Primary care in Northern Ontario for transgender people in the context of the COVID-19 pandemic: A qualitative secondary analysis.

PURPOSE: To examine changes to primary care practice for transgender clients resulting from government mandated public health measures in response to COVID-19 in Northern Ontario. DESIGN: Secondary analysis of qualitative data using interview transcripts from a dataset that included 15 interviews conducted between October 2020 and April 2021. METHODS: The dataset came from a convergent mixed method study exploring the delivery of primary care services to transgender individuals in Northern Ontario. Qualitative interviews with primary care practitioners including nurse practitioners, nurses, physicians, social workers, psychotherapists, and pharmacists providing care for transgender people in Northern Ontario were included in the secondary analysis. RESULTS: Fifteen primary care practitioner providing care to transgender individuals in Northern Ontario participated in the parent study. Practitioners described their understanding of the effect of the early stages of the COVID-19 pandemic changes on their practice and the care experience for their transgender patients. Two themes were identified and described by participants: (1) a change in the delivery of care; and (2) barriers and facilitators to care. CONCLUSIONS: Practitioners' primary care experiences in the early waves of COVID suggest the integral use of telehealth in Northern Ontario transgender care. Nurses working in advance practice and nurse practitioners are essential in providing continuity of care for their transgender clients. CLINICAL RELEVANCE/SIGNIFICANCE: Identification of initial practice changes for the primary care of trans people will illuminate avenues for further research. The urban, rural, and remote practice settings in Northern Ontario provide an opportunity for increasing access for gender diverse people in these areas and for developing increased understanding of uptake of telemedicine practice. Nurses are integral to primary care for transgender patients in Northern Ontario.

Developing a comprehensive curriculum program for nurse practitioners delivering primary care in the long-term care setting.

In the Long-Term Care (LTC) setting, comprehensive primary care is often provided by Nurse Practitioners (NPs). NPs are uniquely positioned to meet the evolving primary care needs of LTC residents. However, caring for this population requires additional education and training due to its special considerations. To meet the learning needs of NPs entering the LTC workplace, a Certificate Program was designed to enhance primary care competencies within the LTC setting. The aim of the program is to increase knowledge, capacity, and confidence of NPs to deliver quality, evidence-based, integrated, and interprofessional primary care to LTC residents. This curriculum is anticipated to address the growing need for LTC services and improve the delivery of high-quality primary care.

Improving Student Perceptions of Simulation Effectiveness With Co-Facilitation From Prebriefing Through Debriefing.

ABSTRACT: Co-facilitation (combining presence and expertise of clinical faculty and simulationists during all stages of simulation) presents an opportunity to improve student perceptions of effectiveness. Using a retrospective before and after comparison, data on students' perceptions were collected from baccalaureate nursing students in clinical courses after each simulation experience. Mean differences in Simulation Effectiveness Tool-Modified scores for pre- and post-implementation were compared, as well as scores between levels of students. Statistically significant improvements in student-rated simulation effectiveness were found with co-facilitation. The authors recommend future studies expanding this methodology and considering co-facilitation where feasible.

Response and innovations of advanced practice nurses during the COVID-19 pandemic: A scoping review.

AIM: Identify and map international evidence regarding innovations led by or involving advanced practice nurses in response to COVID-19. BACKGROUND: COVID-19 necessitated unprecedented innovation in the organization and delivery of healthcare. Although advanced practice nurses have played a pivotal role during the pandemic, evidence of their contributions to innovations has not been synthesized. Evidence is needed to inform policies, practices, and research about the optimal use of advanced practice nurses. METHODS: A scoping review was conducted and reported using the PRISMA-ScR checklist. Electronic databases were searched for peer-reviewed articles published between January 2020 and December 2021. Papers were included that focused on innovations emerging in response to COVID-19 and involved advanced practice nurses. RESULTS: Fifty-one articles were included. Four themes were identified including telehealth, supporting and transforming care, multifaceted approaches, and provider education. Half of the articles used brief and mostly noncomparative approaches to evaluate innovations. CONCLUSION: This is the first synthesis of international evidence examining the contributions of advanced practice nurses during the pandemic. Advanced practice nurses provided leadership for the innovation needed to rapidly respond to healthcare needs resulting from COVID-19. Innovations challenged legislative restrictions on practice, enabled implementation of telehealth and new models of care, and promoted evidence-informed and patient-centered care. IMPLICATIONS FOR PRACTICE: Advanced practice nurses led, designed, implemented, and evaluated innovations in response to COVID-19. They facilitated the use of telehealth, supported or transformed models of care, and enabled health providers through education, mentorship, and mental health support. IMPLICATION FOR POLICY: Advanced practice nurses are a critical resource for innovation and health system improvement. Permanent removal of legislative and regulatory barriers to their full scope of practice is needed.

The integral role of nurses in primary care for transgender people: A qualitative descriptive study.

AIM: To understand nursing activities, training and key supports needed to provide primary care to transgender individuals. BACKGROUND: Discrimination, limited practitioner knowledge and a deficiency of services contribute to health care barriers for transgender individuals. Literature demonstrating how primary care services are delivered, and more specially the role of nurses in this care, is lacking. METHODS: Qualitative description methodology and interviews were used to describe this phenomenon. Participants included nurse practitioners, registered nurses and registered practical nurses. RESULTS: Nurses are important in providing primary care to transgender individuals. While NPs worked to full scope of practice, RNs' and RPNs' roles could be optimized. A key challenge was lack of education; however, mentorship and collaboration contributed to competency development. Ensuring the workplace provided gender-affirming care was key to a safe and inclusive environment. CONCLUSIONS: Supporting nurses to develop capacity and work to full scope of practice can improve access to care. Ongoing opportunities for mentorship and ensuring an inclusive workplace will aid in the provision of care for this vulnerable population. IMPLICATIONS FOR NURSING MANAGEMENT: Development of organisational policies, staff training and appropriate supports, for role optimization and team collaboration, can eliminate barriers experienced by transgender individuals.

Implementing Strengths-Based Nursing and Healthcare Leadership Values to Promote Equitable, Diverse and Inclusive Workplaces: A Guide for Healthcare Leaders.

Inequities in healthcare persist despite equity, diversity and inclusion (EDI) being embedded in the nursing code of ethics (CNA 2017). Strengths-Based Nursing and Healthcare Leadership (SBNH-L) is "a unique, value-driven, embodied approach that guides leaders and managers to create equitable and safe workplace cultures and environments that honour, develop, mobilize and capitalize on the strengths of individuals and their team" (Gottlieb et al. 2021a: 173) that can be used as a framework to promote EDI in the workplace. Herein, we present concrete suggestions for focusing on EDI through an SBNH-L lens in order to improve healthcare environments for practitioners.

Cancer Screening and Prevention in the Transgender and Gender Diverse Population: Considerations and Strategies for Advanced Practice Nurses.

OBJECTIVES: This discussion paper presents recent evidence regarding cancer screening and prevention among the transgender and gender diverse (TGD) community and highlights where and how advanced practice nurses (APNs), particularly those in primary care, can better contribute to closing the gap between healthcare disparities between TGD and cisgendered populations. METHODS: Relevant publications on the topic and professional guidelines and evidence have formed the basis for this discussion paper. RESULTS: TGD individuals are a vulnerable population with unique needs. They remain at risk of cancer and might be at greater risk of developing some cancers compared to cisgendered people but are underscreened. Barriers to gender-affirming care need to be addressed to improve access to prevention and screening services and improve the cancer care experiences and outcomes of TGD people. CONCLUSION: APNs can work in collaboration with TGD individuals and the healthcare system to improve access to culturally safe cancer screening and more effective prevention of cancer and poor cancer outcomes. IMPLICATIONS FOR NURSING PRACTICE: APNs have the potential to improve access to cancer screening for TGD people by increasing their understanding of the needs of the population, providing culturally safe care, and advocating for more preventative care and cancer screening. With greater knowledge and understanding of the needs and preferences of TGD people both broadly and in relation to cancer screening and prevention, targeted interventions and care approaches can be implemented. APNs should also aim to conduct evaluations and research into cancer prevention and screening to build the currently limited evidence base and nursing knowledge in this important field.

Factors influencing nurse practitioner panel size in team-based primary care: a qualitative case study.

BACKGROUND: Lack of access to health care is a worldwide public health crisis. In primary care it has led to increases in the implementation of nurse practitioners and heightened interest in their patient panel capacity. The aim of this study was to examine factors influencing nurse practitioner patient panel size in team-based primary care in Ontario, Canada. METHODS: We used a multiple case study design. Eight team-based primary care practices including rural and urban settings were purposively selected as cases. Each case had two or more nurse practitioners with a minimum of two years experience in the primary care setting. Interviews were conducted in-person, audio recorded, transcribed and analysed using content analysis. RESULTS: Forty participants, including 19 nurse practitioners, 16 administrators (inclusive of executives, managers, and receptionists), and 5 physicians were interviewed. Patient, provider, organizational, and system factors influenced nurse practitioner patient panel size. There were eight sub-factors: complexity of patients' health and social needs; holistic nursing model of care; nurse practitioner experience and confidence; composition and functioning of the multidisciplinary team; clerical and administrative supports, and nurse practitioner activities and expectations. All participants found it difficult to identify the panel size of nurse practitioners, calling it- "a grey area." Establishing and maintaining a longitudinal relationship that responded holistically to patients' needs was fundamental to how nurse practitioners provided care. Social factors such as gender, poverty, mental health concerns, historical trauma, marginalisation and literacy contributed to the complexity of patients' needs. Participants indicated NPs tried to address all of a patient's concerns at each visit. CONCLUSIONS: Nurse practitioners have a holistic approach that incorporates attention to the social determinants of health as well as acute and chronic comorbidities. This approach compels them to try to address all of the needs a patient is experiencing at each visit and reduces their panel size. Multidisciplinary teams have an opportunity to be deliberate when structuring their services across providers to meet more of the health and social needs of empanelled patients. This could enable increases in nurse practitioner panel size.

Barriers and facilitators for accessing and prescribing hormone therapy in primary care for transgender adults: a scoping review protocol.

OBJECTIVE: The objective of this scoping review is to understand the extent and type of evidence in relation to barriers and facilitators experienced by transgender adults in accessing hormone therapy. It will also explore the experiences of primary care practitioners in prescribing hormone therapy in primary care. INTRODUCTION: Providing care to transgender patients is a rapidly growing area of primary care. Despite the existence of clinical practice guidelines that support the prescription of gender-affirming hormone therapy in primary care, only a small number of primary care providers are offering this care. This review will seek to advance research on this topic by examining the barriers and facilitators of hormone prescription for transgender adults in primary care. INCLUSION CRITERIA: This review will consider research on primary care practitioners who prescribe hormone therapy to transgender adults. It will also focus on transgender adults who seek hormone therapy in primary care. Only studies that examine barriers and facilitators in primary care will be included. The review will include qualitative, quantitative, and mixed methods studies, in addition to systematic reviews and meta-analyses. METHODS: The search will include MEDLINE, CINAHL, EmCare, and Nursing and Allied Health Premium. No date limits will be applied to the search. Only articles written in English will be eligible for inclusion. Articles will be reviewed and data extracted by 2 independent reviewers. The results of the extracted data will be presented in a narrative summary with accompanying tables.

Advancing Access to Quality LGBTQIA+ Health Care: Gender Discrimination, Socio-Cultural, and Mental Health Issues: A Mixed-Method Study.

Recent research highlights the lack of knowledge and reduced skills of health care professionals in communicating with people from the LGBTQIA+ community. This often occurs due to reduced continuing education on social issues in the health sector. The purpose of this research was to study the readiness of health care professionals to manage the social and mental health issues of the LGBTQIA+ community. In particular, the cultural competence of health care professionals targeted at gender identity, the recognition of the level of mastery of soft skills, and the relevant experiences of the participants were studied. For the purposes of conducting this research, a mixed methodology was used to pursue an in-depth study of human beliefs, attitudes, perceptions, ideas, and experiences. More specifically, a previously validated research tool was used to measure cultural competence and assess soft skills. At the same time, interviews were conducted with health care professionals for a more complete understanding of their skills and attitudes. The study comprised a quantitative study involving 479 health care professionals and a qualitative study involving 20 health care professionals, with results from each study. The results showed that the health care professionals' knowledge of the LGBTQIA+ community is sufficient, but their skills and attitudes towards gender diversity are limited. In addition, the level of acquisition of soft skills by health care professionals is low, and there is insufficient training for health care professionals with regards to social issues. In conclusion, a targeted and structured educational intervention for health care professionals is required to avoid future unfortunate behaviours, and to ensure that the health care provided to healthy and sick populations, regardless of sexual orientation, is adequate.

Wound management provided by advanced practice nurses: a scoping review.

OBJECTIVE: The objective of the review was to map the similarities and differences in the wound care practices of nurse practitioners, clinical nurse specialists, and advanced practice registered nurses, globally. INTRODUCTION: Advanced practice nurses have graduate education and advanced scope of practice. Adding advanced wound care training to their skillset provides an opportunity for advanced practice nurses to provide wound care. INCLUSION CRITERIA: This review considered for inclusion advanced practice nurses globally who are registered nurses with graduate-level education and advanced training (certification/education) in wound care in any setting. METHODS: The review was conducted using JBI methodology for scoping reviews. The databases searched included MEDLINE, CINAHL, ProQuest Nursing and Allied Health, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Scopus, and ProQuest Dissertations and Theses. To reflect changes in the advanced practice nursing scope of practice, searches were limited to articles published from 2011. Articles in languages other than English were translated. Two reviewers independently reviewed titles and abstracts; relevant sources were retrieved in full and reviewed. An additional independent reviewer resolved any disagreements. Data were extracted using a data extraction tool. Extracted data included similarities and differences in wound care practice (type of wound, practice setting, treatments). RESULTS: There were 2504 abstracts screened, and 158 were screened at full text. Seven articles were included in this review: 3 sources from the United States, 2 from Australia, and 1 each from Canada and The Netherlands. All 7 sources focused on nurse practitioners; wound care education varied from certification in wound ostomy to a master's education in wounds. The practice setting varied; there were 2 primary care clinics; 2 community clinics; 1 wound care center; a suburban hospital, and a study that included tertiary, community, and residential care. Treatments varied, but sources specific to pressure injuries discussed assessments, cleansing, dressings, topical products, and offloading surfaces/equipment, and 1 examined the impact of hiring nurse practitioners as wound care consultants. Sources that discussed treatments for various wounds described comprehensive assessments, diagnostic investigations, referrals, wound management, and medications prescribed. Outcomes included improved healing, decreased incidence, increased patient satisfaction, access to care, and reduced referrals for additional care. CONCLUSIONS: This review outlined the characteristics of advanced practice nurses and their practice settings, types of wounds, and treatments provided. The findings demonstrated positive results with advanced practice nurses providing wound care. Many articles regarding advanced practice nurses with advanced wound care expertise lack the description of the graduate-level education and/or the specifics regarding wound care certification. This prevents comparison of advanced practice nurses with each other and other providers on the impact that advanced practice nurses have on the health care system in relation to wound care, including cost, access to services, and patient satisfaction.

Retention of Canadian Advanced Practice Nurses: What Will It Take?

The retention of Canada's advanced practice nurses (APNs), including clinical nurse specialists and nurse practitioners, is a national health human resources issue. APNs are essential within the Canadian healthcare workforce for meeting patient and population health needs, often in underserved communities. A shortage of APNs will exacerbate barriers to access to care for patients across sectors, including primary, acute, long-term and transitional care settings. This paper provides highlights from literature reporting on the state of APN human resources in Canada, including influential barriers and facilitators, and recommendations for retaining these important leaders in the healthcare workforce.

Sexual Dysfunction in Gay and Bisexual Prostate Cancer Survivors: A Concept Analysis.

Sexual dysfunction is a common side effect of prostate cancer (PCa) treatment, yet it remains poorly defined in the literature. Current definitions are based on heteronormative assumptions which do not consider the unique experiences of gay and bisexual (GBM) PCa survivors. The purpose of this paper is to use Walker and Avant's method to conduct a concept analysis of sexual dysfunction among GBM in the context of PCa survivorship. The review included 46 articles published between 2002-2019. The following attributes were identified: (1) erectile dysfunction, (2) ejaculatory change (anhedonia/anejaculation), (3) urinary incontinence/climacturia, and (4) anodyspareunia. For GBM PCa survivors, sexual dysfunction involves reduced or abnormal functioning of four core elements of a sexual encounter, which inhibit GBM from engaging in and being satisfied with sexual activity.

Aging Love: A Sexual Health Model for Older Adults.

Older adults can remain sexually active despite reproductive and sexual changes. Increases in sexual activity are associated with divorce, separation, widowhood, freedom of expression, and freedom from responsibilities. Possibly from misperceptions and/or lack of knowledge and education, some older adults practice poor sexual health behaviors. Health-care practitioners, along with educational and political institutions, hold misperceptions and lack knowledge, education, and training in older adults' sexual health. This article explores older adults' sexual health and the role of nurses, guided by the Health Belief Model and aesthetic knowing, and presents Aging Love: A Photo Series, created to reflect nursing care of older adults' sexual health.

Wolfgang's Story: A Virtual Simulation Supporting Effective and Supportive Communication With an Older Gay Adult.

Lesbian, gay, bisexual, transgender, queer, intersex, and Two-Spirit (LGBTQI2S) older adults face barriers to quality health care, often because practitioners misunderstand the unique health needs of this population. Education is essential to support nurses in maintaining culturally safe practice. Wolfgang's Story, a virtual simulation developed as an educational resource to address this need, focuses on an interaction between an older gay adult and a nurse during a health-care encounter, exploring the use of appropriate terminology, personal assumptions, biases, and key concepts related to heterosexism and to grief. The aim of the article is to report on the development, implementation, and evaluation of this project.

A Critical Review of Clinical Practice Guidelines for Care of Transgender and Gender Diverse Children and Youth for Use by Primary Care Practitioners.

Purpose: To examine and critique international clinical practice guidelines (CPGs) related to transgender and gender diverse children and youth and to assess the applicability of the guidelines to ethical and affirming primary care practice. Methods: A review was conducted to obtain English language clinical guidelines. Guidelines were obtained from electronic databases, medical associations, government agencies, and community organizations. Guidelines were critiqued by all authors using the AGREE II instrument. Results: Nine documents were reviewed. Overall, there was agreement among reviewers that the scope, purpose, and clarity of presentation of the guidelines was carried out well. Areas identified for improvement in all guidelines included clarity/rigor of methodologic development, inclusion of community stakeholders, and transparency of editorial independence. The Endocrine Society Clinical Practice Guideline scored highest overall. Despite lower overall scores, other guidelines were identified as having strengths of practical utility within primary care and/or in the discussion of specific social, ethical, and cultural considerations of transgender care in differing contexts worldwide. Conclusion: The use of specific, high-quality CPGs can support primary care practitioners to provide gender-affirming care to children and youth. Methodologic improvement in the development of these CPGs is needed to ensure the best possible quality of care is being outlined.

Out of the Closet: Nurse Practitioner Faculty Knowledge, Comfort and Willingness to Incorporate LGBTQ2SA Content into the Curriculum.

BACKGROUND: To improve the health of LGBTQ2SA individuals, nurse practitioners need to increase their knowledge related to the health needs of sexual and gender minorities. However, nurse practitioners often feel unprepared as a result of a lack of content in their educational training. In order to better understand the current state of nurse practitioner education around sexual and gender minorities, it is critical to assess educational preparedness and faculty knowledge teaching the content.Purpose: The purpose of this study was to assess the knowledge and experience of nurse practitioner faculty in Ontario around LGBTQ2SA health and their comfort level teaching this material in the nurse practitioner program. METHODS: This quantitative descriptive study used purposeful sampling to recruit faculty from the Ontario Primary Health Care Nurse Practitioner Program. Data was collected using a modified survey administered on the Opinio platform. RESULTS: Twenty-three individuals completed the study. Most participants felt that LGBTQ2SA health content was important, but rarely or never taught. The most frequently identified strategies to promote faculty readiness to integration of LGBTQ2SA health topics into the curriculum included faculty development seminars, reviewing curriculum to identify gaps and partnering and utilizing LGBTQ2SA specific agencies as clinical sites. CONCLUSIONS: Results indicate that barriers exist at the faculty level which may limit the extent to which LGBTQ2SA health topics are incorporated into the curriculum. Supporting faculty to develop their knowledge and comfort with this topic will allow them to better educate students to care for LGBTQ2SA clients.

Review and Analysis of International Transgender Adult Primary Care Guidelines.

Purpose: To examine and critique current international clinical practice guidelines (CPGs) related to providing primary care to transgender adults and to assess their applicability to practice. Methods: A review was conducted to obtain English language clinical guidelines. Guidelines included in this review were obtained from published journals and gray literature. Guidelines were critiqued using the AGREE II instrument. Results: Seventeen documents were included in the final review. Eleven were specifically designed for primary care practitioners, whereas the remaining six were deemed applicable to primary care. Overall, across the CPGs, the scope, purpose, and clarity of presentation were done well. However, the overall methodological rigor in guideline development was poor. Many CPGs included useful tools that could be helpful for the primary care practitioner. Conclusions: CPGs can be an important support for primary care providers' clinical practice with transgender people, particularly after having received limited formal education in transgender care. Improvements in transgender health CPG rigor and transparency are needed. Future CPGs would benefit from recommendations on the nuanced discussion of gender concepts and interpersonal communication that can create conflict in health care interactions.

Development of an online educational toolkit for sexual orientation and gender identity minority nursing care.

OBJECTIVE: to develop and implement an online education resources to address a gap in nursing education regarding the concept of cultural humility and its application to healthcare encounters with persons who identify as lesbian, gay, bisexual, transgender, queer, intersex (LGBTQI) or Two-Spirit. Improved understanding of LGBTQI and Two-Spirit community health issues is essential to reducing the healthcare access barriers they currently face. METHOD: an online educational toolkit was developed that included virtual simulation games and curated resources. The development process included community involvement, a team-building meeting, development of learning outcomes, decision-point maps and scriptwriting for filming. A website and learning management system was designed to present learning objectives, curated resources, and the virtual games. RESULTS: the Sexual Orientation and Gender Identity Nursing Toolkit was created to advance cultural humility in nursing practice. The learning toolkit focuses on encounters using cultural humility to meet the unique needs of LGBTQI and Two-Spirit communities. CONCLUSION: our innovative online educational toolkit can be used to provide professional development of nurses and other healthcare practitioners to care for LGBTQI and Two-Spirit individuals.

Design Thinking in Nursing Education to Improve Care for Lesbian, Gay, Bisexual, Transgender, Queer, Intersex and Two-Spirit People.

Design thinking methodology is a collaborative strategy with the potential to create innovations. Design thinking is being used increasingly in health care. Design jams are interdisciplinary events that bring together experts and community members to collaborate on creative solutions to health-care problems. This article describes the design thinking process and includes reflection on the authors' participation in a design jam event aimed to address the knowledge-to-action gap that exists in health care for (LGBTQI2S) people.