Nursing Pre-licensure and Graduate Education for LGBTQ Health: A Systematic Review

Abstract

Background:

LGBTQ people experience discrimination and health disparities compared to heterosexual cisgender people. Clinicians report discomfort and insufficient preparation for providing care to LGBTQ people and nursing has been slow to integrate LGBTQ health into curricula.

Purpose:

Conduct a systematic review to examine and critically appraise peer-reviewed literature on nursing student knowledge, skills, and attitudes (KSAs) regarding LGBTQ health and the development/evaluation of LGBTQ health content in nursing curricula.

Method:

A systematic review was conducted (N=1275 articles from PubMed, LGBT Health, CINAHL, ERIC, and Health Source-Nursing/Academic Edition).

Findings:

Twenty articles met inclusion criteria. Twelve studies described curricular interventions; however, there were few validated tools to evaluate content coverage or KSAs. Four themes emerged specific to LGBTQ health content inclusion.

Discussion:

While an emerging science of LGBTQ nursing education has been identified, more work is needed to build and evaluate a comprehensive curricular approach for full programmatic integration of LGBTQ health.

Tweetable abstract:

Greater integration of LGBTQ health content into nursing education should be a priority for nursing education.

Introduction

Nurses may struggle to provide competent nursing care to lesbian, gay, bisexual, transgender, and queer plus (LGBTQ) individuals without foundational training guided by best practices. Seminal work underscores the urgency for nursing programs to codify the integration of LGTBQ+ content throughout undergraduate and graduate curricula. Such curricular work would ensure that students are: (1) competently prepared to provide care for these populations in alignment with best practices, and (2) able to challenge negative perspectives, stigma, and discrimination of LGBTQ individuals seeking health care (De Guzman et al., 2018; Lim & Hsu, 2016). Approximately 4.5 % of the United States population identifies as LGBTQ (Newport, 2018) and LGBTQ health inequities are well documented (Medina-Martínez et al., 2021). As such it is imperative that nursing students are prepared to provide competent healthcare to LGBTQ individuals, families, and communities.

The American Nursing Association (ANA; 2012), the National Institutes of Health (NIH; 2021), and the National Academy of Medicine (Institute of Medicine, 2011) have reached consensus urging academic institutions to establish national standards for training health professional students to provide competent care to LGBTQ individuals. These recommendations remain largely unrealized, however (Bonvicini, 2017; McCann & Brown, 2019). Although troubling, this presents an opportunity for the nursing profession to develop and launch a national strategy to educate nursing students to provide comprehensive, culturally responsive, evidence-based health care to LGTBQ+ individuals, families and communities. Data supporting the need for such a strategy is compelling. For example, a series of studies has found that nurses lack the confidence and knowledge to effectively care for LGBTQ individuals (Knochel et al., 2011; Poteat et al., 2013; Sabin et al., 2015). Experts assert that hostile treatment and discriminatory behaviors towards LGBTQ individuals by nurses and other health care providers further perpetuate LGBTQ health disparities. Such behavior could be lessened through systematic educational training at the undergraduate and graduate levels (Cicero et al., 2019; Clark et al., 2001; James et al., 2016; Knochel et al., 2011; McNair & Hegarty, 2010; Poteat et al., 2013). Given that nursing is the largest health care profession and that nurses are generally recognized as health care providers who spend significant time with individuals seeking health care (American Association of Colleges of Nursing, 2017; Robert Wood Johnson Foundation Initiative on the Future of Nursing et al., 2011), the need for nursing education to incorporate best practices for the care of LGBTQ individuals is paramount.

Misperceptions of nursing students is another crucial concern identified in the literature. Lim and Hsu (2016) found that the majority of studies before the year 2000 identified that students enrolled in nursing programs had misperceptions about gender and sexual activity, harbored negative attitudes towards LGBTQ people and reported that they felt unprepared to provide inclusive and affirming care to LGBTQ people. However, their study also identified that literature published after the year 2000 may point to positive changes in nursing student attitudes towards LGBTQ people. Despite these advances, gaps remain (Lim & Hsu, 2016). For example, while LGBTQ populations report significantly poorer mental health, including higher rates of depression and suicidality than cisgender or heterosexual populations (Bouris et al., 2016; Peters et al., 2020; Sutter, Megan E & Perrin, 2016; Testa et al., 2017; Zeluf et al., 2018), almost 25% of nursing students surveyed did not perceive suicide assessment to be important when evaluating the health of LGBTQ individuals (Strong & Folse, 2015). Such findings underscore the critical need for schools of nursing to strategically prepare nurses who understand the deleterious impact of discrimination and stigma on the health and well-being of LGBTQ individuals.

To increase attention to the importance of culturally responsive and clinically knowledgeable nurses in lessening LGBTQ health disparities, examination of the existing evidence about LGBTQ content in nursing undergraduate and graduate curricula is needed. Thus, we conducted a qualitative systematic review to examine and critically appraise the peer-reviewed literature that covers nursing student knowledge, skills, and attitudes (KSAs) regarding LGBTQ health, as well as the existence, development, and evaluation of LGBTQ health content in nursing curricula.

Methods

Qualitative systematic review methodology is the ideal approach to answer the above aims because it includes a systematic search for relevant literature and allows for inclusion of studies with diverse designs including experimental, non-experimental and qualitative (Pan, 2016). Additionally, the purpose of a qualitative systematic review is to identify themes from the existing literature and consider implications for research and education (Pan, 2016).

Search Strategy and Selection of Articles

Electronic searches of the following databases were completed on June 4, 2020: PubMed, LGBTQ+ Source, CINAHL, ERIC, and Health Source-Nursing Nursing/Academic Edition. Appropriate MeSH terms and key terms included three categories of nursing, education, and sexual and gender minority terms (for detailed search terms see full protocol) (Sherman et al., 2020). Inclusion criteria were: (1) published in English; (2) published peer-reviewed original research articles; (3) published between January 2000 and June 2020; (4) U.S. based; (5) included aggregate or individual findings from nursing students with any level of educational preparation; and (6) reported findings related to characteristics of learners (i.e., KSAs, beliefs), characteristics of the curriculum (e.g., evaluation/description of gaps, KSA content), facilitators and barriers to LGBTQ curriculum integration, educational interventions, or LGBTQ content delivery (andragogy/pedagogy). Exclusion criteria consisted of the following: (1) reviews, dissertations, theses, or DNP projects, (2) grey literature (e.g., white papers, government documents), and (3) abstracts from conference proceedings that did not have an accompanying article. A hand search of the references from the included articles was conducted.

Articles were screened using Covidence – a web-based collaboration software used to conduct systematic and other literature reviews (Veritas Health Innovation, 2021). Title, abstract, and full text review were independently conducted by two reviewers and conflicts were resolved by a third reviewer. See the PRISMA flow diagram (Figure 1) for a full account of screening procedure outcomes based on 2020 PRISMA guidelines (Page et al., 2021).

Figure 1 –

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Diagram.

Data Extraction, Analysis, and Synthesis

A group of five investigators extracted data from the included articles. Data extracted included: (i) study aims/research questions/hypotheses; (ii) population(s) studied, inclusion criteria, and demographic data of study participants; (iii) independent and dependent variables, interventions/educational methodologies, measures specific to LGBTQ populations [beyond demographic data]; (iv) major findings, additional findings, and limitations. Five different team members performed an audit of 25% (n = 5) of the extracted data. We set a minimum agreement threshold for the average extraction accuracy assessment to 75%. Extraction accuracy was rated using three levels of agreement: Fully Agree (100%); Mostly Agree (75%); and Disagree (0%). The average agreement across the assessment was 77.1%. The extracted data for any studies not rated “Fully Agree” were revised to correct the concerns of the auditor, and the revised data were included in the data extractions. Only one study was rated “Disagree;” that study’s extraction was reviewed by a subgroup of the data extraction team. Audits of other studies by the same primary extractor revealed no patterns of disagreement. Following extraction and audits, the extracted data were then separated into three groups of articles: those about nursing faculty, those about practicing nurses, and those about nursing students. Findings from the nursing faculty and practicing nurse analyses are reported elsewhere.

Quality Appraisal & Thematic Analysis

Two reviewers independently conducted quality appraisal of the articles using the Mixed Methods Appraisal Tool (MMAT), Version 2018 (Hong et al., 2019; Ma et al., 2020), together with additional tools to evaluate qualitative, quantitative nonrandomized, and quantitative descriptive studies (Katrak et al., 2004; Lockwood et al., 2015). See Supplemental Materials for full details. Quality appraisal was initially conducted by four members of the study team, with each article undergoing independent appraisal by two reviewers. Discrepancies were resolved in video conference meetings among the two reviewers. Any discrepancies that remained following the video conference were adjudicated by a third reviewer.

Study findings were qualitatively analyzed to examine and synthesize patterns and themes found across the included studies. Thematic analysis was conducted by two members of the review team. Codes and themes were developed independently, and discrepancies were discussed and resolved by the two authors. Narratives describing the themes are presented below.

Findings

The search resulted in retrieval of 1,275 articles. Duplicates were removed leaving 1,240 studies that were reviewed for inclusion. The initial screening of abstracts yielded 234 studies for full-text review based on inclusion and exclusion criteria. The full text review yielded 20 studies that met eligibility criteria (see Figure 1). Table 1 summarizes study purposes, designs, and samples.

Table 1.

Description of Included Studies

Author (year)	Sample	Design	Purpose	Guiding Theory or Framework	Focus of LGBTQ Educational Component	Key Findings
		Pre-licensure Student Studies
Brown et al. (2017)	265 undergraduate nursing students	Cross-sectional online survey (quantitative)	(1) Explore the relationship between undergraduate nursing students’ affective transcultural self-efficacy and their prior contact with and exposure to transgender people in their personal lives or nursing program curriculum and (2) Examine the degree to which openness to experience, empathic concern, perspective taking, affective transcultural self-efficacy, and attribution of controllability predicted ATP among a sample of undergraduate nursing students	None reported	Not applicable	Receiving education specific to transgender health and personally knowing a transgender person were associated with increased confidence in providing culturally competent care to transgender people. A belief that being transgender was due to genetics was significantly associated with more accepting attitudes toward transgender people.
Englund (2018)	331 undergraduate nursing students across four University of Wisconsin campuses	Cross-sectional survey (quantitative)	Investigate the relationship between marginality and minority status in undergraduate nursing students in University of Wisconsin system campuses	None reported	Not applicable	Differences between Caucasian and various racial minorities in marginalization scores but no statistical difference
Maley & Gross (2019)	61 associate degree nursing students	Cross-sectional retrospective content analysis (qualitative)	Describe the exposure of associate degree nursing students to the health disparities in LGBTQ+ populations through a reflective writing assignment	Best practices for addressing LGBTQ+ health disparities (Lim et al., 2014)	Not applicable	The four themes identified: (1) communication, (2) advocacy, (3) increased awareness and knowledge, and (4) empathy development
Maruca et al. (2018)	47 undergraduate nursing students	Pre-test, post-test (quantitative)	Examine whether nursing students’ affirmative practice in caring for LGBTQ persons improves after experiencing a transgender simulation	Jeffries simulation theory (2015) and the International Nursing Association for Clinical Simulation and Learning (INACSL) guidelines (Watts et al., 2021)	Transgender simulation (establish therapeutic communication and to assess anxiety levels while providing safe care)	A statistically significant improvement between pretest and posttest scores related to practice behaviors, but no significant change on beliefs/attitude scores
McNiel & Elertson (2018)	13 undergraduate nursing students	Program evaluation post-test only; cross-sectional (quantitative)	Describe a collaborative training with LGBTQ experts and advocates to increase student awareness and knowledge regarding population health needs and disparities	Students, Staff, and Faculty for Equity (SAFE) committee and guidelines fromthe US Department of Health and Human Services (USDHHS; 2015) report on LGBTQ health and wellbeing	4.5-hour educational workshop 1. Didactic presentation (terms and definitions, role of an LGBTQ ally, LGBTQ special health needs, such as lifelong hormonal therapy, routine health screenings based on birth gender rather than sexual identity, surgical intervention options, current coverage for health services) 2. Interactive exercise reflecting on what they have learned from family, friends, school, religion, and social media regarding LGBTQ populations, Students role-played the “coming out process,” where each student participated in a variety of scenarios that highlighted the lived experiences of individuals in disclosing personal sexuality or identity to family and the community 3. Perspectives of LGBTQ preferred health care provider, nursing faculty, and clinical instructors with population-specific experience 4. Student panel composed of four individuals who identify within the LGBTQ population participated in a question-and-answer session to conclude the educational session.	All 13 students responded yes to the following: 1) I was able to update my communication skills and style, 2) I acquired new or advanced knowledge, 3) I have better awareness upon which to base my decisions and actions in the practice setting, and 4) I gained one or more specific ideas that I can implement in my area of practice. Themes identified from student journaling: listening and building trust, knowledge is power, and coming out is a continual process for LGBTQ individuals.
Ozkara San et al. (2019)	32 accelerated undergraduate nursing students	Program evaluation post-test only; cross-sectional (quantitative)	Describe the development process of an innovative cultural competence educational experience that was part of the students’ program of study and students’ overall reaction to the experience using our usual simulation assessment survey	Best practices for addressing LGBTQ+ health disparities (Lim et al., 2014), Jeffries simulation theory (2015) and the International Nursing Association for Clinical Simulation and Learning (INACSL) guidelines (Watts et al., 2021), Cultural humility and competency (Campinha-Bacote, 2002; Chang et al., 2012; Jeffreys, 2016)	Transgender Standardized Patient Simulation (transgender patient experiencing an oncological emergency)	Following the intervention, students reported increased feelings of preparedness, confidence, and knowledge regarding providing care to transgender patients in the oncology setting.
Schlub & Martsolf (1999)	174 undergraduate nursing students	Cross-sectional survey (quantitative)	Examine the (1) degree of orthodoxy in the Christian religious belief system in student nurses, (2) prevalence of homophobia in nursing students, (3) differences in levels of homophobia based on education level among nursing students, (4) relationship between intrinsic religiousness and homophobia, (5) relationship between orthodoxy in religion and homophobia	None reported	Not applicable	The strength of Christian religious beliefs was directly associated with homophobia scores and 93% of the sample had orthodox Christian beliefs
Stockmann & Diaz (2017)	20 undergraduate nursing students who were enrolled in the mental health course	Post session focus groups; cross-sectional; (qualitative)	Explore undergraduate nursing students’ experiences caring for the mental health needs of a transgender client through simulation	Peplau’s interpersonal relations theory (Peplau, 1991)	Mental health transgender simulation (identify symptoms of anxiety, manage anxiety, and utilize therapeutic communication in a culturally sensitive manner. The simulated transgender manikin, Taylor, presented with severe migraines, anxiety, and feelings of isolation, speech was rapid and disjointed, when participants communicated therapeutically, Taylor’s anxiety was alleviated, as indicated by normal vital signs and subjective data)	Three categories were identified from student focus groups: 1) students had limited experience addressing mental health needs, 2) intervening with client anxiety through prioritizing care and collaboration, and 3) the need for a therapeutic nurse–client relationship and therapeutic communication
Strong & Folse (2015)	58 undergraduate nursing students	Pre-test, post-test (quantitative)	Address the educational needs suggested by the literature and determine whether undergraduate nursing majors’ knowledge, attitudes, and cultural competence toward LGBTQ patients could be improved.	Brennan et al. (2012) curricular recommendations	40- to 45-minute educational intervention (relevant definitions, LGBTQ health disparities, cultural competence, and transgender-specific health care)	Attitudes and knowledge scores regarding LGBTQ patients significantly improved following the intervention
		Advanced Practice Student Studies
Klotzbaugh et al. (2020)	11 advanced nursing students from the advanced pharmacology course sections	Pre-test, post-test (quantitative)	Determine the knowledge of medical guidelines, health disparities, and policies specific to gender minorities both before and after attending a module on gender minority health among advanced practice nursing students in an advanced pharmacology course	None reported	90-minute Gender Minority Health module (gender minority–specific content related to medical knowledge and health disparities, local and national policies, importance of providing a gender affirmative clinical practice)	Medical knowledge and health disparity knowledge significantly improved, and transphobia decreased following the intervention
Kuzma et al. (2019)	99 advanced practice registered nursing students	Program evaluation post-test only; cross-sectional (qualitative)	Describe an innovative method of implementing LGBTQ content into graduate nursing education	Cultural humility and competency (Campinha-Bacote, 2002; Chang et al., 2012; Jeffreys, 2016)	Educational intervention 1. course readings on cultural humility and obtaining a comprehensive sexual health history 2. 1-hour lecture with content on cultural humility and LGBTQ health 3. 90-minute lecture on obtaining a comprehensive sexual health history, in-lab role-play sexual history taking, a 15-minute standardized patient experience, and structured debriefing sessions	Themes included: “(1) the clinical environment, (2) skill development, (3) the LGBTQ focus of the experience, (4) the value of debriefing, and (5) cultural humility and assumptions” p. 718
		Mixed Pre-licensure & Advanced Practice Student Studies
Carabez et al. (2014)	112 undergraduate and graduate nursing students enrolled in the community/public health nursing course	Pre-test, post-test (quantitative)	Determine (1) the baseline knowledge, awareness, and understanding level of fourth-semester nursing students regarding LGBTQ health care needs and (2) Examine the impact of a class assignment on the knowledge, attitudes, and skills of LGBTQ health care needs in nursing students	Health Care Equality Index (Human Rights Campaign, 2014)	LGBTQ Intervention 1. LGBTQ specific readings 2. 2-hour presentation on LGBTQ health issues 3. instruction on how to conduct a scripted interview with two nurse key informants based on the Health Care Equality Index	Knowledge scores significantly increased following the intervention
Rowniak (2015)	44 undergraduate nursing students and 46 clinical nurse leader students	Cross-sectional survey (quantitative)	Determine if age, sex, religiosity, having friends or family members who are gay, and holding the belief that sexual orientation is a matter of choice were associated with higher measures of homophobia	None reported	Not applicable	Higher homophobia scores were significantly associated with “not having a friend or family member who was gay or lesbian, the belief that being gay was a matter of choice, political identification as conservative versus liberal, a greater amount of guidance religion provided in one’s daily life, and the participant’s classification of their religious orientation as being religious versus not religious.” p. 1232
		Mixed Health Professions Student Studies
Acker (2017)	600 undergraduate students majoring in ‘helping professions’ (including nursing students)	Cross-sectional Survey (quantitative)	Examine transphobia among students of helping professions including social work, occupational therapy, nursing, and psychology	None reported	Not applicable	Nursing students had significantly higher levels of transphobia than social work students and overall, transphobia was significantly associated with religiosity, content exposure, and contact with LGBTQ people
Greene et al. (2018)	1010 Students (Medicine, Dental Medicine, Nursing)	Cross-sectional survey (quantitative)	Assess medical, dental, and nursing students’ perceptions of their preparedness to care for LGBTQ patients by measuring their comfort levels with, attitudes toward, and formal training in LGBTQ health	None reported	Not applicable	Students reported generally positive attitudes towards LGBTQ people and expressed interest in receiving more LGBTQ health training
Holloway et al. (2019)	166 students currently studying or having previously studied health sciences (dentistry/predentistry, medicine/premedicine, neuroscience, nursing/prenursing, pharmacy, psychology, public health/prehealth, social work/social welfare)	Cross-sectional (mixed methods)	(1) Describe discrimination and mentorship experiences of LGBTQ students in the health sciences, (2) compare satisfaction of LGBTQ students with academic mentorship by LGBTQ mentors compared with heterosexual/cisgender mentors, and (c) document recommendations of LGBTQ students in the health sciences regarding academic mentorship	Intersectionality (Crenshaw , 1989)	Not applicable	Students reported the quality of their mentoring experiences as very good and suggested the following adaptations to improve the program: increased 1) education on LGBTQ issues, 2) direct conversation about experiences of homophobia and transphobia in academic settings, and 3) advocacy for including LGBTQ content in coursework.
McCave et al. (2019)	494 graduate students (medicine, physician assistant, occupational therapy, social work, doctor of nursing, doctor of physical therapy)	Program evaluation post-test only; cross-sectional (quantitative)	Examine student preparedness to engage in the Interprofessional Education Collaborative competencies	None reported	Workshop 1. 10-minute emergency department video simulation that had been recorded in a hospital examination room featuring a standardized patient, a physician, a nurse, a social worker, and a medical assistant (The simulation showed Peter in the ED after a workplace assault resulting in an ankle injury) 2. Facilitated 15-minute discussion of how the interprofessional core competencies and standards for affirmative practice were upheld and violated by the behaviors of the providers seen in the video 3. 10-minute team huddle to prepare for the initial discharge planning meeting with Peter	Students found the exposure to transgender people sharing their experiences, watching the simulation video, participating in the debrief, and using the discharge checklist useful or very useful in providing affirming care to transgender patients and working on an interdisciplinary team
Schweiger-Whalen et al. (2019)	130 undergraduate nursing students & clinicians; any health care professional or student health care professional	Pre-test, post-test (mixed methods)	Implement a pilot education program and test its effectiveness on the development of LGBTQ cultural competence in health care providers	Fenway Institute trainings and Cultural humility and competency (Campinha-Bacote, 2002; Chang et al., 2012; Jeffreys, 2016)	Converging Cultures Workshop 1. 4 hours intervention with 2 expert lectures and a panel presentation (of 2 gay men, one transgender woman, one transgender man and one woman that identified as queer, the panelists were white and Hispanic ages 23–73 years) and question answer period 2. Converging Cultures lecture taught by a lesbian woman (90min) 3. lecture describing LGBTQ culture, health disparities, using electronic slides derived from recent literature 4. Beyond Blue and Pink (75min) interactive talk led by a transgender man who specializes in community outreach work	Knowledge and attitudes regarding LGBTQ people significantly improved following the intervention
Vance et al (2018)	28 students (Pediatric interns, psychiatry interns, fourth-year medical students and nurse practitioner students) completed both pre/post-test	Pre-test, post-test (quantitative)	Examine the impact of online learning modules on the educational parameters of learners	None reported	Transgender Youth Curriculum (2 part) 1. six interactive, online modules (general transgender terminology, taking a gender history, taking a psychosocial history, performing a sensitive physical examination, and formulating an assessment, psychosocial plan, medical plan) 2. observational experience in a multidisciplinary pediatric gender clinic	Knowledge scores, self-perceived knowledge scores, and self-efficacy scores significantly improved following the intervention
Vance, et al (2017)	20 students (medical students, pediatric interns, psychiatry interns, and 4 nurse practitioner students)	Pre-test, post-test (quantitative)	Determine if a comprehensive curriculum could enhance pediatric students’ and trainees’ perceived knowledge and awareness of the medical and psychosocial issues facing transgender youth	None reported	Transgender Youth Curriculum (2 part) 1. six interactive, online modules (general transgender terminology, taking a gender history, taking a psychosocial history, performing a sensitive physical examination, and formulating an assessment, psychosocial plan, medical plan) 2. observational experience in a multidisciplinary pediatric gender clinic	Transgender knowledge and awareness scores significantly improved following the intervention

Description of Included Studies

The 20 studies addressed several levels of nursing education including associate pre-licensure (n=1), undergraduate pre-licensure (n=8), mixed pre-licensure (n=7), advanced practice (n=2), and advanced practice and pre-licensure (n=2). The studies varied in design and location. See Table 1 for this and additional details regarding the description of the included studies. Study designs included qualitative (n=3), quantitative (n=15), and mixed methods (n=2). Although some studies used data from multiple states, others used data from multiple institutions within a single state or discrete universities. The samples represented rural, suburban, and urban settings, but many did not provide specifics about the location of the study. Among the studies that included a conceptual framework or theory (n=9), a wide variety of models were reported. It was unclear whether the remainder of the studies were atheoretical or if theorical frameworks were used but not reported.

The majority of the studies (n=12) evaluated a wide array of educational interventions; however, no interventions focused on integrating content across an entire nursing program. See Table 1 for additional details regarding interventions employed. Seven interventions focused on care of transgender people, while 5 interventions focused on LGBTQ generally with varying levels of content about transgender people. Pedagogical approach and delivery varied. Interventions specifically for nursing students included lectures, patient simulation, didactic presentations, reflective writing, guided assignments, panel discussions, question and answer sessions, readings, and structured debriefing sessions. When reported, the duration of these interventions ranged from 40 minutes to 4.5 hours, see Table 1 for duration details. Interprofessional interventions consisted of workshops, online modules, video simulations, team huddles, panel discussions, lectures, interactive talks, and observational experiences. Interprofessional interventions varied in duration, and when reported ranged from 35 minutes to 6 hours and 45 minutes; see Table 1 for duration details.

Quality assessment.

Among the 20 studies there were two quantitative non-randomized studies (Englund, 2018; Klotzbaugh et al., 2020), 13 descriptive quantitative studies (Acker, 2017; Brown et al., 2017; Carabez et al., 2015; Chen et al., 2018; Maruca et al., 2018; McCave et al., 2019; McNiel & Elertson, 2018; Ozkara San et al., 2019; Rowniak, 2015; Schlub & Martsolf, 1999; Strong & Folse, 2015; Vance et al., 2017, 2018), three qualitative studies (Kuzma et al., 2019; Maley & Gross, 2019; Stockmann & Diaz, 2017), and two mixed-methods studies (Holloway et al., 2019; Schweiger-Whalen et al., 2019). None of the studies used a randomized control trial design. Overall, methodologic rigor varied across the 20 studies (Supplementary Material), resulting in barriers to evaluating the quality of findings.

Limitations of the reviewed studies encountered by the investigators included sampling and retention issues (Acker, 2017; Brown et al., 2017; Chen et al., 2018; Englund, 2018; Holloway et al., 2019; Klotzbaugh et al., 2020; Maley & Gross, 2019; Maruca et al., 2018; Rowniak, 2015; Schweiger-Whalen et al., 2019; Vance et al., 2018), limited used of validated instruments to assess gaps in curriculum or student LGBTQ KSAs ; Acker, 2017; Chen et al., 2018; Maruca et al., 2018; Strong & Folse, 2015)., response-shift bias (learners may be unaware of what they do not know when completing a pre-test, and then become aware of their deficits following educational intervention; Vance et al., 2018), and social desirability response bias (i.e., tendency to report answers that they perceive others to approve of or think favorably of; Acker, 2017; Chen et al., 2018; Holloway et al., 2019; Maruca et al., 2018). Eleven articles reported small non-representative samples, affected by self-selection bias and depressed recruitment and retention (Acker, 2017; Brown et al., 2017; Chen et al., 2018; Englund, 2018; Holloway et al., 2019; Klotzbaugh et al., 2020; Maley & Gross, 2019; Maruca et al., 2018; Rowniak, 2015; Schweiger-Whalen et al., 2019; Vance et al., 2018). This limited the interpretability of their findings. Lastly, the lack of validated instruments had a negative effect on researchers’ abilities to examine the reliability of findings within their own studies and compare findings across studies.

Across the reviewed studies, there was little consistency in measures used to assess student LGBTQ KSAs. See Table 2 for details regarding the measures used. Twenty different measures and scales were used. Fifteen of these measured LGBTQ attitudes, 11 measured LGBTQ knowledge, and three measured LGBTQ skills. Twenty of 23 measures used were unvalidated (Acker, 2017; Brown et al., 2017; Carabez et al., 2015b; Klotzbaugh et al., 2020; Kuzma et al., 2019; McCave et al., 2019; McNiel & Elertson, 2018; Rowniak, 2015; Schlub & Martsolf, 1999; Schweiger-Whalen et al., 2019; Strong & Folse, 2015; Vance et al., 2017, 2018) and reliability statistics were reported for only 10 of the measures.

Table 2.

Measures used to Assess Student LGBTQI+ Knowledge, Skills, and Attitudes (KSAs)

Measure	Used in Author (year)	Content Assessed	Description of the Measure	Reliability/Validity	K, S, A
Attitudes Towards Lesbians and Gay Men Scale - Modified version (Herek & McLemore, 2011)	Strong & Folse (2015)	Attitudes of the participants regarding the LGBT patient population	3-item version using a 5-point Likert scale; (expanded to include items specific to bisexual and transgender individuals)	(α = 0.95)	A
Attitudes Towards Lesbians and Gay Men Scale (Herek & McLemore, 2010)	Rowniak (2015)	Heterosexual attitudes toward lesbians and gaymen	10-item using a 5-point Likert scale (1=strongly disagree to 5=strongly agree)	(α = 0.89)	A
Attribution of controllability (Sakalli, 2002)	Brown et al. (2017)	“I believe that being transgender is due to learning and preference and not to biologyand genetics.”	1-item using 6-point Likert-type scale (1 = disagreement to 6 = agreement)	Not Reported	A
Gay Affirmative Practice Scale (Crisp, 2006)	Maruca et al. (2018)	Examines attitudes and beliefs to evaluate affirmative practice that models culturally competent care to gay, lesbian, and bisexual populations	30-item using a 5-point Likert scale (1=strongly disagree to 5=strongly agree); higher scores reflect more affirmative practice with LGBT clients	(belief domain α =.93, behavior domain α =.94); Evidence of convergent construct validity using Pearson’s r correlations was .624 (p = .000) between the belief and behavior domains (Crisp, 2006)	A
Gay Affirmative Practice Scale - Belief’s subscale only (Crisp, 2006)	Schweiger-Whalen et al. (2019)	Practitioners’’ beliefs and behaviors regarding treatment of gay and lesbian patients	15-item beliefs subscale using a 5-point Likert scale (1=strongly disagree to 5=strongly agree); higher scores reflect more affirmative practice with LGBT clients	(α =.93) for the belief subscale (Crisp, 2006); full scale has demonstrated factorial, convergent, and discriminant validity (Crisp, 2006).	A
Genderism and Transphobia Scale-Revised (Tebbe et al., 2014)	Brown et al. (2017)	Negative cognitive and affective responses toward transgender people and people who deviate from traditional gender norms and the propensity for violence toward transgender people and people who deviate from traditional gender norms	17-item Genderism/Transphobia subscale and 5-item Gender-Bashing subscale using a 7-point Likert scale (1=strongly agree to 7=strongly disagree)	(α =.94)	A
Holistic Healthcare with Transgender Patients – adapted from Alan Dow’s 2012 Interprofessional Education Collaborative Competency Survey	McCave et al. (2019)	The student and facilitator surveys collected demographic data, satisfaction data, and ability to practice the Interprofessional Education Collaborative sub competencies that had been selected as outcomes for the event	Students had 8 items; facilitators had 7 items using a 5-point Likert scale (1=strongly disagree to 5=strongly agree)	Not Reported	K
Knowledge Quiz	Schweiger-Whalen et al. (2019)	Knowledge related to the delivery of affirmative and inclusive LGBT health care services	13-item multiple-choice test derived from recent literature and a publication of the Fenway Institute covering best practices (Makadon, 2015)	Not Reported	K
Lesbian, Gay, Bisexual, and Transgender Healthcare Scale	Strong & Folse (2015)	Perceptions of competence, cultural sensitivity skills, and nursing curricula	6-item Likert scale (with opportunity for written elaboration by participants)	(α =.54)	K, S
Lesbian, Gay, Bisexual, and Transgender Knowledge Questionnaire	Strong & Folse (2015)	LGBT knowledge	15-item true or false	Alpha coefficient Kuder-Richardson 20 (α =.54)	K
Modern Homonegativity Scale (Morrison & Morrison, 2002)	Rowniak (2015)	Contemporary negative attitudes toward lesbians and gaymen	22-item using a 5-point Likert scale (1=strongly disagree to 5=strongly agree)	(α =.81 to .95 in previous studies; Morrison & Morrison, 2002, 2010) (α =.96 current study)	A
Open-Ended Questions	Schweiger-Whalen et al. (2019)	How the training and panel presenters broadened their awareness of LGBT health	Participants were prompted to discuss any unconscious biases, assumptions, or patterns in thinking that were uncovered, in addition to any unintentional behaviors they have adopted in practice. “What skills have you learned from the training that you intend to employ in future health care encounters with LGBT patients?	Not Reported	A, S
The Index of Homophobia (Hudson & Ricketts 1980)	Schlub & Martsolf (1999)	Homonegativism, anti-homosexual responses	25-item using a 5-point Likert scale (1=strongly disagree to 5=strongly agree); those with a high score have considerable dread or anxiety of being near a homosexual person	Alpha coefficient (r=.90) (Hudson & Ricketts 1980)	A
Transphobia Scale (Nagoshi et al. 2008)	Acker (2017)	Levels of transphobia	9-item using 5-point Likert scale (1=completely disagree to 5=completely agree)	(α =.85)	A
Transphobia Scale (Nagoshi et al. 2008)	Klotzbaugh et al. (2020)	Measure Prejudice against gender minorities	9-item scale using a 3-point Likert scale (1=disagree to 3=agree); Lower scores indicate less transphobia	(α =.82); test-retest stability correlation of .88	A
Unnamed measure	Carabez et al. (2014)	Evaluated which specific assignment components best prepared students to support LGBT clients and allowed students to articulate key concepts learned through the project. Extent to which the interviews provided students with increased research and interviewing skills, as well as knowledge about LGBT clients’ and nurses’ issues.	Not reported	Not Reported	K, S
Unnamed measure	Carabez et al. (2014)	Knowledge in LGBT terminology and issues, sexual orientation, gender identity; Comfort level with using appropriate pronouns for transgender clients and whether or not their personal, cultural, and religious beliefs and their own sexual and gender identities might impact their ability to provide nursing care	14 items; using a five-point Likert scale (1=not at all knowledgeable to 5=expert)	Not Reported	K, A
Unnamed measure	Greene et al. (2018)	Assess students’ perspectives on how both the formal and informal curricula at their respective schools prepared them to care for LGBTQ patients; 1) comfort with providing care to LGBTQ populations, 2) attitudes towards LGBTQ populations and health, and 3) formal training in LGBTQ healthcare	12-item using a 5-point Likert scale (1=strongly disagree to 5=strongly agree)	Face and construct validity established via an interprofessional group of LGBTQ and allied students	K, A
Unnamed measure	Kuzma et al. (2019)	Students’ knowledge of basic LGBTQ health terminology	Not Reported	Not Reported	K
Unnamed measure	McNiel & Elertson (2018)	Participant beliefs regarding caring for patients who identify as LGBTQ	4-item; yes or no questions	Not Reported	A
Unnamed measure	Vance et al. (2018)	Transgender clinical exposure and self-perceived knowledge of medical and psychosocial considerations for transgender youth	24 items using a 5-point Likert scale (1=not at all knowledgeable to 5=completely knowledgeable); 9-item fill-in-the-blank and multiple-choice questions; 13 self-efficacy items asked learners to rate their confidence to clinically evaluate and counsel transgender youth (0=not at all confident to 10=completely confident)	Not Reported	K, A
Unnamed measure	Vance, et al. (2017)	Knowledge/awareness of transgender youth medical and psychosocial considerations	20 knowledge/awareness items using a five-point Likert scale (5=extremely knowledgeable/aware); 11 questions using a five-point Likert scale (5=very satisfied or strongly agree)	Not Reported	K
Unnamed measure (adapted from Braun, Garcia-Grossman, Quiñones-Rivera, and Deutsch, 2017)	Klotzbaugh, et al. (2020)	Content-based questions measuring transgender specific medical knowledge, cultural awareness, knowledge of healthcare disparities and health policy	One point is given for each correct response, higher scores indicate greater knowledge in each module domain	Not Reported	K

Themes Identified from Included Articles

Four main themes were identified: Students are aware of their need for improved LGBTQ learning; LGBTQ curricular interventions result in substantive and significant learning; Direct interaction with LGBTQ people results in significant learning; and Facilitators and barriers to LGBTQ health education impact curricular effectiveness.

Students are aware of their need for improved LGBTQ learning.

Through the collection of student evaluation, post-activity reflection, or simulation debrief data, six papers reported on students’ awareness of their need for improved LGBTQ learning (Brown et al., 2017; Carabez et al., 2015; Chen et al., 2018; McNiel & Elertson, 2018; Schweiger-Whalen et al., 2019; Strong & Folse, 2015). Students spoke to the importance of this content for their professional learning needs and expressed interest in learning more about LGBTQ healthcare needs, disparities, and skills for practice. However, Carabez et al. (2015b) and Greene et al. (2018) also reported a degree of student dissatisfaction with their program-specific LGBTQ learning opportunities, with large numbers of students noting LGBTQ learning experiences had been absent or not always effective. Such results highlight the need for improved content inclusion as well as further evaluating the quality of LGBTQ content segments in nursing programs.

LGBTQ curricular interventions result in substantive and significant learning.

Twelve of the 20 studies tested curricular interventions to improve LGBTQ KSAs (Table 1). All intervention studies employed either a pre-test/post-test (n=7) or a post-test only (n=5) design to measure knowledge, beliefs, attitudes, experiences, and/or skills. Post-test results demonstrated that incorporation of LGBTQ educational content into curricula resulted in improvements in knowledge, attitudes, and skills across studies. Researchers reported that their interventions resulted in substantive and significant improvements with meaningful change in awareness and understanding of LGBTQ health disparities (Maley & Gross, 2019; McNiel & Elertson, 2018; Strong & Folse, 2015). Other results indicating substantive and significant learning and significant changes overtime included increased positive attitudes and knowledge (Carabez et al., 2015b; Kuzma et al., 2019; Schweiger-Whalen et al., 2019; Strong & Folse, 2015; Vance et al., 2017, 2018), reduced transphobia (Klotzbaugh et al., 2020), perceived improvement in skills for providing LGBTQ health care (Carabez et al., 2015b; Kuzma et al., 2019), and improved perceived self-efficacy (Vance et al., 2018). Students seemed especially to benefit from debriefing or question/answer sessions following a given educational experience (Kuzma et al., 2019; McNiel & Elertson, 2018; Schweiger-Whalen et al., 2019; Vance et al., 2018).

Direct interaction with LGBTQ people results in significant learning.

This theme was exemplified in seven studies that used direct interaction with LGBTQ individuals as an intervention component (Carabez et al., 2015; McCave et al., 2019; McNiel & Elertson, 2018; Schweiger-Whalen et al., 2019; Strong & Folse, 2015; Vance et al., 2018). A variety of statistically significant improvements in learning were identified in students’ knowledge about and attitudes toward LGBTQ people (Kuzma et al., 2019; Strong & Folse, 2015), increased self-efficacy relative to providing LGBTQ care (Vance et al., 2018), empowerment to address LGBTQ healthcare needs (Carabez et al., 2015; McNiel & Elertson, 2018), improved communication skills (Carabez et al., 2015; McCave et al., 2019; Schweiger-Whalen et al., 2019), cultural awareness and empathy development (Kuzma et al., 2019; McCave et al., 2019; Schweiger-Whalen et al., 2019), self-awareness around insensitive behaviors and bias (Kuzma et al., 2019; Schweiger-Whalen et al., 2019), and the development of commitment to LGBTQ health advocacy (McCave et al., 2019; Schweiger-Whalen et al., 2019). Such outcomes demonstrate the efficacy of direct interaction with LGBTQ people in fostering significant learning.

Facilitators and barriers to LGBTQ health education impact curricular effectiveness.

Several facilitators and barriers to integrating LGBTQ health content into nursing curricula were identified. Facilitators focused on recommendations to improve content integration including content-specific recommendations, pedagogical approaches to content delivery, where (e.g., in which courses or in which part of a course) to integrate content, and how to access and build alliances with LGBTQ experts and community members (Brown et al., 2017; Carabez et al., 2015; Chen et al., 2018; Holloway et al., 2019; Ozkara San et al., 2019; Rowniak, 2015; Stockmann & Diaz, 2017; Vance et al., 2017). Some barriers included (a) the impact of religiosity, (b) limited course or program resources, and (c) student self-selection into optional content, among others. In studies that assessed homophobia and/or transphobia, higher levels of homophobia or transphobia were associated with a number of factors such as higher levels of reported religiosity, more conservative political perspectives, and fewer personal and educational experiences with LGBTQ people (Acker, 2017; Brown et al., 2017; Rowniak, 2015; Schlub & Martsolf, 1999). Limited curricular resources was the most common barrier (McCave et al., 2019; McNiel & Elertson, 2018; Schweiger-Whalen et al., 2019; Vance et al., 2017, 2018). Examples of limited resources included minimal opportunities for clinical exposure and engagement with LGBTQ people, as well as resources needed for LGBTQ specific content development and integrative implementation. Importantly, exposure to LGBTQ people and content through relatively brief educational interventions was shown to improve attitudes toward LGBTQ individuals while significantly decreasing expressions of bias (Klotzbaugh et al., 2020; Strong & Folse, 2015). Lastly, two studies noted intervention engagement and uptake were hindered by student self-selection into the optional intervention or curricular content (Chen et al., 2018; Schweiger-Whalen et al., 2019). These findings demonstrate that the balance of educational facilitators and barriers impacts curricular uptake, development, and effectiveness.

Discussion & Recommendations

This integrative review of LGBTQ content in pre-licensure and graduate nursing education revealed an overall low but increasing level of scholarly activity around teaching/learning interventions and research focused on improving nursing students’ attitudes, knowledge, and skills in caring for LGBTQ people. A majority of the papers (n = 12) report beginning initiatives describing additive (i.e., adding content by way of an elective course, single educational component in 1 topic, etc. verses a full programmatic integration of LGBTQ health content), single-site educational interventions with convenience sampling and without use of validated evaluation tools (Carabez et al., 2014; Klotzbaugh et al., 2020; Kuzma et al., 2019; Maley & Gross, 2019; Maruca et al., 2018; McNiel & Elertson, 2018; Ozkara San et al., 2019; Schweiger-Whalen et al., 2019; Stockmann & Diaz, 2017; Strong & Folse, 2015; Vance et al., 2017; Vance et al., 2018). A smaller subsection of the papers (n = 6) reported descriptive survey research, also using convenience sampling with variable geographic and/or institutional representation (Acker, 2017; Brown, et al., 2017; Englund, 2018; Greene et al., 2018; Rowniak, 2015; Schlub & Martsolf, 1999).

While our final sample of 20 articles highlights the limited amount of research on LGBTQ education in pre-licensure and graduate nursing, the trend towards greater attention to LGBTQ content in nursing educational programs is demonstrated by 19 of the 20 articles being published after 2015. Several important developments occurred from 2010 to 2016, perhaps contributing to the increased activity in more recent nursing LGBTQ scholarship:

• Healthy People 2020 (Department of Health and Human Services, n.d.) included goals for LGBTQ health and wellbeing

• National Academy of Medicine (formerly the Institute of Medicine) report on LGBTQ health was published in 2011 (Institute of Medicine (IOM), 2011)

• National Institutes of Health office of Sexual and Gender Minority Research (National Institutes of Health, 2021) was established in 2015

• US Supreme Court decision on marriage equality was delivered in June 2015 (Gates & Brown, 2015)

• Although it did not address LGBTQ people directly, the 2015 revision of the ANA Code of Ethics for nursing (Fowler, 2015) incorporated strong language on social justice, anti-discrimination, and reducing health disparities

• US Department of Health and Human Services Office for Civil Rights codified new rules (US Department of Health and Human Services, 2015) regarding nondiscrimination for LGBTQ people in health facilities receiving federal funding, affirming Affordable Care Act prohibitions against LGBTQ discrimination in health insurance coverage and health care in 2016

These and other historic changes (e.g., LGBTQ lives reflected in media, education, and government) have resulted in dramatically increased visibility of LGBTQ people and their health needs across multiple institutional sectors, arguably including within nursing education and scholarship.

Despite these important advances and some evidence that attention to LGBTQ content in nursing educational programs is growing, the overall low number of studies in our review underscores the need for research in this area. The dearth of research is likely due, in part, to the difficulty that nurse educators (compared to nurse researchers) have in securing protected time for scholarship, including writing for publication. In a survey of Midwest nurse practitioner (NP) and certified nurse-midwifery (CNM) program coordinators and lead faculty (Smith et al., 2021), the resource constraint of faculty time was one of the most frequently reported barriers to incorporating LGBTQ content into NP and CNM curricula. It is also likely that more educators than represented in this review are engaged in efforts to improve nursing education related to LGBTQ health, as evidenced by the attendance of schools across the nation at the National Nursing LGBTQ Health Summit (Hughes et al., 2022).

Several of the cross-sectional survey studies described in the review (n = 6; Acker, 2017; Brown et al., 2017; Carabez et al., 2015; Chen et al., 2018; Rowniak, 2015; Schlub & Martsolf, 1999) demonstrate that homophobia, transphobia, and limited exposure to LGBTQ individuals is commonly reported by undergraduate and graduate nursing students. Study findings that educational interventions improve attitudes, knowledge and skills provide hope that as more nursing programs incorporate LGBTQ content, nursing care for these population groups will improve and sexual and gender minority health disparities will diminish.

Intervention studies in this review typically reported one-time or relatively brief curricular enhancements that focused more on LGBTQ knowledge and attitudes than skills and competencies. In general, a goal- or target-level set of competencies was not described, nor did it appear that investigators expected more than very basic improvements in awareness, empathy, or correction of misconceptions about LGBTQ people and their health. None of the studies reported a systematic or scaffolded approach toward building practice competencies capable of fostering substantive and significant changes in the health and wellbeing of LGBTQ individuals, families, or communities. While simulation was commonly used, it often focused on a one-time encounter, often with a transgender person, which paradoxically can further objectify transgender people if not skillfully managed and accompanied by sufficient depth of learning about LGBTQ people overall. One way to decrease objectification of LGBTQ lives in simulation may be to make the patients gender identity and sexuality not central to the core educational content in the simulation. Every person has a gender identity and a sexuality. Normalize the appearance of LGBTQ lives within the simulation content throughout a curricular program.

Limitations

This integrative review provides the first comprehensive examination of the peer-reviewed literature pertaining to the state of LGBTQ education for pre-licensure and graduate nursing students in the US. However, the review has limitations that should be considered when evaluating the results. Studies may have been missed during the article selection process due to publication bias, the search strategy (pulling articles from only five prominent databases), inter-rater reliability (each article was independently screened by two of the eight people contributing to the article selection process), and/or the inclusion and exclusion criteria used to identify articles (focusing on US-based samples may have limited understanding of other promising educational interventions used in other countries, and may have missed pertinent articles that have been published after 2020). Additionally, data extraction was performed by five team members and a 25% audit of the extracted data was performed to examine extraction quality. Conducting a 25% audit rather than having two independent extractors for each article may have reduced the consistency and accuracy of extracted data. Finally, few robust standardized measures exist to guide article quality appraisal for integrative reviews that include numerous types of study designs. Our team developed a comprehensive measure using existing tools and adding items to assess pertinent data not covered in those tools. The creation and use of the adapted measure for quality appraisal has yet to undergo psychometric testing; thus, no test of the measure exists beyond inter-rater reliability. Despite these limitations, this review provides important information and an overall understanding of the literature, including important gaps in knowledge about LGBTQ nursing education. Such information is essential to guide future research, intervention development, and curricular change.

Recommendations

Research.

Although research is growing, additional studies with more rigorous methods are needed to demonstrate improved student learning outcomes when increased LGBTQ educational content and learning activities are incorporated into nursing curricula, and the congruency of these outcomes with documented areas of LGBTQ health needs. The development of validated measures is needed to evaluate student outcomes, lending confidence to findings and permitting comparison across studies to identify the most effective teaching methods. One such tool has recently become available and should be tested in future research, Gender and Sexual Diversity Sensitivity Scale (GSDSS; Rew et al., 2022). In particular, studies with longitudinal and experimental designs and those that assess skills and competencies are needed. Additionally, future studies should be theoretically grounded in a relevant conceptual framework to guide evidence-based intervention development and evaluation.

Education.

A broader and more robust approach to the integration of LGBTQ content across courses and curricular levels is needed. Single educational offerings or content limited to one course prevents students from developing a holistic understanding of the complex history, identities, needs, and strengths of LGBTQ individuals, families and communities across the lifespan. Schools of nursing should consider more comprehensive approaches to integrating LGBTQ content such as the Tool for Assessing LGBTQ Health Training (TAHLT) in pre-licensure nursing curricula (Sherman et al., 2022). This tool was developed as an initiative to integrate LGBTQ content across programs in one school of nursing and provides a validated framework across five domains of knowledge, skills, and attitudes. The TAHLT has shown promise as a framework for building greater content depth and competency development into LGBTQ curriculum development.

Because nursing education’s regulatory bodies (accreditors, certifying organizations, and licensing agencies) significantly affect curricula and program requirements, these organizations can also exert significant influence on the improvement of LGBTQ content in nursing education. Through required content areas (diversity/inclusion, population health, cultural competence, or social determinants of health, for example), accrediting bodies in particular have an opportunity to strengthen specific standards that would require nursing programs to more clearly integrate LGBTQ subject matter into nursing curricula. This would help to ensure that processes for accountability and evaluation of LGBTQ learning outcomes are apparent. The recent changes to the American Association of Colleges of Nursing (AACN) Essentials can be used as one tool for modifying content to include LGBTQ content (American Association of Colleges of Nursing, 2021). Establishing more robust curricular standards would also inspire publishers of nursing textbooks to bolster LGTBQ+ content consistent with national standards.

Additionally, schools of nursing should work in partnership with practice sites and communities to ensure that educational content relevant to the care of LGBTQ people contributes to high quality clinical care. Events such as the National Nursing LGBTQQ Health Summit (Hughes et al., 2022) provide key opportunities for nursing leaders to come together to develop a strategic vision and plan of action to remedy the current deficits in the education of nursing students about the health needs of LGTBQ+ individuals. Additional educational content can be found at the World Professional Association of Transgender Health website (https://www.wpath.org) and the National LGBTQQIA+ Health Education Center (https://www.LGBTQqiahealtheducation.org).

Conclusions

Although there are encouraging signs of an emerging science of LGBTQ education in nursing, substantially more work is needed to build integrated pedagogical approaches, validated tools, protocols, competency measures, and to document the impact of curricular changes on LGBTQ health outcomes and satisfaction with care. Key stakeholders (i.e., schools of nursing, regulatory bodies, and nursing publishers) should strive to ensure that students receive both didactic and clinical knowledge about LGBTQ health generated from empirically sound evidence to support competent and affirming nursing care for all LGBTQ people and communities. As nursing programs build LGBTQ content into nursing curricula, care must be taken to integrate this content fully with the depth of curricular content in population health, social determinants of health, social justice, intersectionality, cultural competence, and political advocacy.

Highlights.

• LGBTQ educational interventions in nursing curricula are increasing

• Homophobia and transphobia persist among nursing students

• LGBTQ content in curricula can improve students’ knowledge, skills, and attitudes

• Students benefit from LGBTQ health didactic content and clinical experiences