Sexual and Gender Minority Communication Skills (SGM Comskil) Training for Oncology Clinicians: Development, Implementation, and Preliminary Efficacy

Abstract

Enhancing communicative competence of healthcare providers (HCPs) is a critical initiative for improving the healthcare experience of sexual and gender minority (SGM) cancer patients. This study presents the development, implementation, and preliminary efficacy of a new training curriculum for improving oncology HCPs’ skills in providing a safe and welcoming environment for SGM cancer patients (SGM Comskil training). Thirty-three (N = 33) oncology HCPs including nurses, nurse leaders, and nurse practitioners participated in a 4.25-hour SGM Comskil Training between July and August 2019. Overall, participants reported highly favorable evaluations of the training, with more than 80% of the participants reacting positively to 12 of the 15 evaluation items assessing engagement and reflectiveness for experiential role-plays with lesbian, gay, bisexual (LGB) and transgender standardized patients (SPs), respectively. Participants also demonstrated significant improvements in SGM healthcare knowledge, self-efficacy, beliefs toward LGB and transgender persons, and SGM-sensitive language use skills following the training. Encouraged by the feasibility of conducting this experiential training with busy cancer care HCPs and the initial favorable participant evaluation of the SGM Comskil training, results clearly indicate that this training can be rolled out into clinical settings to ensure its translational potential. The next steps should assess observable changes in communication skills and SGM-sensitive language skills with SGM patients and improvements in SGM patients’ healthcare experience.

The term sexual and gender minority (SGM) encompasses people whose sexual orientation, gender identity and expression, or reproductive development varies from traditional, societal, cultural, or physiological norms.¹ Recent estimates indicate that 11.3 million American adults (about 4.5% of U.S. population) identify as SGM, which include lesbian, gay, bisexual, transgender, and intersex (LGBTI) people.² A sparse but growing body of evidence suggests that SGM populations are at an increased risk for and have poorer outcomes to certain cancers such as breast, cervical, and anal cancers.^3–16 Despite the increased risk, SGM populations are less likely to seek healthcare services or lack a regular healthcare provider (HCP),^4,17,18 less likely to engage in early detection and cancer screening,^4,19,20 and may engage in behaviors associated with increased cancer risk, including elevated rates of smoking, alcohol use, obesity, nulliparity (among SGM assigned female at birth), anal receptive sex (among SGM assigned male at birth), and lower rates of exercise.^3,17,21,22 The cumulative evidence suggests increased cancer risk and poorer outcomes for SGM oncology patients.²³

Contributing to those disparities are experiences of healthcare discrimination and stigma, including refusal of care, biases, derogatory statements (microaggressions), lack of HCPs’ awareness, and insensitivity to the unique needs of the community and others.^19,24,25 Several factors contribute to the underutilization of healthcare services by SGM persons including lower levels of insurance coverage,^18,26 lower satisfaction with cancer care treatment,^27,28 higher rates of psychological distress,²⁸ higher rates of perceived discrimination in the healthcare setting,^29–34 and shortage of HCPs skilled in SGM health.^3,34–38 While some of these barriers are at the organizational and system-level, a number of them are modifiable factors within HCP–SGM patient relationship.

Systematic review of experiences and unmet needs of sexual minority (SM) cancer patients suggest the following themes:³⁹ lack of appropriate opportunities for sexual orientation disclosure, fear of homophobia or discrimination by HCPs, microaggressions from HCPs (dismissive language, disparaging remarks, reluctance to address LGB sexuality, and noninclusion of same-sex partners/spouses), HCP heteronormative attitudes (i.e., the implicit assumption that all individuals are heterosexual), HCP ignorance about unique healthcare needs of SM patients, and scarcity of health professionals competent in SM health. However, studies regarding communication barriers experienced by gender minority (GM) patients are lacking. The growing evidence on such communication pitfalls emphasize the need for HCP education and training, particularly to ensure SGM-affirming healthcare environments.

Enhancing communication competence of HCPs is a critical initiative for improving the healthcare experience of SGM patients, particularly SGM cancer patients.⁴⁰ Medical education does not routinely encompass SGM health issues beyond HIV/AIDS.^41–43 Similarly, most nurses have not received training on the care of SGM patients.⁴⁴ In order to improve clinical competence, many national healthcare organizations have developed practice recommendations and guidelines for creating SGM safe healthcare experiences including the National Academy of Medicine,⁴ and the Joint Commission,⁴⁵ and the value of those recommendations have been underscored in oncology.⁴⁶ Even so, oncology HCPs lack knowledge, do not facilitate disclosure of sexual orientation and gender identity (SOGI), and report a need for training.^23,47,48 Therefore, it is timely and imperative to not only develop an SGM sensitivity communication skills (SGM Comskil) training for oncology HCPs but also test its feasibility and preliminary efficacy on SGM patient outcomes in order to work toward closing the disparities gap in SGM oncology healthcare.

We piloted a new SGM Comskil training module for oncology HCPs, aimed to teach participants (a) strategies to create a safe and welcoming environment for SGM patients; (b) skills to invite all patients to share SOGI information and provide a clear rationale for collecting this data; and (c) tasks involved in inquiring about and inviting SGM patients’ family of choice in medical decision-making.

Preliminary Work

In order to support the development of the SGM Comskil training module, we elicited feedback from Memorial Sloan Kettering (MSK) HCPs to determine interest in training and to identify barriers and challenging scenarios that arise when working with SGM oncology patients. A survey was administered to MSK HCPs (N = 1,253) that quantitatively assessed their knowledge, beliefs, and communication behavior toward SGM patients,⁴⁷ and qualitatively examined their communication experiences and challenges in providing SGM patient care.⁴⁹ Findings demonstrated useful communication strategies employed by oncology HCPs to encourage SGM patients’ SOGI disclosure, communication, and structural/administrative challenges faced by HCPs in providing care, and suggested recommendations from oncology HCPs to improve their care delivery for SGM patients. This research directly informed the development of SGM Comskil training module. As a next step, we presented all the developed materials (PowerPoint, exemplary video scripts, role play scenarios) of the SGM Comskil training to SGM cancer survivors, caregivers, and researchers (N = 11) in a focus group for their feedback, and made recommended changes to the materials throughout.

SGM Comskil Curriculum Content

The training curriculum followed the guidelines of the Comskil Model, a skills-based approach to teaching communication skills in a cancer setting.⁵⁰ Consistent with the Comskil Conceptual Model,⁵⁰ we presented six recommended communication strategies (a priori plans) to achieve the communication goal: (a) make introductions, (b) set the agenda, (c) invite families of choice/support system and inquire about the patients’ healthcare agent, (d) develop an accurate, shared understanding of the patient’s situation: psychosocial needs and concerns; and other factors influencing their treatment decision, (e) empathically respond to the patients’ emotion/experience, and (f) connect to appropriate MSK resources. The strategies are accomplished through the use of communication skills (standalone verbal utterances) and process tasks (set of verbal and nonverbal behaviors that create a conducive environment for effective communication; Table 1).

TABLE 1.

Blueprint for the SGM Comskil Training

Strategy	Skills	Process Tasks
1. Make introductions	Ask open questions (name, gender, sex, pronouns) Check patient preference (regarding caregiver) Provide rationale	Avoid being heteronormative/cisnormative Introduce yourself Reframe questions, if not clear to the patient
2. Agenda setting	Declare agenda items Invite agenda items Negotiate agenda (if appropriate) Acknowledge (if appropriate) Validate (if appropriate)	Sit at eye-level Express a willingness to help
3. Invite families of choice/support system, and asking about healthcare agent	Ask open questions (about social support, family of choice and/or biological family, person accompanying the patient, non-involvement, etc.) Endorse question asking Check preferences (for involving others in medical decision making, families of choice, etc.) Normalize	Invite families of choice/support system, and asking about healthcare agent Introduce joint decision-making Make partnership statements
4. Develop an accurate, shared understanding of the patient’s situation: (a) psychosocial needs and concerns; (b) other factors influencing their treatment decision	Check understanding Ask open questions Invite questions Check patient preference	Correct misunderstandings
5. Empathically respond to the emotion/experience	Encourage expression of feelings Acknowledge Validate Normalize Praise patient efforts	Identify patient’s strengths and sources of support
6. Connect to appropriate MSK resources	Ask open questions Endorse question asking Review next steps	Make referrals Express a willingness to help Make partnership statements

METHODS

Participants and Procedure

Thirty-three (N = 33) oncology HCPs including nurses, nurse leaders, and nurse practitioners (NPs) participated in a 4.25-hour duration SGM Comskil Training between July and August 2019. The HCPs were from a number of settings across the hospital including acute care, critical care, and urgent care and were selected based on a screening questionnaire they completed.

Participation selection was based on convenience sampling, and was determined based on various factors, including the participants’ availability to attend the training, no prior participation in any training on improving SGM sensitivity, and noted reasons for their interest in attending the training. The training and research reported in this paper received exemption from the Institutional Review Board at Memorial Sloan Kettering Cancer Center.

Training Format

The SGM Comskil training included a combination of didactic lecture with exemplary skill demonstration videos (75 minutes), followed by facilitator-led small group role plays (180 minutes). The didactic lecture included a snapshot of the SGM census, an orientation to SGM terminology, SGM cancer disparities, the importance of SOGI disclosure, the barriers and facilitators of SOGI disclosure, a snapshot of preliminary studies done at MSK that guided the development of training, and a recommended blueprint presenting six sequential strategies to facilitate a safe and welcoming environment for SGM patients. Exemplary videos were embedded into the didactic presentation to illustrate key skills. The didactic was copresented by the first (Banerjee) and last (Walters) authors. Following the didactic, participants were split into groups of three to begin the role-play sessions with clinician and Comskil facilitators leading the discussion in each room. These experiential exercises allowed each participant practice specific strategies with an LGB or a transgender simulated patient (SP, portrayed by trained actors), followed by a second role play exercise that allowed each participant to practice learned skills with a transgender or LGB SP, respectively.

Measures

Study measures included knowledge, attitudinal, and behavioral outcomes of HCPs participating in the SGM Comskil training: LGBTQ healthcare knowledge (pre- and post-training), training evaluation (post-training), self-efficacy (pre- and post-training), beliefs toward LGB people (pre- and post-training), beliefs toward transgender people (pre- and post-training), communication skills uptake, and SGM-sensitive language use (assessed using SPAs, at both pre- and post-training). Table 2 presents descriptive information for all study measures.

TABLE 2.

Descriptives for all Study Measures

Measure	Cronbach’s α	M	SD	Cronbach’s α	M	SD
	Pre-training			Post-training
Self-efficacy	0.85	3.28	0.65	0.85	4.09	0.44
Beliefs toward LGB people
Discreetness	0.86	5.64	0.77	0.84	6.17	0.44
Homogeneity	0.66	5.91	0.55	0.66	6.13	0.53
Beliefs toward transgender people	0.95	6.46	0.80	0.89	6.67	0.53
Self-efficacy	0.85	3.28	0.65	0.85	4.09	0.44
Communication skills uptake (overall)	n/a	4.64	2.03	n/a	5.61	2.30
SGM-sensitive language use
Positive	n/a	3.53	1.58	n/a	0.21	0.59
Negative	n/a	4.76	1.66	n/a	0.06	0.24
	Cronbach’s α	M	SD	Cronbach’s α	M	SD
	Role play with LGB SPs			Role play with transgender SPs
Training evaluation*
Engagement	0.84	4.28	0.62	0.86	4.32	0.57
Novelty	0.55	3.69	0.73	0.70	3.69	0.87
Reflectiveness	0.96	4.71	0.48	0.89	4.69	0.40

Abbreviations: LGB = lesbian, gay,bisexual; SP = standardized patient.

^*Training evaluation was completed by participants only at post-training.

LGBTQ Healthcare Knowledge.

LGBTQ healthcare knowledge measure was an adapted version of the knowledge measure used by Shetty et al.⁴⁸ and Sanchez et al.⁵¹ with two additional items added by the study team. The overall measure consists of 13 items assessing HCP knowledge about LGBTQ avoidance of healthcare (2-items), lesbians and cancer risks (5-items), LGBTQ adolescents and suicide risk (1-item), LGBTQ older adults and depression (1-item), transmen/transwomen and breast/prostate cancer risks, respectively (2-items), and safe healthcare for LGBTQ people (2-items). Items were scored as true/false/don’t know, and all correct answers were scored as 1 and others 0; don’t know answers were considered incorrect answers. An overall knowledge score was calculated for every participant by summing their total correct scores.

Training Evaluation.

This measure was modeled after prior program evaluation measures,⁵⁰ created by the study team. Participants completed a post-training evaluation, consisting of 15 statements using a 5-point Likert scale with anchors of (1) “strongly disagree” to (5) “strongly agree.” The statements measured post-training attitudes regarding engagement (e.g., “The role play was interesting to me”), novelty (e.g., “I’ve never done anything like what I did in the role play today”), and reflectiveness (e.g., The role play made me think about my communication skills with LGBTQ patients).

Self-efficacy.

Self-efficacy was modeled after prior self-efficacy measures,⁵² created by the study team. The measure consists of eight items using a 5-point Likert scale with (1) “strongly disagree” to (5) “strongly agree,” such as “I am confident in my knowledge of the terminology (sexual orientation, sex at birth, gender identity, preferred pronouns, families of choice) commonly used in the LGBTQ discourse.” A higher score indicates high confidence.

Beliefs Toward LGB People.

Beliefs toward LGB people were assessed using a shortened version of the Sexual Orientation Beliefs Scale (SOBS) developed by Arseneau et al.⁵³ and consisted of eleven items (out of original 32) with highest loadings on prior factor analyses, using a 7-point Likert scale with (1) “strongly disagree” to (7) “strongly agree.” For the purpose of this study, we only focused on two sub-factors related to beliefs toward LGB people: discreetness (items reflecting beliefs that sexual orientation groups, e.g., gay, straight-are unique, nonoverlapping categories) and homogeneity (items emphasizing sameness of members of a given sexual orientation) category. A higher score on each of the sub-factors indicates favorable beliefs toward LGB people.

Beliefs Towards Transgender People.

Beliefs toward transgender people were assessed using a shortened version of the Genderism and Transphobia Scale, developed by Hill & Willoughby.⁵⁴ The measure consists of fifteen items using a 7-point Likert scale with (1) “strongly agree” to (7) “strongly disagree”. A higher score indicates favorable beliefs toward transgender people.

Communication Skills Uptake, via Standardized Patient Assessment.

All participants completed Standardized Patient Assessments (SPA). A SPA is an 8-minute video-recorded interaction between the HCP and the SP on a provided clinical scenario, using standardized scripts by the SP. Each participant completed one SPA immediately prior to their SGM Comskil training and one SPA following training. Communication skills uptake was assessed by indicating the presence/absence of each of the 21 skills used in the SPA. We used an adapted version of the Comskil coding system (CCS)⁵⁵ to code all the video-recorded SPAs. The CCS codes presence/absence of verbal utterances (skills) that are present in the HCP–SP interaction but does not code nonverbal behaviors. The adapted CCS includes 21 individual skills, grouped under six communication skills categories: agenda setting, checking, questioning, information organization, and empathic communication. Given the small number of participants, we combined all scores received in the six categories to have overall skills scores for pre- and post-training. The range of scores that a participant could receive was from 0 to 21.

SGM-Sensitive Language Use via SPA.

Based on prior research,^40,56 we developed a checklist of 15 SGM-sensitive language use behaviors including both positive language use (n = 7, e.g., asking about gender identity, introducing self with pronouns, asking for preferred name, etc.) and negative language use (n = 8, e.g., use of heterosexist or transphobic terminology, cis-gender normativity, assumption of sexual pathology or abnormality, etc.). Coders coded presence/absence of each of the SGM-sensitive language use behaviors. Summed scores were created; higher score on positive behaviors and a lower score on negative behaviors indicated favorable use of SGM-sensitive language. Range of scores that a participant could receive was from 0 to 7 for positive language use and 0 to 8 for negative language use.

Coding

Two trained coders coded all the SPA videos using the CCS adapted to clinical scenarios within the context of taking a history with an SGM patient. We assessed inter-coder agreement at the beginning of coding and at the midpoint by double coding 10% of data. Due to the large number of possible codes in any interaction and the variable units of analyses, we used a time-chunk method to determine inter-coder agreement.⁵⁵ In particular, we assessed coders’ percentage agreement on 15-second blocks of an 8-minute interaction (i.e., 32 blocks). After each inter-coder agreement, we assessed for percentage agreement, resolved all disagreements (first author), and continued with coding only when the coders achieved a minimum of 75% agreement.

Data Analysis

For training evaluation, a rating of “agree” or “strongly agree” was considered to be an indicator of satisfaction with the module and was analyzed descriptively. Because the knowledge items were scored dichotomously, we assessed change in score for each individual item using McNemar’s test, and a paired t-test for overall change in knowledge. For assessing improvements in self-efficacy, beliefs toward LGB and transgender persons, communication skills, and SGM-sensitive language use respectively, paired t tests were used to assess significant pre-, post-training differences. Two-tailed significance tests were used and p < .05 was considered statistically significant. The data were analyzed using SPSS 24 for Windows (IBM Corporation Armonk, New York).

RESULTS

Descriptive Results

Across the 33 HCPs trained, a majority (n = 30, 91%) were registered nurses, followed by a nurse leader and two NPs. Participants came from different clinical services, including outpatient (n = 13, 40%), inpatient (n = 11, 33%), peri-op (n = 8, 24%), and pediatrics (n = 1, 3%). Participants varied in age from 25 to 70 years (M = 39.64, SD = 12.93) and a majority were women (n = 30, 91%), White (n = 24, 73%), non-Hispanic (n = 27, 82%), and identified as heterosexual/straight (n = 28, 85%).

LGBTQ Healthcare Knowledge Scores

LGBTQ healthcare knowledge scores improved significantly, [t(32) = −3.75, p < .001] from pre- (M = 8.12, SD = 2.27) to post-training (M = 9.52, SD = 1.94). Table 3 presents change scores for each of the knowledge items, as well as overall. Of the 13 knowledge items, there was an increase in percentage of correct scores on 9 items, item #s 1–4,6,7,9,10,12 (significant increase on 3 items, item #s 1,4,6), no change on 3 items (item #s 5,8,11), and a decrease in percentage of correct scores on 1-item (item #13) from pre-to post-training.

TABLE 3.

Distribution on Knowledge Items from Pre- to Post-Training (N = 33)

	Pre-training		Post-training
	Incorrect N (%)	Correct N (%)	Incorrect N (%)	Correct N (%)	χ2 (df)	p value
1. Lesbian/gay/bisexual people avoid accessing healthcare due to difficulty communicating with healthcare providers	6 (18.18)	27 (81.82)	0 (0)	33 (100)	4.17 (1)	<.05
2. Trans people avoid accessing healthcare due to difficulty communicating with healthcare providers	2 (6.06)	31 (93.94)	0 (0)	33 (100)	0.50 (1)	.50
3. Human Papillomavirus-associated cervical dysplasia can be found in lesbians with no history of heterosexual intercourse	11 (33.33)	22 (66.66)	6 (18.18)	27 (81.82)	1.78 (1)	.18
4. There is a higher risk of breast cancer among lesbian women when compared to heterosexual women	26 (78.79)	7 (21.21)	12 (36.36)	21 (63.64)	10.56 (1)	<.001
5. Among adolescents, there is an association between being LGBT and suicide/suicidal ideation/suicidal tendencies	1 (3.03)	32 (96.97)	1 (3.03)	32 (96.97)	0.00 (1)	1.00
6. Lesbians are more likely to suffer from obesity than heterosexual women	19 (57.58)	14 (42.42)	10 (30.30)	23 (69.70)	4.27 (1)	<.05
7. Lesbians are less likely to abuse alcohol than heterosexual women	17 (51.52)	16 (48.48)	14 (42.42)	19 (57.58)	0.27 (1)	.61
8. The incidence of depression in older gays and lesbians is greater than in the general population	32 (96.97)	1 (3.03)	32 (96.97)	1 (3.03)	0.00 (1)	1.00
9. Heterosexual women are more likely to be smokers than lesbian women	20 (60.61)	13 (39.39)	18 (54.55)	15 (45.45)	0.08 (1)	.77
10. Trans men (people born as women who identify as men) who have had a mastectomy are at risk for breast cancer.	15 (45.45)	18 (54.55)	11 (33.33)	22 (66.66)	1.50 (1)	.22
11. Trans women (people born as male who identify as women) who have undergone gender affirming surgery are at a risk for prostate cancer	9 (27.27)	24 (72.73)	9 (27.27)	24 (72.73)	0.00 (1)	1.00
12. Healthcare providers should create an environment that encourages disclosure of sexual orientation and gender identity	2 (6.06)	31 (93.94)	0(0)	33 (100)	0.50 (1)	.50
13. The Joint Commission recommends hospitals create welcoming and safe environments for LGBT patients	1 (3.03)	32 (96.97)	2 (6.06)	31 (93.94)	0.00 (1)	1.00
14. Overall knowledge score^	M = 8.12, SD = 2.27		M = 9.52, SD = 1.94		t(32) = −3.75	<.001

χ² represents the McNemar’s Chi-squared test.

Overall knowledge score was calculated for all participants by summing their total correct scores.

Training Evaluation

Overall, participants rated the SGM Comskil training favorably. Specifically, more than 80% of the participants indicated that they “agreed” or “strongly agreed” with 12 of the 15 evaluation items for the role plays with LGB SP, and for the role plays with transgender SP respectively (Table 4). Descriptive results indicated that participants rated the two role plays more favorably for engagement and reflectiveness, but less favorably for novelty.

TABLE 4.

Participant-Rated Evaluations for SGM Comskil Training (N = 33)

Items from Module Evaluation	M (SD)	Endorsement N (%)	M (SD)	Endorsement N (%)
	Role Play With LGB SP		Role Play With Transgender SP
Engagement	4.28 (0.62)	30 (91)	4.32 (0.57)	27 (81.8)
1. The role play was interesting to me	4.48 (0.71)	31 (94)	4.61 (0.56)	32 (97)
2. I got easily distracted during the role play (R)	3.97 (0.92)	27 (81.8)	4.00 (0.79)	27 (81.8)
3. I enjoyed this role play	4.12 (0.78)	29 (87.9)	4.15 (0.76)	28 (84.8)
4. This role play was boring (R)	4.55 (0.56)	32 (97)	4.52 (0.62)	31 (94)
Novelty	3.69 (0.73)	15 (45.5)	3.69 (0.87)	16 (48.5)
5. I’ve never done anything like what I did in the role play today	2.91 (1.21)	13 (39.4)	3.15 (1.25)	13 (39.4)
6. The role play was different than other communication skills training I have participated in	3.79 (0.99)	23 (69.7)	3.58 (1.25)	21 (63.6)
7. The role play was unique.	4.36 (0.78)	29 (87.9)	4.33 (0.74)	30 (91)
Reflectiveness	4.71 (0.48)	32 (97)	4.69 (0.40)	32 (97)
8. This role play made me think about the importance of communication skills	4.73 (0.52)	32 (97)	4.70 (0.53)	32 (97)
9. This role play made me think about reasons for making changes in my communication with LGBTQ patients	4.76 (0.44)	33 (100)	4.76 (0.44)	33 (100)
10. This role play made me think about specific things I can do about my communication skills	4.73 (0.52)	32 (97)	4.73 (0.45)	33 (100)
11. This role play helped me figure out how I can incorporate communication skills in my clinical interactions regularly	4.70 (0.53)	32 (97)	4.73 (0.45)	33 (100)
12. This role play encouraged me to maintain my communication skills	4.58 (0.61)	31 (94)	4.52 (0.67)	30 (91)
13. The role play provided new information about communication skills and process tasks	4.59 (0.63)	32 (97)	4.73 (0.57)	31 (94)
14. The role play made me think about my communication skills with LGBTQ patients.	4.76 (0.50)	32 (97)	4.79 (0.42)	33 (100)
15. The role play made me think about my peers’ communication skills	4.59 (0.62)	30 (91)	4.58 (0.66)	30 (91)

Abbreviation: SP = Standardized Patient (i.e., a trained actor).

Items 1 to 15 were scored on a 5-point Likert scale with anchors at (1) “Strongly Disagree” to (5) “Strongly Agree.”

Endorsement = percentage of participants that endorsed “Agree” or “Strongly Agree” (Items 1–15).

Self-Efficacy

Participants’ overall self-efficacy to communicate effectively with SGM patients significantly improved [t(30) = −8.17, p < .001] from pre- (M = 3.26, SD = .65) to post-training (M = 4.11, SD = .45). Each of the eight self-efficacy items significantly improved from pre- to post-training (Table 5).

TABLE 5.

Changes in Self-Efficacy from Pre- to Post-training (N = 33)

Self-Efficacy Items	Pre-training M (SD)	Post-training M (SD)	t(30)
1. I am confident in my knowledge of the terminology (sexual orientation, sex at birth, gender identity, preferred pronouns, families of choice) commonly used in the LGBTQ discourse	3.15 (1.03)	4.00 (0.71)	−5.38**
2. I am confident in my ability to describe the healthcare disparities experienced by LGBTQ populations	2.94 (1.060	3.82 (0.85)	−4.79**
3. I am confident in demonstrating understanding of communication skills	3.33 (0.99)	4.06 (0.50)	−4.42**
4. I am confident in my ability to describe MSK resources for LGBTQ patients	2.30 (0.92)	3.61 (0.75)	−7.16**
5. I am confident in my skills to create a safe and welcoming environment for LGBTQ patients	3.73 (0.72)	4.30 (0.47)	−4.67**
6. I am confident in my ability to describe the challenges of engaging and supporting the “family of choice” around pivotal cancer care decisions	3.21 (1.02)	4.18 (0.58)	−6.07**
7. I am confident in my ability to provide a safe and welcoming environment for patients to disclose and discuss their LGBTQ status	3.74 (0.82)	4.39 (0.56)	−3.78**
8. I am confident in my ability to empathically enquire about LGBTQ patients’ support system and invite their families of choice in medical decision-making	3.79 (0.86)	4.36 (0.49)	−3.30*
Overall self-efficacy	3.26 (0.65)	4.11 (0.45)	−8.17**

Abbreviation: MSK = Memorial Sloan Kettering.

^*p < .01.

^**p < .001.

Beliefs Toward LGBT People

Belief toward LGB people became more favorable from pre- (M = 5.61, SD = .78) to post-training (M = 6.17, SD = .44) for discreetness [t(30) = −4.62, p < .001]; and from pre- (M = 5.88, SD = .52) to post-training (M = 6.16, SD = .52) for homogeneity [t(30) = −2.61, p < .05].

Similarly, beliefs toward transgender people became more favorable [t(28) = −2.58, p < .05] from pre- (M = 6.42, SD = .82) to post-training (M = 6.65, SD = .54).

Communication Skills and SGM-Sensitive Language Use Uptake

Overall use of communication skills improved from pre- (M = 4.64, SD = 2.03) to post-training (M = 5.61, SD = 2.30), but the change was not statistically significant, t(32) = −1.88, p = .07. Use of positive SGM-sensitive language improved significantly [t(32) = −3.98, p < .001] from pre- (M = 3.56, SD = 1.58) to post-training (M = 4.76, SD = 1.66). The change in use of negative SGM-sensitive language use [t(32) = 1.31, p = .20] from pre- (M = .21, SD = .06) to post-training (M = .06, SD = .24) was not significant.

DISCUSSION

This is the first HCP-focused in-person experiential intervention designed specifically to enhance SGM sensitivity in an oncology setting. The training was favorably received as evidenced through high training evaluation ratings, and resulted in significant improvements in SGM healthcare knowledge, self-efficacy, attitude toward LGB and transgender patients respectively, and SGM-sensitive language use. With encouraging and favorable evaluation of the training, the next steps include assessment of observable change in clinicians’ communication skills with SGM patients and improvements in SGM patients’ experience with regard to clinician empathy, communication of safe and welcoming healthcare environment for SGM oncology patients, and satisfaction with communication.

Participants rated SGM Comskil training as engaging and reflective, but not necessarily novel. This finding was not surprising, given the heightened focus on effective communication skills training in nursing schools and GME programs.⁵⁷ However, it was encouraging to note that despite familiarity with communication skills training, HCPs were engaged in the role plays with both LGB and transgender SPs respectively and found the sessions engaging and reflective.

The results of our study demonstrated minor improvements in communication skills uptake and significant improvements in SGM-sensitive language use by HCPs from pre- to post-training. These findings are significant and add to our prior research that communication skills can be learned,⁵⁸ and HCPs can use SGM-sensitive language in their routine clinical assessments of patient history in cancer care. The heightened focus of the training on SGM sensitivity may have primed participants to focus more on SGM-sensitive language use instead of general communication skills, and that may have resulted in higher uptake of SGM-sensitive language use skills as compared to general communication skills.

The training also led to improvements in knowledge, self-efficacy, and favorable beliefs toward LGB and transgender patients respectively. Recent studies have demonstrated a lack of medical knowledge around SGM healthcare,^23,47,48 highlighting a crucial need for all oncology HCPs to improve medical knowledge around SGM patient healthcare. Additionally, our study adds to the available literature on LGBT oncology healthcare,⁴⁷ indicating that improved knowledge is associated with high self-efficacy and favorable beliefs and attitudes toward SGM oncology patients.

Implications of the Study

Building upon the emerging clinical practice guidelines for SOGI assessment in healthcare settings,⁵⁹ this work contributes to the field by providing preliminary efficacy results of a training focused on teaching HCPs communication strategies to create a safe and welcoming environment for SGM patients, skills to invite all patients to share SOGI information and provide a clear rationale for collecting this data; and tasks involved in inquiring about and inviting SGM patients’ family of choice in medical decision making. Encouraged by the feasibility of conducting this experiential training with busy cancer care HCPs and the initial favorable participant evaluation of the SGM Comskil training, results clearly indicate that this training can be rolled out into clinical settings to ensure its translational potential. With medical national organizations such as the National Academy of Medicine, the American Association of Medical Colleges, the National Institutes of Health, the American Society of Clinical Oncology, the Joint Commission, and the Agency for Health Care Quality recommending LGBT competency training HCPs,^47,60 the SGM Comskil training is both timely and provides an empirical approach toward reducing disparities in oncology healthcare for SGM patients. The next steps in establishing effectiveness of this training include assessment of observable changes in communication skills and SGM-sensitive language skills with SGM patients, and SGM patient-reported outcomes.

This study was implemented at one comprehensive cancer center in the northeast United States that has a well-established communication skills training and research lab dedicated to improving clinical communication. As such, the results may not be generalizable to other cancer centers or hospital settings. Future work must focus on ways to disseminate the training to other cancer care settings. Second, our multidisciplinary clinician participants included clinical nurses and Advance Practice Providers (i.e., NPs and nurse leaders). Future studies should examine feasibility and uptake of training with other members of the oncology healthcare team including oncologists, fellows, and physician assistants. Third, the application of SGM Comskil training to study patient outcomes is warranted to assess effectiveness of training for SGM oncology patients.

CONCLUSIONS

This paper presents the development, implementation, and initial evaluation of an SGM Comskil training for oncology HCPs to create a safe and welcoming healthcare experience for SGM patients with cancer. Results demonstrate that such a training at a major cancer center is feasible, evaluated favorably, and has the potential to improve participants’ self-efficacy, SGM healthcare knowledge, beliefs toward LGBT persons, and SGM-sensitive language use.

Statement of Public Health Significance:

One of the critical initiatives for improving healthcare experience of SGM patients is to enhance communicative competence of HCPs, and the novel SGM Comskil training is designed to address this critical need. Promising results from the pilot trial increase enthusiasm for testing its translational potential.