One of the challenges faced in society today is that the human service professions have been unable to keep up with sociopolitical shifts in society, and faculty across undergraduate programs have been slow to initiate effective positive space training (PST) programs (Lim, Johnson, & Eliason, 2015). As one of the largest human service professions, nursing has been particularly negligent in one area: preparing professionals regarding cultural sensitivity to the lesbian, gay, bisexual, transgender, two-spirit, and queer (LGBTTQ+) communities (Eliason, DeJoseph, & Dibble, 2010). Current literature suggests there is lack of learning experiences for students regarding LGBTTQ+ communities (Daley & MacDonnell, 2015). This is a real concern that lack of knowledge and sensitivity may translate into health inequity (Knight, Shoveller, Carson, & Contreras-Whitney, 2014).
In Canada, the legalization of same-sex marriage in 2005 may have enabled the LGBTTQ+ communities to be more comfortable with disclosing their identity to family, friends, and coworkers (Haghiri-Vijeh, 2013); however, legal inclusion has not ensured social acceptance and safety. Discrimination and stigma toward LGBTTQ+ communities persist nationally and internationally within the health and social care systems (Lim & Hsu, 2016), and alarmingly, some nurses have reported that they would refrain from providing care to clients from LGBTTQ+ communities if given a choice (Merryfeather & Bruce, 2014). PST is an educational process that prepares people and creates places that are supportive and welcoming of LGBTTQ+ communities. The purpose of this study was to determine the impact of PST on nursing and allied care students' knowledge and comfort levels and satisfaction with the program.
METHOD
A mixed-method quasi-experimental study was conducted using surveys and focus group interviews. The study was approved by the institution's research ethics board; all students were invited to participate and gave informed consent. Participants were community college students from 10 programs, including nursing, practical nursing, and other health and social disciplines.
The three-hour PST used a human rights framework to guide content with an examination of terminology; understanding myths and realities; and communicating with sensitivity. The course was designed using constructivist principles where students learn by building on what they already know and challenging existing knowledge. Sessions were delivered to groups of 30 to 50 students. Learning activities included role-playing communication strategies, implementing an inclusion checklist, reflective exercises, and video-based case situations and discussion. Training was provided by an equity advisor and two faculty.
Data were collected using two surveys. The Positive Space Training Competency Tool was completed by students before and after training. It consisted of three items developed and validated by the research team to capture change in major training outcomes. Cronbach's alpha for the survey in the current study was .94. Students also completed the seven-item Training Utility and Satisfaction Survey, which measured student satisfaction and perceived usefulness of the training. The survey was developed by Ryan, Campbell, and Brigham (1999) and modified and validated by the research team. Cronbach's alpha in the current study was .90, providing evidence for the reliability of the survey (Polit & Beck, 2017). Focus group interviews were conducted with students to gain a deeper understanding of student learning and attitudes after the training. Descriptive statistics were calculated using SPSS Version 23. A content analysis was conducted with the open-ended item and the focus group data.
RESULTS
All students (n = 160) completed the pretest and posttest surveys. Most students (n = 56, 35.7 percent) were aged 21 to 26 years; however, age groups ranged from 18 to 55. The majority (n = 64, 41 percent) were first-semester students from a range of community and health programs; eight (5 percent) were from nursing. Students represented more than 28 ethnic groups and numerous religious beliefs; 15 percent reported that they had a family member from the LGBTTQ+ communities, and the majority (58.5 percent) had a friend from the LGBTTIQ+ communities.
Positive Space Training Competency Tool
The level of statistical significance was .05. Students made statistically significant gains on the three course competency items following the course: knowledge of LGBTTQ+ communities (pretest, M = 2.7, SD = 1.0; posttest, M = 4.2, SD = 0.66); ability to correctly address someone from LGBTTQ+ communities (pretest, M = 2.9, SD = 2.6; posttest, M = 4.5, SD = 2.4); and comfort level communicating in an inclusive language with members of the LGBTTQ+ communities (pretest, M = 3.3, SD = 1.1; posttest, M = 4.3, SD = 0.73.
Training Utility and Satisfaction Survey
The median score was 30/35 (85.7/100), indicating that most students felt the training was useful. The majority of students reported that the content and learning activities were very effective; all items scored 4.3 or higher out of a possible 5.0. Most students (n = 155, 96.8 percent) recommended the training become part of their curriculum; 94 percent said they would recommend PST to other students.
Focus Groups
The participants indicated that the training had been very beneficial and that the most helpful part of the program included reviewing the individual definitions of the LGBTTQ+ acronym and learning about the meaning of each group's identity. They reported they had gained insight into inclusive communication techniques and how to use language sensitively in clinical or the field. They felt they better understood situations that LGBTTQ+ people might encounter, and a strong majority noted that they now felt confident they could respond appropriately if they witnessed homophobic comments or incidents. A small minority, four students, shared comments that indicated a degree of bias regarding LGBTTQ+ people continued.
Participants noted that they were disseminating their new-found PST knowledge to friends who had not attended training. Participants also started to educate their families and members of their religion groups. One student stated: "I was able to express this at a family dinner, a Good Friday dinner. My mother-in-law said something wrong, and I was able to refer back to the PST. We all ended up having a big conversation about everything and we were going over some of the terminology and sharing."
DISCUSSION
The finding that most students increased their comfort and knowledge in communicating with LGBTTQ+ communities after training is encouraging and has been reported in an earlier study (Lim, Brown, & Justin Kim, 2014). The results confirm that the training content and learning activities were effective and that the learning had a ripple effect among friends and family. That said, not all students made gains; some of the qualitative data suggest that a one-time session may not be enough to explore biases and effect attitude changes.
One limitation of the study was the convenience sampling and participation of students from one site, which limits generalizability. One recommendation would be to divide the training into two longer sessions or to reduce the size of the groups to provide more time to discuss issues and key learnings in greater depth. The finding that some of our students are biased and lack knowledge has also been reported in other studies and has implications for how students may provide care to diverse clients when they graduate (Craig, Dentato, Messinger, & McInroy, 2016). Educators should continue to integrate PST content into curricula and evaluate outcomes. Research regarding the benefit of interdisciplinary sessions and best practices for teaching positive space content is needed. In conclusion, it is important for students in the health and social professions to be exposed to and understand the diversity of the communities they care for, and this includes clients with diverse gender and sexual identities. PST can be an effective way to bring about change.
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