||||
| P.M. What is your definition of affirmative and inclusive health care in the 21st century? P3. My definition for affirmative and inclusive health care in the 21st century would be just making sure the patients, all patients are comfortable and understand their rights as a patient and understand that you were there to help that like as a healthcare provider, you’re there to help them and not hurt them and Just making it specifically making sure, well, not, well, specifically making sure that like transgender patients or patients that identify a certain way. Are just as comfortable as Patients who stick to the Just patients who are. The Yes, yes, that’s what I was like before. Cisgender |
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After the conclusion of the intervention implementation, all 7 faculty participants were scheduled for a private, virtual Zoom Professional interview to gather qualitative data via the process and outcome guiding interview question responses. The process and outcome guiding questions, which were asked during participant interviews, can be seen in Table 2. All private Zoom interviews with each participant were recorded on a private and secure device, as well as transcribed through Zoom and saved to a private and secure device. Following the conclusion of the participant interviews, the interview transcripts were reviewed multiple times to gain familiarity with participant responses.
| Table 2. Process and Outcome Interview Questions. | ||||||
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| Process Guiding Questions | ||||||
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| Outcome Guiding Questions | ||||||
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All raw qualitative data from each participant’s interview responses were then organized in a table to allow initial in vivo coding. However, before the initial coding process, initial transcripts were discussed with the participants via an informal Zoom meeting that lasted between 5-10 minutes so the project manager could member check the data with the individual and ensure their thoughts were portrayed accurately. The member checking Zoom meetings went through participant responses to each interview question.
Interview data were analyzed using Braun and Clarke’s (2006) thematic analysis approach, which follows 6 specific phases. These are (1) familiarizing yourself with the data, (2) generating initial codes, (3) searching for themes, (4) reviewing themes, (5) defining and naming themes, and (6) producing the report. This approach to engaging with the data allows for a specific focus on crucial parts of the data sets (Braun & Clarke, 2006). The goal was to produce themes that were rooted in the raw data collected from the participant interviews and accurately reflect the impact of the intervention.
Completion numbers for the assignment are presented below in Table 1. The number of in-person students totaled 60, and the number of students who completed the assignment were 27 in the fall plus 29 in the spring, for a total of 56 students. The number of online students totaled 80, and the number of students who completed the assignment were 27 for the fall plus 29 in the spring, for a total of 56 students. The overall total was 140 students, with assignment completion by 112 students.
Following the initial coding phase of all participant interviews, the project manager proceeded by organizing the codes into a table that included process/outcome questions. Collating the data allowed for an evaluation of the data on a broader level and to begin to identify similarities in the codes. This is the beginning of formulating themes from the data by identifying and organizing similarities. An example can be seen in Table 3, which demonstrates how the project manager listed out the codes based on a process question. Table 3 considers the interview data from all participants regarding process question 1.
| Table 3. List of Codes. | |
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| Process Question 1 | Initial Transcript Codes |
| What is your definition of affirmative and inclusive health care in the 21st century? |
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The next phase of thematic analysis involved refining the data to group information in a meaningful way. The purpose is to review the data to identify if your emerging themes form a coherent pattern (Braun & Clarke, 2006). The project manager grouped similar codes to form a category that brought together a summarized version of the code’s meaning. An example of this data analysis and the formation of categories or sub-themes based on the similarities can be seen in Table 4.
| Table 4. Formation of Categories. | |
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| Initial Code | Category (Sub-Themes) |
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Equality and respect in health care |
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Accept all gender identities |
The finality of theme development indicated through the data that it is important for all healthcare professionals to accept and treat all patients equitably and with respect. Healthcare professionals must also be versed in gender identity and the inclusive language that promotes a holistic healthcare experience. To achieve this outcome in healthcare, education is key, and it begins with educators in CCBC’s SHP capturing their health profession students before graduation. Continuing the conversation about affirmative and inclusive healthcare will enable health professionals to embrace the differences of our patients and to provide an optimal environment for those of all gender identities.
Phase 5 of Braun and Clarke’s (2006) thematic analysis is the point where the categories or sub-themes developed from the codes are considered to create themes that tell the story of the data. In addition, it is an evaluation of the themes to ensure there is not too much overlap between them. The project manager developed the main themes through the categories or sub-themes that were identified from the initial coding. The final analysis resulted in 5 themes that represent the data collected from the participants’ viewpoints of the intervention. The 5 themes with corresponding categories/sub-themes can be seen in Table 5.
| Table 5. Identified Themes. | |
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| Categories/ Sub-Themes | Themes |
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Accept all patients for who they are and treat everyone equitably and respectfully in health care. |
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Understanding of gender identity and gender language to treat the patient holistically. |
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Education and training are paramount to ensure patients of all gender identities feel safe and seen in health care. |
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Teaching affirmative and inclusive health care to students and professionals through engagement and active learning experiences. |
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Openly communicating about affirmative and inclusive health care and embracing our differences. |
The purpose of the intervention was to implement a faculty workshop on affirmative and inclusive healthcare to improve the pedagogical application of affirmative and inclusive healthcare for transgender and gender non-conforming individuals by faculty. The problem of practice was the gap between the ideal outcome of a curriculum that includes affirmative and inclusive healthcare for transgender and gender non-conforming individuals, and the current outcome, where affirmative and inclusive healthcare is not included in the curriculum. During the implementation of the intervention, it became evident that the problem of practice needs to be addressed, and that the faculty workshop is a plausible solution to solve the issue. Vital information was gathered through the analysis of the data and an investigation into participants’ views of the intervention’s content.
One component of the intervention that stood out in the data and had clear implications for improvement at CCBC in general and its SHP programs in particular was the use of simulation in the faculty training workshop. The pre-recorded simulation video demonstrated a negative encounter for a transgender individual with their doctor’s office personnel and evoked a great deal of emotion from the participants.
Another component of the intervention that was well-received, as demonstrated in the participant interview data, was the demonstration of implicit bias using Harvard’s Project Implicit tool. The mission of Project Implicit is to educate the public about biases they may have using online tests. The site includes a transgender test that was shown to the participants, which they can then show to their students in selected courses or lesson plans. Results are confidential and for personal growth only. As a healthcare practitioner and educator, it is important to be aware of your biases regarding certain populations of people, in this case, transgender individuals. According to Schiralli et al. (2022), gender stereotypes and biases can be internalized and can be associated with negative health impacts for gender-expansive populations. Therefore, bringing the conversation forward about implicit bias helped educators conceptualize how they can recognize this for themselves and educate their students about it.
Faculty participants’ perspectives and investment in the faculty workshop are the key to changing current conditions at CCBC for the better. According to Soled et al. (2022), clinicians’ perspectives are vital to discovering solutions and interventions that identify gender-affirming care and the gaps in professional training that improve healthcare conditions for transgender and gender non-conforming individuals. Additionally, it is important to identify the fact that it is not the responsibility of the patient to teach clinicians about affirmative and inclusive healthcare, yet most medical training facilities require no training on the topic (Baldwin et al., 2018). Faculty participants understood the need for this training and its implications for healthcare graduates of the SHP at CCBC.
During the collection of data, there were suggestions as to what modifications could have been made to the intervention to improve its efficacy. One suggestion was to have an information sheet to refer back to, given the amount of new information presented in the faculty training workshop. This addition of an information sheet would be a good reference for participants to refer to when creating a new student curriculum that includes affirmative and inclusive health care. In addition, another modification would be to incorporate a simulation where participants actively engage and communicate with a patient to apply what was presented in the faculty training workshop. This addition to the training would enhance the knowledge gained by the participants and increase the ability to disseminate this knowledge to their students.
A major takeaway from the intervention was the limited knowledge SHP faculty participants possessed before attending the faculty workshop on affirmative and inclusive healthcare. P1 stated, “The whole presentation was excellent. I thought I knew a lot, but I found that I didn't, but that's being open-minded. That's why I participated.” In addition, P3 stated, “not understanding how things come, like how things became the way they are and like not understanding the gender roles that I think is such a big issue. And if teachers don't understand it, then they can't adequately teach their students.” P6 went on to say “100% improved it just gave you an insight of how to be a better professional. Okay, insight of how to be a better professional. And that, so it changed me, you know, it changed me to how to properly address a patient.” The data demonstrates that there was little foundation on the topic of affirmative and inclusive healthcare before the intervention, and the faculty workshop made a difference in participants’ understanding and knowledge base.
The intervention supports the case for ongoing faculty professional development on the topic of affirmative and inclusive health care. P5 stated, “that this is something that you can do. And for professional development. And I thought it, you know, it may be nice to have a simulation with some of the nurses with this too.” In addition, P6 stated, “I think the dean of SHP is going to be approaching you to talk at the August full faculty, you know, health profession to do it quick for everybody.” P1 noted, “But also just having people more aware and more educated on this topic will automatically produce a better outcome. You know, they have some prior experience before they're faced with it, always makes the situation better.” Ongoing training and faculty development would promote a climate of inclusivity and equity within the SHP. According to Proctor et al. (2020), faculty development is vital in developing skilled educators at academic institutions, and results in multiple benefits such as better-prepared medical educators and prevention of burnout. Continued training on affirmative and inclusive healthcare for faculty of the SHP provides an environment in which educators are set up for success with the tools they require for continuous improvement of health profession pedagogy.