Leadership Initiatives in Patient-Centered Transgender Care

Healthy People 2020 Goals

One of the Healthy People 2020 stated goals is to improve the health and wellness of transgender people.²⁹ The objective is to increase the number of population-based data collection systems used to monitor transgender people from the baseline of 2 to a total of 4 by 2020. The data systems would be assigned to collect relevant data, such as mental health; HIV status; illicit drug, alcohol, and tobacco use; cervical and breast cancer screening; health insurance coverage; and access to health care.

Health Care Staff Readiness

Transgender persons face health care challenges with major health disparities due to their gender identity. Transgender persons as a defined population are not well understood by HCPs. In a survey, 50% of transgender respondents reported that they had to teach their medical provider about transgender care.⁶ Negative perceptions of transgender persons are well established and have contribute to the poor health care access and services that transgender persons receive. Transgender persons are often denied access to care, denied visitation rights, and are hesitant to share information for fear of bureaucratic exclusion or isolation.

There is a lack of evidence-based studies to guide care and help HCPs gain greater understanding of this population's unique needs.³⁰ Additionally, a significant lack of knowledge, skills, cultural competence, and awareness exist in providing transgender care. Research on nursing attitudes concerning transgender care consistently found negative attitudes, and physicians also frequently reported witnessing derogatory comments and discriminatory care from colleagues.^31,32 The study by Carabez and colleagues found that practicing nurses rarely received the proper education or training in transgender health issues, and many were unaware of the needs of this population.³³ In addition, many HCPs were uncomfortable working with transgender patients. Physicians also expressed knowledge deficits on gender identity disorders due to a lack of training and ethical concerns about their roles in providing gender-transitioning treatment.²⁶

Although the VHA directive states that transgender services and treatment should be standardized, the VHA has not approved, defined, or endorsed specific standards of care or clinical guidelines within the organization for transgender care, further heightening HCP concerns.⁹ The clinical practice guidelines available for addressing preventive care for transgender patients are primarily based on consensus of expert opinion.³⁴ Expert opinion has produced the Standards of Care (SOC) for the Health of Transsexual, Transgender, and Gender Nonconforming People, published by the World Professional Association for Transgender Health (WPATH) and cited by the IOM as the major clinical practice guidelines for providing care to transgender individuals.² Transgender care at the VHA is guided by the WPATH standards of care.³⁵

The VHA has created national educational programs and policies with targeted goals to provide uniform, culturally competent, patient-centered care. Online transgender health presentations are available, and at least 15 VHA facilities have transgender support groups.³⁰ While the VHA supports a patient-centered philosophy for transgender patient care, many facilities do not currently have organizational initiatives that enhance clinical preparation of HCPs or have sufficiently modified the environment to better accommodate the health care needs of transgender veterans.

DNP Preparation

The DNP terminal degree provides nurses with doctoral-level training in organizational and systems leadership, leading quality improvement, and implementing systemwide initiatives by using scientific findings to drive processes that improve quality of care for a changing patient population.³⁶ Preparation in research analysis of evidence-based interventions also is essential to evaluating practice patterns, patient outcomes, and systems of care that can identify gaps in practice. Training in health care policy and advocacy, information systems, patient care technology, and population health also is provided so that DNPs are competent to develop system strategies to transform health care through clinical prevention and health promotion.

QSEN Framework

In keeping with the IOM's Future of Nursing initiative recommendations that graduate nurses be prepared as leaders in education, practice, administration, and research, there is an increasing focus on providing graduate-level nursing education and training to ensure quality and efficiency of health outcomes.³⁷ The Quality and Safety Education in Nursing (QSEN) project, initiated at the RWJF by Linda Cronenwett, PhD, RN, identifies a framework for knowledge, skills, and attitudes that defines the competencies that nurses need to deliver effective care to improve quality and safety within health care systems.³⁸ These core competencies include quality improvement, safety, teamwork and collaboration, patient-centered care, evidence-based practice, and informatics. The RWJF and the American Association of Colleges of Nursing later expanded the project initiative to prepare nursing faculty to teach the QSEN competencies in graduate nursing programs.³⁶

The DNP nurse leader is ideally suited to manage this project by applying competencies from the QSEN framework. Using open communication and mutual respect, the nurse leader is poised to effectively develop interprofessional teams to collaborate and initiate transformational changes that improve quality and patient-centered care delivered within the health care organization.