In April 2018, the American Nurses Association released a position statement on nursing advocacy for LGBTQ+ populations. The “Q” stands for queer or questioning and the “+” indicates inclusivity of other sexual and gender minorities not spelled out within the LGBTQ acronym.1 Key nursing organizations, such as the American Academy of Nursing (AAN), International Society of Psychiatric-Mental Health Nurses, National Association of Pediatric Nurse Practitioners, National Association of School Nurses, and National Student Nurses' Association, among others, have issued position statements in support of LGBTQ rights. Although the ongoing discourse on LGBTQ health is centered on improving patient outcomes, there's little attention given to exploring the experiences of LGBTQ nurses and other healthcare professionals.
Nursing experts have decried the nursing industry's silence on LGBTQ issues, including a lack of published articles in leading nursing journals.2 This finding has special significance to a profession that seems to have coined the phrase “if you didn't write it, you didn't do it.” In the decade since the National Academy of Medicine's (formerly the Institute of Medicine) damning report on the research gaps in LGBTQ health, the nursing profession has made important strides in publicizing support for LGBTQ equity.3 This article offers an actionable discussion on how to create an LGBTQ-inclusive work environment for all healthcare workers.
Current US demographics attest to the unstoppable diversity of the populace. As of 2017, approximately 60.7% of Americans are non-Hispanic White, 18.1% Hispanic or Latino, 13.4% Black, 5.8% Asian, and 1.3% Native American and Alaskan Native.4 Although ethnic or racial identity is readily apparent in most cases, people typically stand at a busy intersection of multiple and overlapping identities. Although we collectively identify as nurses, we're also parents, grandparents, children, spouses, and so on. Gender identity and roles intersect with cultural and socioeconomic identities and sexual orientation. With increasing diversity, equity takes on a more nuanced interpretation.
A 2016 Gallup report estimated that 4.1% of the adult US population (approximately 10 million people) identify as LGBTQ.5 This represents a notable increase from 3.5% in 2012. Likewise, millennials (individuals born between 1980 and 1996) who identify as LGBTQ were up from 5.8% in 2012 to 7.3% in 2016. The report also noted higher LGBTQ identification among women.5 These data are significant for the nursing profession in many ways. Nursing remains a predominantly female profession, with only 9.1% of nurses being male.6 Due to the prevailing stereotype that all female nurses are heterosexual and every male nurse is presumed gay until proven otherwise, nursing is unique in the discussion of the LGBTQ spectrum. The origin of these assumptions is tied with the very name of the profession itself, equating nursing as a function of women.
Workplace protection: A brief history
Diversity and inclusion in the workplace continue to permeate American discourse. The evolutionary track of diversity and inclusion has roots in numerous legislative milestones. Notable legislative progress includes Title VII of the Civil Rights Act of 1964, which prohibits employment discrimination based on race, color, religion, sex, or national origin.7 Other vulnerable groups gained protections through the Equal Pay Act of 1963; the Age Discrimination in Employment Act of 1967; Sections 501 and 505 of the Rehabilitation Act of 1973 outlawing discrimination against qualified individuals with disabilities who work in the federal government; Titles I and V of the Americans with Disabilities Act in 1990, which prohibit employment discrimination against qualified individuals with disabilities in private businesses and in state and local governments; and the Genetic Information Nondiscrimination Act of 2008, which prohibits employment discrimination based on genetic information. It's important to note that the Department of Justice in 2017 reversed the Equal Employment Opportunity Commission's lower court position on Title VII and gender identity, explaining the law's ban on sex discrimination can't be read to protect transgender workers because “sex” at the time Title VII was passed “meant biological sex.”8
Several states have enacted laws to protect LGBTQ people in the workplace.9 Most notably, while voting to enact rules that govern their legislative body, the US House of Representatives voted in January 2019 to ban employment discrimination for LGBTQ employees for the first time in history. This represents a great leap forward for the House, but LGBTQ workers remain unprotected by federal law.10
Corporate America and LGBTQ workers
The Human Rights Campaign (HRC) publishes a Corporate Equality Index (CEI) report annually. The CEI is a nationally recognized self-reporting benchmarking tool that rates corporations on their policies pertaining to LGBTQ workers. The four key rating criteria are: nondiscrimination policies, equitable benefits for LGBTQ workers and families, internal education and accountability to promote LGBTQ inclusion, and a public commitment to LGBTQ equality.11 Of the 609 businesses rated as among the “best places to work for LGBTQ equality in 2018” (meeting every criterion with a 100% rating), only 21 were in the healthcare industry, compared with 127 law firms.10 It's notable that many of the highest scoring companies are also some of the most profitable and top-performing.11
In addition to the CEI, the HRC also publishes an annual Healthcare Equality Index (HEI), which serves as the national LGBTQ benchmarking tool to evaluate inpatient facilities' policies and practices related to the equity of their LGBTQ patients, visitors, and employees. Relevant to LGBTQ workplace inclusion, the facilities self-report policies on employment nondiscrimination, staff training, and employee benefits and policies.12 In 2018, a record 626 healthcare facilities participated in the survey. Of these, 418 earned a perfect score and were designated a “LGBTQ healthcare equality leader.”12 Hospitals have a unique challenge not only to provide LGBTQ patient-centered care, but also demonstrate commitment to upholding LGBTQ-affirmative policies for employees.
In 2011, The Joint Commission published Advancing Effective Communication, Cultural Competence, and Patient- and Family Centered Care for the Lesbian, Gay, Bisexual, and Transgender (LGBT) Community: A Field Guide. This report lays out principles and strategies for equitable treatment and inclusion of LGBT employees.13 Compliance with LGBT workplace inclusion may have indirect repercussions on facility accreditation.
Nurses, whether they identify as LGBTQ or not, have a sexual orientation, gender identity, and gender expression. There are about 4,015,250 RNs and 922,196 LPNs/LVNs in the US.14 Extrapolating from current estimates that 4.1% of the adult US population identify as LGBTQ, it can be assumed that approximately 202,435 of all RNs and LPNs/LVNs may identify as LGBTQ. Because sexual orientation and gender identity are largely invisible characteristics that require disclosure for others to be aware, the exact number of LGBTQ nurses will never be fully known because of the inherent challenges of self-disclosure.15 Of note, an HRC study reported that 46% of LGBTQ workers are “closeted” at work.16
Appearance makes the identity of some LGBTQ employees readily apparent to others. When there's no choice about whether to disclose, an inclusive workplace is especially important, particularly for transgender employees.15
Little is known about the experiences of LGBTQ nurses in spite of the fact that they may constitute one of the largest subgroups within the nursing profession.17 A 2008 national probability survey representative of the US population found that one in four LGBTQ employees reports experiencing employment discrimination in the last 5 years.18 The decision to “come out” to colleagues and/or patients (or to remain “in the closet”) is linked to a litany of negative emotions, such as anxiety, fear, rejection, and shame. From a systems standpoint, the stress experienced by LGBTQ nurses resulting from a hostile, homophobic work environment may lead to work dissatisfaction, burnout, and increased turnover, making it difficult for LGBTQ staff members to be authentic at work.15 Here we're best reminded that the essence of caring comes from bringing our authentic selves to the nurse–patient relationship.19
The impetus to cultivate a climate of inclusivity is both common sense and regulatory. It isn't difficult to imagine that a noninclusive environment is bad for any business. See Table 1 for summarized findings of a 2018 national, probability-based survey on LGBTQ workplace climate.16 In another study, disclosure of sexual orientation at work was related to discrimination and antecedent variables. Perceived discrimination was associated with negative work attitudes and fewer promotions.20
Advocating for inclusion
The AAN explicitly opposes employment discrimination based on sexual orientation and gender identity in its position statement.21 When nurses and nursing organizations support LGBTQ rights, they're, in essence, supporting their own. Efforts to increase inclusion benefit everyone. Given that the nursing profession is predominantly female, an important aspect of advancing women in the workforce is acknowledging and developing a more thorough understanding of LGBTQ women.15
Workplace inclusion leads to higher levels of job satisfaction and commitment.22 Being “out” at work correlates with a satisfying relationship with colleagues.23 LGBTQ-inclusive workplaces can increase employee engagement by allowing staff members to be authentic, spend less effort on self-editing, and reduce costs by decreasing turnover.15 When staff members feel respected, needed, and liked, they perform better. Fostering an atmosphere of sincere acceptance in the workplace can bring out the best in people. Consequently, being a better worker helps careers develop.
Magnet®-recognized organizations have provided evidence of superior outcomes for both patients and staff. However, there are no data available on how the Magnet Model promotes an LGBTQ-inclusive workplace. Magnet is grounded in transformational leadership; structural empowerment; exemplary professional practice; new knowledge, innovations, and improvements; and empirical outcomes.24 These elements frame the suggested best practices of promoting PRIDE in the workplace.
PRIDE at work
Transformational leadership calls for advocacy. The nurse leader can start by asking, “Does the organization's mission and vision demonstrate inclusivity?” Currently, 21 states and the District of Columbia prohibit employment discrimination based on sexual orientation and gender identity. Separately, eight states prohibit employment discrimination based on sexual orientation and gender identity in the public sector. Changing laws doesn't guarantee culture change. Nurse leaders are urged to exercise intentionality in creating an inclusive workplace. A good starting point is to review the latest HEI report from the HRC (www.hrc.org/hei) to see how your institution meets the benchmarks for LGBTQ employee equity. Consider the following suggestions for inclusivity, using the acronym PRIDE.
Promote support and alliance
Creating an inclusive environment requires concerted effort, focus, and structural empowerment. An inclusive workplace allows an employee to feel safe and expend more energy on work productivity and less energy covering up who they are.15 The conscious or unconscious bias healthcare workers possess potentially affects not just the way they care for patients, but also the way they treat one another. The nurse leader should support alliances between LGBTQ and non-LGBTQ staff. And staff members who choose to come “out” should be supported.
For staff members who undergo gender transition, support from leadership and staff is paramount. Nurse leaders can enforce zero-tolerance of bullying and support staff members who are bullied or witness others being bullied or discriminated against because of their sexual orientation or gender identity.1 Providing gender-neutral restrooms for staff, patients, and visitors is one of the most visible signs of an organization's commitment to inclusion.
Recruitment, retention, and resource group
Structural empowerment is one of the pillars of employee retention. Nurse leaders can reach out to LGBTQ staff to act as recruitment spokespersons or diversity champions. Hospitals can set up a booth at job fairs organized by LGBTQ organizations to enhance the diversity pool of qualified applicants. Employees who feel stressed and disengaged because of the pressure to cover up their identity are more likely to leave their job. For employers, legal vulnerability increases when employees feel disenfranchised.25
An inclusive workplace not only affects LGBTQ workers, but all employees. Open-minded employees, especially those who are a part of other minority groups, see LGBTQ inclusion as an indication of support for all minority groups. Therefore, creating an inclusive workplace can help retain more than just the LGBTQ worker. Through incremental actions such as providing LGBTQ resources and recognizing LGBTQ employees and allies on the hospital website, organizations send a clear message of embracing all workers and promote retention.
Some institutions may already have an existing LGBTQ group for employees. If none exists, nurse leaders can facilitate the creation of an LGBTQ employee resource group (ERG), which is similar to a unit practice council without the pressure. An ERG is designed to provide mentorship, assist with career development, support the facility's mission, and offer a built-in way for employees to connect with coworkers for social support.15 Through an LGBTQ ERG, champions for inclusive workplaces can be identified, mentored, and recognized for capacity building. Nursing leadership can provide a toolkit and offer guidance on how to start an ERG. Data show that companies with ERGs have positive workplace experiences and higher productivity.15
Interdisciplinary collaboration and communication
As one of the mantras of safe patient care, interprofessional collaboration is integral to sustainable workplace inclusion efforts. Buy-in from all stakeholders is essential and inclusive language is imperative. For example, a clear message that partners or spouses, regardless of sex or gender identity, are welcome at company activities sets an expectation by executive leadership. The dissemination of LGBTQ policies and programs should occupy a prominent place on the institution's website. Nurse leaders can contribute to empirical outcomes by conducting small studies on LGBTQ staff job satisfaction in collaboration with local, in-house researchers, which meets the new knowledge, innovations, and improvements domain of the Magnet Model.
Participating in LGBTQ events, such as the local Pride parade and other celebratory events, is a way for the organization to literally walk the walk. The participation of leaders, managers, or executives who identify as LGBTQ at these events is even more crucial because they can serve as role models. Company advertisements should feature diverse populations and inclusive slogans. Recognizing the accomplishments and contributions of LGBTQ nurses during Nurses Week is one way to demonstrate structural empowerment.
Education and training
Finally, education and training will help the organization disseminate innovations and new knowledge related to diversity and inclusion. Exemplary professional practice involves validation of staff competencies in LGBTQ-related issues regarding communication and collaboration. Of particular importance is employee training and updating corporate policies to reflect best practices for staff members who are in gender transition. All managers, nurse leaders, and executives should possess competencies in diversity recruitment, handling inappropriate humor and offensive jokes, inclusive communication (such as use of the employee's preferred pronoun), and how to handle breaches in policies and procedures.
Dispelling myths and stereotypes should be a key focus in staff education. Training may include exploration of historical underpinnings of LGBTQ rights, cultural competency, and health disparities based on the notion that, ultimately, we're all patients. Simulation, coaching, and mentorship are excellent active learning strategies for staff education and preceptorship. See Table 2 for a list of resources that provide materials for training and education.
Nurse leaders and allies of LGBTQ individuals have the potential to usher the future workforce into an unapologetically inclusive workplace. Transformational leaders practice to the full extent of their education to make a brave LGBTQ-inclusive workplace an everyday reality for a historically stigmatized population. Leaders who demonstrate empathy and competency will ultimately become full partners in creating an organization that's truly welcoming. The nursing profession must make strides in LGBTQ policy, practice, education, and research. Promoting PRIDE at work can be adopted as a framework to design sustainable policies and practices that embrace LGBTQ inclusion.