Presentation
PS7 - Investigating Barriers and Facilitators to Psychosocial Safety for TGNB Patients: Insights From Clinical Observations
SessionPoster Session 2
DescriptionIntroduction:
Mistreatment of and discrimination against transgender and non-binary (TGNB) patients are prevalent challenges within the healthcare system. While individual bias and discrimination certainly contribute to negative patient experiences, many of the barriers to psychosocial safety are systemic in nature. Although healthcare systems across the country offer gender-affirming care, there remain significant systemic breakdowns. These include insufficient staff training, poor healthcare facility design, and lack of appropriate processes and technology to support clinicians and staff in providing psychosocially safe care. These barriers compromise patient safety by contributing to avoidable patient suffering among one of the most vulnerable patient populations.
This study aims to identify facilitators and barriers to psychosocial safety for TGNB patients. We conducted direct observations of clinical visits for gender-affirming care and other health-related needs, as well as pre-operative care. By examining these encounters, we illuminate specific areas for improvement and provide a basis for developing actionable recommendations to enhance the safety and overall experience of TGNB patients in healthcare settings.
Methods and Materials
Direct observations were performed at gender clinic visits (appointments focused on providing gender-affirming care), non-gender clinic visits (appointments focused on needs other than gender-affirming care), and hospital-based surgical centers (pre-operative areas) in Southern California. Trained observers shadowed TGNB patients throughout their visit, starting from their arrival to their appointment and ending upon their departure. Observation notes were timestamped and documented during each observation, in real-time, to identify interactions, events, or other systemic factors contributing to a positive, negative, or neutral patient experience. Additionally, patient demographics (age, pronouns, gender identity) and visit demographics (clinic name, visit date, reason for visit) were collected for each observation.
A coding scheme was developed for the study to further classify areas within the healthcare system contributing to facilitators and barriers impacting TGNB patient psychosocial safety during visits. The classification categories included:
a) Psychosocial safety – facilitator: features of the healthcare environment that support psychological and social well-being of the patient.
b) Psychosocial safety – barrier: features of the healthcare environment that hinder the psychological or social safety of the patient.
c) Staff behavior – prosocial: actions taken by healthcare staff that promoted compassion, care, and support.
d) Staff behavior – antisocial: actions taken by healthcare staff that contributed to negative patient experience (e.g., rude, dismissive, or unkind behavior).
e) Patient clinical concerns: a request or statement made by the patient related to their medical care highlighting specific health needs or preferences.
f) Patient behavior: emotional or behavioral responses exhibited by the patient indicating discomfort, stress, or unease in the clinical setting.
g) Personal anecdotes: patient sharing personal stories or experiences during the observation that may or may not be related to their present visit.
h) Uneventful ‘normal’ clinical observations – routine interactions and events occurring within the healthcare setting.
i) Uncertain – instances where the impact on the patient’s experience is unclear or not immediately evident.
At the conclusion of the appointment, patients were asked to complete the Consultation and Relational Empathy (CARE) measure, which is a 10-item questionnaire used to measure perceived provider empathy during the visit. Each question asked the patient to rate their experience (from 1 = poor to 5 = excellent) with their healthcare provider and focus on various aspects of the interaction. Data were analyzed using descriptive statistics to calculate the number and percentage of observation notes categorized within each of the nine codes, as well as averages for patient age and observation duration.
Results
A total of 58 direct observations were performed between July 2023 to August 2024 (13 months) across thirteen clinics and hospital-based surgical centers in Southern California. The age range for patients observed was between 14 to 72 years of age, with an average age of 33. The average observation duration was 52.44 minutes. Of the 58 observations, 19 (32.76%) were conducted during clinical appointments for gender-affirming care, 19 (32.76%) were performed during non-gender-affirming clinical visits for care involving other health needs (e.g., kidney stones, allergies, geriatric medication, etc.), and the remaining 20 (34.48%) observations involved observing a patient’s journey through pre-operative care prior to receiving gender-affirming surgery.
Across the 58 observations, a total of 720 observation notes were documented. Of these, 397 (55.14%) were general notes documenting interactions between clinical staff and patients or events occurring during each visit (e.g., vitals, changing into hospital gowns, etc.). 135 (18.75%) instances of psychosocial safety facilitators were documented during clinical or pre-operative visits. The facilitators included positive interactions between clinical staff and patients (e.g., use of correct pronouns or lived name, providing a safe space to discuss gender health or identity), or aspects of the environment that promoted inclusivity and privacy through hospital design (e.g., adequate distance between the check-in counter and waiting room seats, thickness of exam room walls that reduced noise/overhearing other conversations, restrooms marked with blank white triangle, etc.). Eighty-five instances (11.81%) of psychosocial safety barriers were documented. Some examples of these barriers involved challenges with technology (e.g., patient’s chart included their dead name, gender identity was not available as an option in EPIC), the design of the built environment (e.g., lack of privacy during appointment check-in, conversations in other exam rooms could be heard), or negative experiences with clinical staff (e.g., use of incorrect pronouns or deadnames, inappropriate conversations between staff). The remaining 103 observation notes included personal anecdotes shared by patients (n=48, 6.67%), prosocial (n=28, 3.89%) or antisocial (n=6, 0.83%) behavior exhibited by clinical staff, and emotions (n=16, 2.22%) or clinical concerns (n=5, 0.69%) expressed by the patient during the visit.
A total of 35 CARE measure questionnaires were completed capturing patients’ perceptions of empathy across various healthcare providers. The scores were distributed as follows: physicians (n=25, average score = 42.76), nurses (n=5, average score = 43.4 ), speech language pathologists (n=2, average score = 50), nurse practitioners (n=1, average score = 33), physical therapists (n=1, average score = 50), and other clinical staff (n=1, average score = 45). When broken down by visit type, patients attending gender-affirming care (n=10) reported an average CARE measure score of 46.80, while other clinic visits (n=25) had an average score of 41.84).
Conclusions
Findings from direct observations of TGNB patients during clinical or surgical visits revealed various breakdowns within the healthcare system contributing to psychosocial patient harm. Based on these findings, we propose several recommendations for improving the clinical work-system: redesigning electronic health records to ensure that updated demographic and health information is easily accessible and accurately reflected for all users could reduce the use of incorrect pronouns or names, as well as minimizing the occurrence of inappropriate or inaccurate questions regarding gender health – especially if combined with comprehensive training programs and other resources to support gender affirming care in all healthcare interactions. Additionally, improving the physical design of clinics and hospital environments could create more inclusive and welcoming spaces for TGNB patients. Such changes could involve implementing gender-neutral restrooms and creating private areas for sensitive health discussions.
Mistreatment of and discrimination against transgender and non-binary (TGNB) patients are prevalent challenges within the healthcare system. While individual bias and discrimination certainly contribute to negative patient experiences, many of the barriers to psychosocial safety are systemic in nature. Although healthcare systems across the country offer gender-affirming care, there remain significant systemic breakdowns. These include insufficient staff training, poor healthcare facility design, and lack of appropriate processes and technology to support clinicians and staff in providing psychosocially safe care. These barriers compromise patient safety by contributing to avoidable patient suffering among one of the most vulnerable patient populations.
This study aims to identify facilitators and barriers to psychosocial safety for TGNB patients. We conducted direct observations of clinical visits for gender-affirming care and other health-related needs, as well as pre-operative care. By examining these encounters, we illuminate specific areas for improvement and provide a basis for developing actionable recommendations to enhance the safety and overall experience of TGNB patients in healthcare settings.
Methods and Materials
Direct observations were performed at gender clinic visits (appointments focused on providing gender-affirming care), non-gender clinic visits (appointments focused on needs other than gender-affirming care), and hospital-based surgical centers (pre-operative areas) in Southern California. Trained observers shadowed TGNB patients throughout their visit, starting from their arrival to their appointment and ending upon their departure. Observation notes were timestamped and documented during each observation, in real-time, to identify interactions, events, or other systemic factors contributing to a positive, negative, or neutral patient experience. Additionally, patient demographics (age, pronouns, gender identity) and visit demographics (clinic name, visit date, reason for visit) were collected for each observation.
A coding scheme was developed for the study to further classify areas within the healthcare system contributing to facilitators and barriers impacting TGNB patient psychosocial safety during visits. The classification categories included:
a) Psychosocial safety – facilitator: features of the healthcare environment that support psychological and social well-being of the patient.
b) Psychosocial safety – barrier: features of the healthcare environment that hinder the psychological or social safety of the patient.
c) Staff behavior – prosocial: actions taken by healthcare staff that promoted compassion, care, and support.
d) Staff behavior – antisocial: actions taken by healthcare staff that contributed to negative patient experience (e.g., rude, dismissive, or unkind behavior).
e) Patient clinical concerns: a request or statement made by the patient related to their medical care highlighting specific health needs or preferences.
f) Patient behavior: emotional or behavioral responses exhibited by the patient indicating discomfort, stress, or unease in the clinical setting.
g) Personal anecdotes: patient sharing personal stories or experiences during the observation that may or may not be related to their present visit.
h) Uneventful ‘normal’ clinical observations – routine interactions and events occurring within the healthcare setting.
i) Uncertain – instances where the impact on the patient’s experience is unclear or not immediately evident.
At the conclusion of the appointment, patients were asked to complete the Consultation and Relational Empathy (CARE) measure, which is a 10-item questionnaire used to measure perceived provider empathy during the visit. Each question asked the patient to rate their experience (from 1 = poor to 5 = excellent) with their healthcare provider and focus on various aspects of the interaction. Data were analyzed using descriptive statistics to calculate the number and percentage of observation notes categorized within each of the nine codes, as well as averages for patient age and observation duration.
Results
A total of 58 direct observations were performed between July 2023 to August 2024 (13 months) across thirteen clinics and hospital-based surgical centers in Southern California. The age range for patients observed was between 14 to 72 years of age, with an average age of 33. The average observation duration was 52.44 minutes. Of the 58 observations, 19 (32.76%) were conducted during clinical appointments for gender-affirming care, 19 (32.76%) were performed during non-gender-affirming clinical visits for care involving other health needs (e.g., kidney stones, allergies, geriatric medication, etc.), and the remaining 20 (34.48%) observations involved observing a patient’s journey through pre-operative care prior to receiving gender-affirming surgery.
Across the 58 observations, a total of 720 observation notes were documented. Of these, 397 (55.14%) were general notes documenting interactions between clinical staff and patients or events occurring during each visit (e.g., vitals, changing into hospital gowns, etc.). 135 (18.75%) instances of psychosocial safety facilitators were documented during clinical or pre-operative visits. The facilitators included positive interactions between clinical staff and patients (e.g., use of correct pronouns or lived name, providing a safe space to discuss gender health or identity), or aspects of the environment that promoted inclusivity and privacy through hospital design (e.g., adequate distance between the check-in counter and waiting room seats, thickness of exam room walls that reduced noise/overhearing other conversations, restrooms marked with blank white triangle, etc.). Eighty-five instances (11.81%) of psychosocial safety barriers were documented. Some examples of these barriers involved challenges with technology (e.g., patient’s chart included their dead name, gender identity was not available as an option in EPIC), the design of the built environment (e.g., lack of privacy during appointment check-in, conversations in other exam rooms could be heard), or negative experiences with clinical staff (e.g., use of incorrect pronouns or deadnames, inappropriate conversations between staff). The remaining 103 observation notes included personal anecdotes shared by patients (n=48, 6.67%), prosocial (n=28, 3.89%) or antisocial (n=6, 0.83%) behavior exhibited by clinical staff, and emotions (n=16, 2.22%) or clinical concerns (n=5, 0.69%) expressed by the patient during the visit.
A total of 35 CARE measure questionnaires were completed capturing patients’ perceptions of empathy across various healthcare providers. The scores were distributed as follows: physicians (n=25, average score = 42.76), nurses (n=5, average score = 43.4 ), speech language pathologists (n=2, average score = 50), nurse practitioners (n=1, average score = 33), physical therapists (n=1, average score = 50), and other clinical staff (n=1, average score = 45). When broken down by visit type, patients attending gender-affirming care (n=10) reported an average CARE measure score of 46.80, while other clinic visits (n=25) had an average score of 41.84).
Conclusions
Findings from direct observations of TGNB patients during clinical or surgical visits revealed various breakdowns within the healthcare system contributing to psychosocial patient harm. Based on these findings, we propose several recommendations for improving the clinical work-system: redesigning electronic health records to ensure that updated demographic and health information is easily accessible and accurately reflected for all users could reduce the use of incorrect pronouns or names, as well as minimizing the occurrence of inappropriate or inaccurate questions regarding gender health – especially if combined with comprehensive training programs and other resources to support gender affirming care in all healthcare interactions. Additionally, improving the physical design of clinics and hospital environments could create more inclusive and welcoming spaces for TGNB patients. Such changes could involve implementing gender-neutral restrooms and creating private areas for sensitive health discussions.
Authors
Event Type
Poster Presentation
TimeTuesday, April 14:45pm - 6:15pm EDT
LocationFrontenac Foyer