Nursing students and role modeled behavior while caring for LGBTQ + people: a cross-sectional, descriptive study

The proportion of people globally who identify as lesbian, gay, bisexual, transgender, queer, and other diverse sexual and gender identities (LGBTQ +) has grown steadily in recent years [1‐3]. As this population grows, so does the need for accessible healthcare that is comprehensive and culturally inclusive. Historically, LGBTQ + people have experienced stigmatization and discrimination due to their sexual orientation or gender identity in all areas of society, including healthcare [4].

When seeking care, LGBTQ + people encounter healthcare systems that are not built to accommodate diverse sexual and gender identities, as well as healthcare professionals who have had limited educational preparation to effectively deliver inclusive and affirming LGBTQ + care [5]. People who are lesbian, gay, bisexual, or other diverse sexualities (LGB) encounter heteronormativity, (i.e., the default assumption that all people are heterosexual). Heteronormativity manifests as healthcare providers’ assumptions about the gender of patients’ partners as well as stigmatizing behaviors (e.g., excluding LGBTQ + partners from visiting), resulting in a lower quality of care [5, 6]. Transgender and people with diverse gender identities (T +) report similar heteronormative and stigmatizing experiences but also report instances of misgendering (i.e., referring to a person by incorrect pronouns or sex, such as using he/him pronouns for a transgender woman who uses she/her), deadnaming (i.e., referring to a patient by the name they were given at birth instead of their chosen name), and denial of healthcare services [7, 8]. LGBTQ + people broadly describe having to educate healthcare professionals on their healthcare needs as related to their sexual orientation and/or gender identity [5‐8].

Stigmatization in healthcare is one of many forms of stress experienced by LGBTQ + people that can lead to the poor health outcomes observed in this population. This process has been described as minority stress, where proximal stressors (e.g., internalization processes and anticipation of mistreatment) occur due to the marginalization of diverse sexual and gender identities and distal stressors (e.g., experiences of stigma; [9‐11]). Exposure to distal stressors is associated with poor health outcomes, including an increased risk of substance use disorders [12, 13], disordered eating [14], depression [15, 16], poor physiological health [17‐19], and other adverse conditions [20]. Proximal stressors, such as delaying or avoiding healthcare services due to previous experiences of stigmatizing behaviors or anticipation of such behavior, are also associated with poor health outcomes [21‐23]. These multifactorial challenges have resulted in the need for inclusive and affirming LGBTQ + practices and systems in healthcare to advance health equity for LGBTQ + people.

One pathway to improve the healthcare experiences of LGBTQ + people is through the education of healthcare professionals. Education on inclusive and affirming care for LGBTQ + people has been integrated into numerous areas of healthcare education, such as simulations and lectures on LGBTQ + health outcomes, to promote the best health outcomes for LGBTQ + patients [24‐26]. Despite those advances in education, LGBTQ + people continue to report mistreatment in healthcare settings. For example, a survey conducted in 2022 of over 90,000 T + people in the United States (US) found that almost half of participants experienced mistreatment in healthcare during the past twelve months [27], an increase from the previous survey conducted in 2015 [28]. A 2022 survey by the Center for American Progress found that one out of every five LGBTQ + people experienced mistreatment in healthcare during the past year, and one out of every three reported mistreatment in mental healthcare settings [20]. These findings indicate that further efforts to improve LGBTQ + healthcare experiences are needed. One pathway to improvement is to examine the education of healthcare professionals outside of the classroom and evaluate the socialization process in clinical training environments.

Clinical environments are a space where pre-licensure healthcare professionals apply skills and gain knowledge of real-world contexts. These can also be the environments where LGBTQ + people encounter mistreatment. In these settings, students practice their required skills, but they are also educated through role-modeling by professionals to acclimate within the social norms both within their respective careers and within the healthcare environment. Bandura’s Social Learning Theory describes how an individual acquires knowledge from their background, their education, and their observations of the people who surround them [29]. A key concept involves mimicking others’ behaviors and the reinforcement of those extrinsic behaviors. While curricula aimed at providing education on the use of LGBTQ + inclusive and affirming practices pose an opportunity to improve care delivery, the behavior modeled to students during clinical experiences should also be considered. Students’ experiences working with healthcare professionals can either support the implementation of knowledge gained from curricula or be in conflict, potentially encouraging undesirable behavior when caring for LGBTQ + people. In addition to the role-modeled behavior itself, there is an imbalance of power, where students defer to practicing healthcare professionals as knowledgeable authority figures. This can reinforce the learning of incorrect behaviors and may also inhibit students’ and recent graduates’ willingness to speak out when witnessing patient mistreatment. One study of patient weight bias among medical students found that students who observed their faculty or mentors making weight-stigmatizing statements were more likely to hold negative beliefs about people in larger bodies [30, 31]. This association has also been observed in care delivery, as medical students who observed weight-stigmatizing behaviors on the part of faculty were found to provide a lower quality of care during a standardized patient simulation [32]. Compared to medical students, the relationship between role-modeling and patient care among nursing students and recent graduate nurses, specifically, has been understudied. Previous studies have found that nursing students and recent graduates’ behaviors are influenced by preceptors and other nurses; however, social learning related to LGBTQ + patients specifically was not examined [33‐35]. While curricular interventions are needed to improve nursing student knowledge and preparedness to care for LGBTQ + people [25, 26], the influence of role modeling in clinical settings has not been adequately studied. The purpose of this study was to describe the role-modeled behaviors observed by nursing students and recent graduate nurses related to the care of LGBTQ + patients in clinical settings.

A comprehensive review of current literature revealed no studies have examined role-modeled behavior within healthcare settings concerning LGBTQ + stigmatizing behaviors. However, role-modeled behaviors in other healthcare contexts have been studied. Other studies involving undergraduate nursing students found that incidences of implicit and explicit weight bias by healthcare professionals were observed in clinical settings, which they reported as contributing to feelings of internal conflict [34, 35]. Another study found that despite professionalism being taught during their medical education, a third of medical students reported observing unprofessional behavior by physicians in their clinical settings, while 3% observed unprofessional behavior by nurses [42]. Almost 10% of the study’s participants reported incidences of implicit and explicit bias related to race, religion, and other personal characteristics, a lower incidence than observed in the present study of LGBTQ + bias. Another study found that almost 20% of medical students perceived that faculty lacked respect for diversity, although the study did not examine observations made within clinical settings specifically [43]. Further, the study found that racial minority students were more likely to report a perceived lack of respect for diversity by faculty, which led the study’s authors to hypothesize that being a member of the marginalized group might increase awareness or recall of bias-related incidents. Given that approximately 11% of our sample identified as LGBTQ + , a corresponding increase in awareness or memory of the bias-related incidents is possible.

Comparable literature on role modeling in healthcare professions, particularly nursing, is scarce as research predominantly focuses on clinical skills and orientation to professional roles, with a focus solely on same-profession faculty and assigned mentors [32, 44]. This study, describing how the behavior of healthcare professionals across the healthcare team is observed by nursing students and recent graduate nurses, points to an opportunity to expand existing notions of who acts as role models for nursing students and recent graduate nurses, and to examine how multidisciplinary roles contribute to either the normalization of stigmatizing or inclusive care practices toward LGBTQ + patients.

When participants described their stigmatizing behaviors towards LGBTQ + patients, almost a third reported that they had engaged in one or more behaviors. This result was noteworthy because almost 88% of participants reported having an LGBTQ + close friend or family member, a considerably higher percentage than reported in a recent study of the US general population, where only 51% of adults knew someone who is LGBTQ + [45]. Conversely, just over a tenth of our sample self-identified as LGBTQ + , although this is lower than recent survey findings of the US population where 20% of adults aged 18–23 years, similar to the age range of the present sample, identified as LGBTQ + [46]. The present sample also showed broadly positive attitudes toward LGBTQ + people. However, when analyzing the subscales, participants’ attitudes were more negative toward T + people. This may explain why the most frequent type of LGBTQ + stigmatizing behavior that participants reported engaging in was misgendering a patient. Similarly, in the examples of LGBTQ + stigma provided by open-text responses gender identity and T + people were consistently mentioned. While causality cannot be determined, role-modeled LGBTQ + stigma may be a contributing factor as the most common type of stigmatizing behavior role modeled by healthcare professionals was also related to gender identity and T + people.

It is also of note that all of the themes included examples of stigma that occurred in the context of conversations among healthcare professionals, outside of direct patient interaction. These role-modeled stigmatizing behaviors from multiple parts of the healthcare team reinforce these behaviors as acceptable, normalizing prejudice as part of the healthcare culture. The observations of these behaviors among various healthcare professionals outside of direct patient interactions place pressure on students and recent graduates to participate, as the sense of belonging is important for students [47] and power differentials impair students’ ability to speak out [48, 49].

Many nursing students and recent graduates observe role models, from various disciplines within the healthcare team, engage in stigmatizing behaviors toward LGBTQ + patients, most notably T + people. Despite positive LGBTQ + attitudes and having close friends and family who are part of the LGBTQ + community, students themselves also engage in stigmatizing behaviors in clinical settings. Continued efforts to address implicit and explicit LGBTQ + bias in healthcare settings should be applied in both didactic and clinical settings to address role-modeled behaviors and subsequent socialization of students and recent graduates. The incorporation of role modeling into research to reduce LGBTQ + stigma in healthcare provides an important perspective that can improve healthcare professional education. Advancement of this area of research can lead to more supportive healthcare institutions where LGBTQ + people can focus on healing in safe, inclusive spaces. Future research should also ensure that outcomes can be measured with both LGB and T + populations separately as the present study identified that participants had worse attitudes toward T + people than LGB and the majority of stigmatizing behaviors noted were related to gender identity and T + individuals.