1. Wyckoff, Elizabeth D. DNP


This study implemented an educational intervention to increase lesbian, gay, bisexual, and transgender (LGBT) cultural competence among nurses using a pretest-posttest design. A statistically significant increase in cultural competence was identified. Once informed of the health status disparities among this demographic, nurses can influence healthcare environments and promote policies to be inclusive of lesbian, gay, bisexual, and transgender patients. Improved cultural competence through professional development can lead to decreased barriers to care.


Article Content

Cultural competence is defined as caring for patients' health needs while consciously accounting for differences between the nurse's personal beliefs and value system and the patient's cultural beliefs (de Chesnay, Hart, & Brannan, 2016). Cultural competence training has emerged through the years to include not only racial and ethnic diversity but also sexual orientation such as lesbian, gay, bisexual, and transgender (LGBT; Substance Abuse and Mental Health Services Administration, 2016). Cultural training has been shown to prepare nurses to care for this minority by increasing nurses' understanding of healthcare issues and lifestyle preferences unique to this population (Gendron et al., 2013).



In recent years, the health of LGBT individuals has emerged as an area needing improvement in health care. Conditions such as heart disease, hypertension, diabetes, and illicit drug use have been found to be more common in LGBT patients than heterosexual patients. These health concerns are due to low levels of physical activity, increased rates of obesity, more cigarette use, and higher levels of stress (Caceres et al., 2017). LGBT patients are less likely to have health screenings, such as a mammogram and prostate-specific antigen tests (Fredriksen-Goldsen, Kim, Barkan, Muraco, & Hoy-Ellis, 2013). LGBT patients also exhibit increased stress levels, depression, and suicidal ideations and attempts. This stress was also found to impact patients' health by impeding their desire to seek health care (Frost, Lehavot, & Meyer, 2015). LGBT individuals are less likely to seek care due to experiencing rejection, prejudice, and discrimination among healthcare providers. Furthermore, health events were three times more likely to occur for those who experienced a prejudice healthcare event (Frost et al., 2015). In order to receive the correct screenings and treatments, LGBT individuals need healthcare providers who are aware of their specific health needs and can respond to them with understanding and nonjudgmental attitudes toward their lifestyle. Competency training in healthcare facilities can lead to decreased discrimination, as the providers understand the health concerns of these individuals (Reisner et al., 2015).



With an increased focus on organizational cultural competence, to include sexual minorities, the Office of Minority Health released national standards to guide the implementation of cultural competence training in healthcare organizations (Koh, Gracia, & Alvarez, 2014). These standards promote equity and quality of health care in addition to decreasing health disparities among minorities. Organizations are encouraged to implement systems that promote open and respectful communication with all populations. As part of this, the standards suggest training for employees to enhance their communication skills and knowledge related to minorities within their care. Cultural competence training has been identified as a way to improve the quality of care provided and to promote positive patient health outcomes among the LGBT community (Lim, Brown, & Justin Kim, 2014).



Cultural Competence of Nurses

The literature demonstrates an increase in cultural competence of nurses after receiving education regarding the LGBT population. Hardacker, Rubinstein, Hotton, and Houlberg (2014) reported significant gains in knowledge following the implementation of training modules. In a study focusing on nurse practitioners, a 12% increase in LGBT cultural competence was seen after implementing a focused learning module (Elminowski, 2015). Similarly, training was offered to healthcare workers caring for LGBT older adults. The pretest and posttest comparison revealed a significant increase in respondents' awareness of LGBT issues. Results also describe an increase in participants' comfort level of working with LGBT individuals (Gendron et al., 2013).


Age also appears to be a factor in nurse cultural competence. Hardacker et al. (2014) found that nursing students and nurses who were younger had more initial knowledge regarding LGBT topics. They also expressed eagerness to increase their cultural competence. Cicolini et al. (2015) found a positive relationship between level of education and cultural competence. Years of experience as a nurse also led to an increase in cultural competence. In the field of nursing education, only 36% of educators were aware of issues in LGBT health and 43% reported having limited education of LGBT patients (Lim, Johnson, & Eliason, 2015).


LGBT Health Disparities and Barriers to Care

Several studies have examined LGBT health concerns. Whitehead, Shaver, and Stephenson (2016) found that 40% of sexual and gender minorities used tobacco and 14% ranked as high risk for alcohol use. Another study found a higher percentage of bisexual women to be obese compared to heterosexual women (Ward, Dahlhamer, Galinsky, & Joestl, 2014). In a survey of 125 LGBT adults focusing solely on mental health, 78% of individuals reported a mental illness diagnosis with depression ranking the highest (McCann & Sharek, 2014).


An additional concern in LGBT health is the access to health care and healthcare utilization. Ward et al. (2014) reported a slightly higher percentage of heterosexual respondents having a regular place of medical care than LGBT respondents. Transgender persons were three times as likely to choose a healthcare provider who cared for other LGBT patients and had knowledge of the LGBT population (Whitehead et al., 2016). Rounds, McGrath, and Walsh (2013) found knowledge of LGBT issues and clear communication were important factors for choosing a healthcare provider. These respondents also noticed when providers used belittling responses, argumentative dialogue, or even decreased eye contact (Rounds et al., 2013).



Evidence-Based Practice Model

Rosswurm and Larrabee's (1999) model for evidence-based practice change was chosen to guide this study. The purpose of the model is to assist nurses through a systematic process of implementing evidence-based practice. Rosswurn and Larrabee's model encourages the use of quantitative data, qualitative data, clinical experience, and circumstantial evidence to develop evidence-based practice guidelines and decisions.


Midrange Nursing Theory

Madeleine Leininger's (2006) culture care theory of diversity and universality was used as the theoretical framework of the study. This theory was chosen for its connection of cultural competence and care, as opposed to theories that only examine the culture. The unique view of this theory allows the study participant to examine their culture, learn about the LGBT culture, and then use this new awareness to provide holistic care.



Clinical Question

In order to examine the influence of cultural competence training for nurses, the researcher proposed the following clinical question. In nurses working in an acute care medical surgical setting, how does LGBT cultural competence training affect nurse cultural competence of LGBT patients?


Sample and Setting

Registered nurses and licensed practical nurses were recruited for participation in the study. Because the study focused solely on development of nurses, other staff members such as patient care technicians, secretaries, and physicians were excluded. The setting for the project was a 420-bed acute care setting located in the Southeastern United States and employed approximately 1,000 nurses. This hospital provides an array of services, including the fields of orthopedics, oncology, urology, nephrology, neurology, pediatrics, cardiology, behavioral medicine, surgery, critical care, emergency medicine, and labor and delivery. The data collection and intervention occurred in an educational room within the hospital. The room contained seating and tables for approximately 30 people and contained the needed technical equipment, such as a computer and projector, for the presentation.


Data Collection Tools

The Gay Affirmative Practice (GAP) Scale measures practitioners' behaviors and beliefs when caring for lesbian or gay patients (Crisp, 2006). Permission to use the scale was obtained from the developer, Dr. Catherine Crisp. The GAP Scale consists of 30 items composed of a belief subscale and a behavior subscale of 15 questions each. Previous tests found an overall reliability of .95 for this tool. Reliability for the belief domain ([alpha] = .93) and the behavior domain ([alpha] = .94) was also established. Confirmatory factory analysis was used to establish factorial validity and revealed that each item was at .60 or higher. In addition, convergent construct validity was tested for each domain using Pearson's r correlations. Analysis revealed a correlation of .62 (p = .000) between the belief domain and the Heterosexuals' Attitudes Toward Homosexuals Scale. The behavior domain showed a correlation with the Attitudes Toward Lesbians and Gay Men Scale of .47 (p = .000). Discriminant validity was assessed for the tool in its entirety by performing correlations with the Social Desirability Scale. Results showed no significant correlation (r = .021, p = .691; Crisp, 2006).


The overall reliability values of the tool for this study were .93 for the preintervention total GAP score and .95 for the postintervention total GAP score. The preintervention belief domain reliability was .92, with postintervention reliability at .94. The behavior domain also showed reliability for this study with preintervention reliability of .93 and postintervention of .96.



This project implemented a training for nurses concerning LGBT cultural competence. The training consisted of a learning module entitled "Providing Quality Care to Lesbian, Gay, Bisexual, and Transgender Patients: An Introduction for Staff Training" (National LGBT Health Education Center, n.d.). The presentation containing 34 slides was organized into three sections covering the topics of LGBT terminology, health disparities of the LGBT population, and effective communication with LGBT patients. The information was presented via lecture to the attendees. Handouts were also provided so participants could follow the lecture and take notes. The length of the intervention was 30-45 minutes and included the pretest, intervention presentation, posttest, and snack breaks for the participants.



Institutional review board approval was obtained from the facility setting and Troy University. Recruitment of participants from the nursing population took place via flyers and in-person recruiting visits to the hospital units. Dates of the educational settings were made available to the target population. Participants had a choice of six dates and times to attend over a 2-week period with sessions being convenient for those who were working day, evening, or night shifts.


At the beginning of the session, participants were given a packet containing informed consent documents, two copies of the GAP Scale, and a demographic questionnaire. Participants were asked to complete the GAP Scale as a preintervention measurement of LGBT cultural competence. They also provided demographic information including age, level of education, and years of nursing experience. Following this, the educational intervention was presented. The participants were then asked to complete the GAP Scale for postintervention data.



Participant responses from the preintervention and postintervention questionnaires were recorded in the Statistical Package for the Social Sciences, Version 24. Preliminary analysis was conducted using descriptive statistics to evaluate frequency, measures of central tendency, measures of dispersion, and distribution. Internal reliability coefficients were computed on all scales. Data were analyzed using descriptive and inferential statistics.


Description of the Sample

The sample consisted of 30 participants. Variables addressed in this study included the age, level of education, and years of practice for the participants. The mean age of the participants was 37.73 (SD = 11.6), with a range of 21-63 years. Most participants were educated at the associate degree level (n = 15, 50%) and had been working less than 5 years (n = 16, 53.3%). A description of the sample is provided in Table 1.

Table 1 - Click to enlarge in new windowTABLE 1 Description of the Sample

Description of the Variables

The GAP Scale was used to measure cultural competence based on the beliefs of participants and their clinical behaviors with gay and lesbian clients. Total scores for the scale could range from 30 to 150, with a higher score indicating a higher level of cultural competence. Each subscale consisted of 15 questions and could range in score from 15 to 75. A description of these variables is presented in Table 2.

Table 2 - Click to enlarge in new windowTABLE 2 Means, Standard Deviations, and Ranges for Continuous Variables

Evaluation of the means provide evidence that all postintervention total scores are higher than the preintervention total scores. Likewise, evaluation of the total score ranges provide evidence that all postintervention total score ranges are higher than the preintervention total score ranges. Based on the Likert scale used for this study, higher total scores and ranges provide evidence that the educational intervention improved LGBT cultural competence of nurses participating in the study. Table 3 contains results for the paired-samples t test of total GAP Scale and subscales.

Table 3 - Click to enlarge in new windowTABLE 3 Paired-Samples

Total Scores

Pretest total scores ranged from 74 to 144 and increased to 88-150 posttest. Paired-samples t tests were used to examine differences in GAP scores preintervention and postintervention. Significant differences were found in preintervention and postintervention total GAP scores, t(29) = -4.22, p < .05. Additional inferential statistics were examined to determine if age, level of education, or years of work could predict results on the GAP Scale or for either subscale. No significant findings were identified.


Belief Subscale

Within the belief domain, preintervention scores ranged from 41 to 85 with posttest scores of 48-75. However, despite a mean difference of 2.77, the t test examining the difference in preintervention belief total score and postintervention belief total score was not statistically significant, t(29) = -1.72, p > .05. Of interest within the belief subscale were responses to the question regarding if nurses should learn about diversity. Preintervention scores showed 43.3% of respondents strongly agreed with postintervention scores rising to 60%. Furthermore, 26.7% of respondents strongly agreed that they should help patients develop positive identities preintervention, with this score increasing by 20% postintervention. The preintervention belief scores contrast with the questions in the behavior section, which showed lower initial scores. The author selected questions with distinctly different results between the preintervention and postintervention scores to highlight. Frequencies of selected items from the belief portion of the GAP Scale are located in Table 4.

Table 4 - Click to enlarge in new windowTABLE 4 Frequencies of Selected Items From the Belief Portion of the Gay Affirmative Practice Scale

Behavior Subscale

Behavior subscale scores ranged from 15 to 69 pretest and from 15 to 75 posttest. With a mean difference of 10.47, the t test examining the difference in preintervention behavior total score and postintervention behavior total score was statistically significant, t(29) = -4.15, p < .05. When asked if respondents seek to educate themselves about gay/lesbian concerns, a 10% response for always was received with an increase to 50% postintervention. The number of participants who usually or always helped reduce shame increased from 40% to 63.3% after the intervention. The author selected questions with distinctly different results between the preintervention and postintervention scores to highlight. Frequencies of selected items from the behavior portion of the GAP Scale are located in Table 5.

Table 5 - Click to enlarge in new windowTABLE 5 Frequencies of Selected Items From the Behavior Portion of the Gay Affirmative Practice Scale (

Discussion of the Findings

Results of this study are consistent with current research findings (Elminowski, 2015; Hardacker et al., 2014). A review of literature established that the use of educational interventions enhances the nurses' LGBT cultural competence. Further research will be needed to determine why there is no statistically significant difference in the total scores related to preintervention and postintervention beliefs. One possible explanation of this is the necessity for nurses to discard bias to care for patients. Nurses might see it necessary to change their actions, but not their beliefs. This could explain the lack of significant change in belief subscale scores. Additional studies are also needed to examine the gap between practitioner beliefs in the need for culturally competent care and lack of actual behaviors in the clinical setting. Longitudinal studies would be beneficial to examine behavior implementation and continued use.



Limitations for this study included a small sample size of 30 participants. Although this did allow inferential statistics to be performed, it limited the generalizability of the study. The use of only one facility also decreased the ability to generalize the study results. Between the planning phase and implementation phase of the project, the study site changed scheduling from 8-hour shifts to 12-hour shifts. This resulted in difficulty scheduling class times that participants would attend around a longer work day. Finally, the researcher encountered difficulty in locating a measurement tool that addressed bisexual and transgender patients. The GAP Scale is established for use in measuring cultural competence related to lesbian and gay patients. Expansion of this tool to include the bisexual and transgender population would provide greater support for the research findings.



The project was implemented to determine whether an educational intervention could improve the LGBT cultural competence of acute care nurses. Overall, the results indicated that the intervention had a positive impact on the cultural competence of nurses. The potential impact this study can have on nursing practice centers around the nurses' preparation to care for a diverse patient population. Nursing professional development practitioners play a crucial role in assessing staff nurses' readiness to care for this patient population and implement training to increase cultural competence. By completing educational requirements related to the LGBT lifestyle and health concerns, the nurse will be better prepared to create a welcoming, caring, and knowledgeable environment for patients.




Caceres B. A., Brody A., Luscombe R. E., Primiano J. E., Marusca P., Sitts E. M., & Chyun D. (2017). A systematic review of cardiovascular disease in sexual minorities. American Journal of Public Health, 107(4), e13-e21. doi:10.2105/AJPH.2016.303630a [Context Link]


Cicolini G., Della Pelle C., Comparcini D., Tomietto M., Cerratti F., Schim S. M., [horizontal ellipsis] Simonetti V. (2015). Cultural competence among Italian nurses: A multicentric survey. Journal of Nursing Scholarship, 47(6), 536-543. doi:10.1111/jnu.12165 [Context Link]


Crisp C. (2006). The Gay Affirmative Practice Scale (GAP): A new measure for assessing cultural competence with gay and lesbian clients. Social Work, 51, 115-126. doi:10.1093/sw/51.2.115 [Context Link]


de Chesnay M., Hart P. L., & Brannan J. (2016). Cultural competence and resilience. In de Chesnay M., & Anderson B. A. (Eds.), Caring for the vulnerable: Perspectives in nursing theory, practice, and research (4th ed., pp. 33-47). Burlington, MA: Jones & Bartlett Learning. [Context Link]


Elminowski N. S. (2015). Developing and implementing a cultural awareness workshop for nurse practitioners. Journal of Cultural Diversity, 22, 105-113. Retrieved from[Context Link]


Fredriksen-Goldsen K. I., Kim H. J., Barkan S. E., Muraco A., & Hoy-Ellis C. P. (2013). Health disparities among lesbian, gay, and bisexual older adults: Results from a population-based study. American Journal of Public Health, 103(10), 1802-1809. doi:10.2105/AJPH.2012.301110 [Context Link]


Frost D. M., Lehavot K., & Meyer I. H. (2015). Minority stress and physical health among sexual minority individuals. Journal of Behavioral Medicine, 38, 1-8. doi:10.1007/s10865-013-9523-8 [Context Link]


Gendron T., Maddux S., Krinsky L., White J., Lockeman K., Metcalf Y., & Aggarwal S. (2013). Cultural competence training for healthcare professionals working with LGBT older adults. Educational Gerontology, 39, 454-463. doi:10.1080/03601277.2012.701114 [Context Link]


Hardacker C. T., Rubinstein B., Hotton A., & Houlberg M. (2014). Adding silver to the rainbow: The development of the nurses' health education about LGBT elders (HEALE) cultural competency curriculum. Journal of Nursing Management, 22(2), 257-266. doi:10.1111/jonm.12125 [Context Link]


Koh H. K., Gracia J. N., & Alvarez M. E. (2014). Culturally and linguistically appropriate services-Advancing health with CLAS. New England Journal of Medicine, 371(3), 198-201. doi:10.1056/NEJMp1404321 [Context Link]


Leininger M. M. (2006). Culture care diversity and universality theory and evolution of the ethnonursing method. In Leininger M. M., & McFarland M. R. (Eds.), Culture care diversity and universality: A worldwide nursing theory (2nd ed., pp. 1-41). Sudbury, MA: Jones and Bartlett Publishers. [Context Link]


Lim F. A., Brown V. R. Jr., & Justin Kim S. M. (2014). Addressing health care disparities in the lesbian, gay, bisexual, and transgender population: A review of best practices. American Journal of Nursing, 114(6), 24-34. quiz 35, 45. doi:10.1097/01.NAJ.0000450423.89759.36 [Context Link]


Lim F. A., Johnson M., & Eliason M. (2015). A national survey of faculty knowledge, experience, and readiness for teaching lesbian, gay, bisexual, and transgender health in baccalaureate nursing programs. Nursing Education Perspectives, 36(3), 144-152. doi:10.5480/14-1355 [Context Link]


McCann E., & Sharek D. (2014). Survey of lesbian, gay, bisexual, and transgender people's experiences of mental health services in Ireland. International Journal of Mental Health Nursing, 23, 118-127. doi:10.1111/inm.12018 [Context Link]


National LGBT Health Education Center. (n.d.). Providing quality care to lesbian, gay, bisexual, and transgender patients: An introduction for staff training. Retrieved from[Context Link]


Reisner S. L., Hughto J. M., Dunham E. E., Heflin K. J., Begenyi J. B., Coffey-Esquivel J., & Cahill S. (2015). Legal protections in public accommodations settings: A critical public health issue for transgender and gender-nonconforming people. The Milbank Quarterly, 93(3), 484-515. doi:10.1111/1468-0009.12127 [Context Link]


Rosswurm M. A., & Larrabee J. H. (1999). A model for change to evidence-based practice. Journal of Nursing Scholarship, 31(4), 317-322. Retrieved from[Context Link]


Rounds K. E., McGrath B. B., & Walsh E. (2013). Perspectives on provider behaviors: A qualitative study of sexual and gender minorities regarding quality of care. Contemporary Nurse, 44(1), 99-110. doi:10.5172/conu.2013.44.1.99 [Context Link]


Substance Abuse and Mental Health Services Administration. (2016). Cultural competence. Retrieved from[Context Link]


Ward B. W., Dahlhamer J. M., Galinsky A. M., & Joestl S. S. (2014). Sexual orientation and health among U.S. adults: National health interview survey, 2013. National Health Statistics Report, 77, 1-10. Retrieved from[Context Link]


Whitehead J., Shaver J., & Stephenson R. (2016). Outness, stigma, and primary health care utilization among rural LGBT populations. PLoS One, 11(1), e0146139. doi:10.1371/journal.pone.0146139 [Context Link]