DEIB Case Study: Providing Gender-affirming Care (Nursing)

by Jacquelyn McMillian-Bohler, PhD, CNM

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    00:01 Hi, I'd like to introduce you to our next case.

    00:04 This is Michael. Michael is a 25-year-old client who presents to the obstetric unit reporting back and abdominal discomfort.

    00:13 Michael is requesting to be referred to as "he" by the staff.

    00:17 Michael's very upset because his wristband says that he is a female.

    00:22 He reports being 36 weeks pregnant, and he has the onset of "what feels like contractions." And these contractions started about an hour ago.

    00:31 And they're in his low back, and they were occurring about every five minutes.

    00:36 Michael was given a maternal pre-admission form to fill out when he arrived on the unit.

    00:41 It asked questions about what type of medications.

    00:44 He was taking before and during pregnancy.

    00:46 Michael reported he was taking testosterone, which he discontinued about four months prior to achieving pregnancy.

    00:53 He is a Gravida 1, P 0.

    00:56 He has lots of questions about some of the content on the form.

    00:59 And it's very difficult for him to answer some of the questions.

    01:03 He's very anxious. As he reports traveling from out of state.

    01:08 The nurse prepares to perform a vaginal exam to determine where Michael is in labor.

    01:14 Now let's take all that information that we just collected in Michael's history.

    01:19 We're going to highlight the findings that require immediate follow up by the nurse.

    01:24 This time we want to focus on gender affirming, or gender inclusive language in our care.

    01:31 Let's go through them one by one and really unpack what should be highlighted.

    01:36 Michael requests that he be referred to as "he".

    01:40 However, on his wristband, it lists him as a female.

    01:44 All of that should be highlighted.

    01:46 When a client requests to use pronouns, he, she, they or something else, it's important that we honor that, because that allows the client to feel like they belong on the unit.

    01:58 It's just like, if your name is Mary, and someone calls you, Jim, that wouldn't be okay.

    02:03 So whatever the client prefers to be called, or whatever the client uses, as their pronoun is what we should use.

    02:11 Michael is 36 weeks, and he has the onset of what feels like contractions.

    02:15 They started about an hour before he arrives.

    02:17 So certainly this is important in terms of his medical care.

    02:21 But this is not really related to gender affirming care.

    02:24 So we won't highlight that one in this case.

    02:27 Next, Michael was given a maternal pre-admission form.

    02:32 Maternal, which goes along with the feminine gender pronouns.

    02:37 So we want to make sure that whenever we're giving anyone a form in a maternal unit, that we use gender inclusive language, on the top of that form, and all the way throughout that form.

    02:50 Remember, we're going for a sense of belonging.

    02:53 Michael did report that he was taking testosterone, which he discontinued about four months prior to pregnancy.

    02:59 Now, this is important to note in the general sense of things, but since it was stopped before pregnancy, then we're not concerned about any effects to the fetus.

    03:07 So this does not need to be highlighted at this time.

    03:11 In the next item, we learn that Michael is having some difficulty completing the form.

    03:16 Now, if this case were only about maternity care, in general, then we might not highlight this item.

    03:23 But again, having questions on a form that are unable to be completed because they're not gender affirming, that's a problem.

    03:31 Therefore, this should be highlighted as well.

    03:33 And the last bullet, Michael appears anxious.

    03:37 He's traveling from out of state. That part not unusual.

    03:41 That would make everyone anxious.

    03:43 However, the nurse says that she is about to perform a vaginal exam.

    03:49 There's the language again.

    03:51 Vaginal refers to female anatomy.

    03:54 So for Michael who identifies as a male, he may not use the word vagina.

    03:59 So it's very important that whenever we're talking to a new client, that we ask them, "What are the words you use to describe your anatomy?" That is how we are gender affirming, and gender inclusive.

    04:13 After the pelvic exam, the nurse notifies the healthcare provider that the client is in active labor.

    04:20 And then the healthcare provider writes some orders.

    04:24 The Standing Orders are for vital signs, starting the fetal heart rate monitor, admitting Michael for labor and obtaining IV access.

    04:33 In the next question, we're going to determine whether Michael is at risk or not at risk for the following barriers while he's receiving care.

    04:41 Here's the long list.

    04:43 Let's go through each one of these individually and determine what Michaels at risk for.

    04:49 I'm going to pause for a second here and give you just a minute to look at each of these situations and determine on your own if you You think Michael is at risk or not at risk.

    05:06 Now let's see which answers are correct? Is Michael at risk for a lack of specialty knowledge from health care providers? Absolutely.

    05:15 Transgender persons all over the country and all over the world are constantly at risk for the lack of knowledge of the healthcare system.

    05:24 Risk of traumatization.

    05:26 Yes, Michael is also at risk for this.

    05:29 We've already discussed one incident. The vaginal exam.

    05:33 But there are lots of opportunities for events and traumatization on an obstetrical unit.

    05:39 Denial of care due to gender diversity.

    05:42 Michael is not at risk for this particular situation, because of the Affordable Care Act.

    05:47 The Act allows for everyone regardless of gender identity to receive the full spectrum of care.

    05:54 A non inclusive environment is Michael at risk for this.

    05:58 Absolutely. There are going to be many instances in terms of non gender affirming language, non gender inclusive language.

    06:06 People who stigmatize others that are different from them that are going to occur all over the place.

    06:11 Definitely at risk for this one.

    06:13 Involvement with protective Child Services.

    06:16 Again, the Affordable Care Act specifically talks about this and protects transgender persons from any situation that would involve Child Protective Services.

    06:25 Denial of insurance coverage for the delivery.

    06:28 Absolutely not. All deliveries will be covered, regardless of gender identity.

    06:33 So Michael is not at risk for this.

    06:37 So again, let's look at the risk for, and then not at risk for answers for Michael.

    06:44 Based on the information we've covered so far, let's look at a different question.

    06:51 The nurse determines that Michael is most at risk for experiencing blank from the healthcare staff due to blank.

    06:59 Take a moment and look at both option one and two, and decide what answers you would place in the box.

    07:12 So let's look at each option to determine which one is correct.

    07:15 So under Option one, a delay in care.

    07:19 Well, Michael's already here for labor.

    07:22 So, this is likely not the right answer.

    07:25 A decrease in the quality of care.

    07:27 We've already experienced several episodes where the staff have not used the correct anatomical terms, or had the correct forms that were gender affirming.

    07:37 So there are definitely some issues around knowledge that are affecting quality of care.

    07:42 Maybe you've peeked over at Option two when you see knowledge deficits.

    07:46 We might want to hold on to that answer.

    07:48 But let's keep going.

    07:50 An adverse event.

    07:51 Is it possible that Michael could experience an adverse event? Sure. But does that beat quality of care? Nope, it doesn't.

    08:01 So quality of care definitely is the correct answer for Option one.

    08:06 Now let's look at Option two.

    08:08 You already noted that knowledge deficits certainly apply here.

    08:13 But let's look at the other two answers.

    08:15 Barriers to insurance providers.

    08:17 The Affordable Care Act protected us from that.

    08:20 So that is not the correct answer.

    08:22 And social stigma.

    08:23 Social stigma is certainly an issue for transgender people, but it's usually related to delaying health care, which is not an issue in this case.

    08:32 So the correct answer to this question is that the nurse determines the client is most at risk for experiencing a decrease in quality of care from the healthcare staff due to knowledge deficits.

    08:46 For the next set of questions, we will determine what are the most immediate and effective ways for overcoming the identified barriers and providing care to the client? We have four options in this case.

    09:01 So let's look at each one individually.

    09:04 Seek out gender diverse educational resources.

    09:08 Well, certainly this is important.

    09:10 However, we're looking for immediate ways to address the issues.

    09:14 And this will take a little time.

    09:16 So this answer will not work.

    09:18 The next option, interview the client regarding preferences.

    09:23 If it's a choice, you should always choose it.

    09:26 Interviewing the client means that we are asking for preferences and being willing to follow along.

    09:32 This will always get us to the right place.

    09:35 Doesn't allow for assumptions or anything else.

    09:38 Interviewer. Ask. Yes. Yes. Yes.

    09:41 So let's look at the other options.

    09:43 Apologize ahead of time that the preferred terminology will likely be misused.

    09:49 So asking ahead of time to do something that is offensive does not make it okay. So this is not the correct answer.

    09:57 And finally referenced previous electronic medical records.

    10:01 Well, that might provide information on previous health conditions, but it may not provide the information that we want to know about this particular client's wants and needs.

    10:12 Remember, we're talking about gender affirming care, and those needs may change.

    10:17 So we need to ask the client every time, every visit.

    10:20 So this is also not the correct answer.

    10:23 Interview the client? Yes, yes, yes.

    10:27 Michael's labor has progressed. He is now 8 centimeters.

    10:32 And he is requesting that the nurse use the term front pelvic opening rather than vaginal opening.

    10:37 His vitals remain stable, and his TOCO diameter or fetal monitor is still in place.

    10:44 The contractions are now two to three minutes apart.

    10:47 Now we have a new nurse coming on shift.

    10:50 So let's look at the quotations to see if our nurse is giving gender affirming communication with the new nurse.

    10:58 Look at this list and see which of these statements complies with gender affirming care.

    11:11 Now let's go through each one individually.

    11:14 The nurse says, "I call the information technology to have the chart flag to notify staff that the client identifies as 'he'." Should the nurse do this? Absolutely.

    11:27 The Maternal heart rate has been stable between 80 to 100 beats per minute.

    11:32 The first thing you might see in this statement is the heart rate It is within normal limits However the issue here is the term "maternal" We often default to feminin terms such as "maternal" Michael identifies as male, therefore the gender affirming term should be "paternal" This is seemingly a benign statement but this would be incorrect, even in conversations between colleagues.

    11:56 The significant other is currently at the bedside.

    11:59 Significant Other. It does not identify gender language.

    12:03 So it's not binary. It's open.

    12:06 Definitely want to check this one.

    12:09 The client identifies as transgender.

    12:11 It it asked about chest feeding the baby, 'it'.

    12:16 Definitely not gender affirming.It should not be checked.

    12:19 And finally, I completed the cervical exam through the front pelvic opening.

    12:25 Remember, this is the terminology that Michael requested.

    12:28 So this is a gender affirming communication statement.

    12:32 These are the options that are correct.

    12:35 Michael has had his baby.

    12:38 And so now let's take a peek and see what's going on.

    12:43 He delivered a healthy baby through his pelvic opening.

    12:47 Skin to skin contact was immediately initiated and the client was evaluated after delivery and everything is going well.

    12:56 Michael responded that initially.

    12:58 He was very uncomfortable when he received a wristband that identified him as a female.

    13:03 He was also given a form that displayed maternal instead of paternal.

    13:09 Maternal is not how he describes himself.

    13:12 He also stated he understood that it could be confusing, but he was glad the wristband was able to be fixed.

    13:19 He also felt like everyone was trying to do their best to be respectful to someone who identifies as trans.

    13:26 He was especially appreciative of the correct use of terminology, and that showed respect for his body.

    13:33 Look at the statements provided here and determine which statements affirm that Michael perceives that he received gender affirming care.

    13:45 Now, let's break down the answer.

    13:47 The first statement, Michael says, "I understand it can be confusing, and I'm glad the wristband was fixed quickly and I was given an apology." This is a positive statement.

    13:58 Michael acknowledges that a mistake was made.

    14:01 But he also feels better that he was given an apology and the error was corrected.

    14:07 The next statement.

    14:08 "I especially liked how terminology was used to fit and respect my body." Again, a positive response. Michael feels heard and respected.

    14:19 And the next statement, Michael says, "I feel like everyone was trying to do their best to be respectful to someone who was trans." Michael is appreciative that the staff was respectful regardless of his gender identity and diversity, Another positive statement.

    14:35 Finally, maternal is not how I would describe myself.

    14:39 Remember the admission form. Maternal, not paternal.

    14:44 That is not how Michael identifies.

    14:46 So this would not be an example of providing gender affirming care.

    14:52 Here's the final list.

    About the Lecture

    The lecture DEIB Case Study: Providing Gender-affirming Care (Nursing) by Jacquelyn McMillian-Bohler, PhD, CNM is from the course NGN DEIB Case Studies.

    Author of lecture DEIB Case Study: Providing Gender-affirming Care (Nursing)

     Jacquelyn McMillian-Bohler, PhD, CNM

    Jacquelyn McMillian-Bohler, PhD, CNM

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