Introduction: Gender minorities, including transgender and gender diverse (TGD) individuals face health disparities and significant barriers in accessing healthcare. Lack of access to providers knowledgeable in TGD health needs is the single greatest barrier to care. Existing literature on TGD care has almost exclusively focused on physicians and there is scant literature on the role of nurses. We aimed to describe exemplars of nurse-led TGD care internationally to better understand the structure, process, and outcomes of nurse-led TGD care as well as recommended best practices nurse-led TGD care.
Methods: This descriptive cross-sectional study used a convenience sample of nurse-led TGD clinics drawn from international endocrine nursing organizations. Identified clinics completed an online survey based on the Donabedian Model of quality care (structure, process, outcome). Structure included a description of health system, guidelines used by the clinic, team composition/organization, and contextual medico-legal issues. Process assessed nursing roles/activities and perceived promoters/barriers to TGD care. Outcomes were assessed by identifying metrics employed by the clinics. Two independent investigators reviewed survey responses and collated descriptive findings in tables, used thematic analysis to identify salient features and themes, and validated the synthesis with respondents.
Results: Five established TGD clinics were identified from the United States (n=3), United Kingdom, and Sweden. Clinics were government funded (n=2), based within academic medical centers (n=2), and a free-standing community practice. Respondents included both registered nurses and advance practice nurses (nurse practitioners/nurse prescribers) who provide pediatric (n=2), adult (n=1), and care across the lifespan (n=2). Common structure elements included: creating a welcoming environment, interprofessional team, and use of clinical guidelines. The process of care was characterized by: commitment to a gender-affirming philosophy and person-centered care, emphasis on collaborative care/team communication, and dedicated time for case management. Few outcomes were measured (primarily client census). All clinics noted the importance of access to care, training clinicians/staff, and structured data collection methods as promoters of high-quality TGD care.
Discussion: Findings suggest nurses play an important role in increasing access to gender-affirming and person-centered care. Nursing care emphasizes interprofessional collaboration, health promotion, empowerment, and patient advocacy. We identify promoters and best practices based on expert opinion - yet more work is needed to establish evidence-based practices and nurse-sensitive outcome measures for TGD care.
13 May 2023 - 16 May 2023