Using Patient Voices to Improve Culturally Safe Care for Transgender and Non-Binary Populations: A Quality Improvement Project

Date of Award

Summer 6-11-2023

Scholarly Projects

Projects: SPU Access Only

Degree Name

Doctor of Nursing Practice (DNP)



Faculty Chair

Lena Hristova

Faculty Reader

Darryl DuVall

Executive Summary

Executive Summary

Background and Significance

Transphobia is a major contributing factor to systemic barriers that affect social determinants and the access to optimal health care (Grummel & Collins 2021, Jabson et al., 2016; Selix & Rowinak 2018). Prior to the Patient Protection and Affordable Care Act of 2010 (ACA), no rules were mandated that prohibited discrimination against transgender and non-binary (TGNB) people in the health care system (Grant et al., 2011). Systemic barriers and health determinants that work against achieving optimal health, put this population at high risk for many public health problems including substance use disorders, mental health illnesses, higher risk of suicidality, and homelessness (Grant et al, 2011; U.S Department of Health Services, 2020). Awareness of the explicit and implicit biases of healthcare workers can help in the development of accessible, nonjudgmental, and safe care that will ensure proper health outcomes.

Problem statement

A community health assessment conducted by King County Public Health (KCPH) highlighted the complex set of systemic and interpersonal barriers LGBTQ populations experience (KCPH, 2019). Creating a comfortable environment and building a rapport by asking appropriate questions about client’s identity and pronouns are essential to providing adequate care that is patient centered (Lewis, 2016). Creating space to facilitate discussion around patient-reported experiences will help drive improvements in the current practices in serving TGNB clients and is necessary in addressing community health needs.

Purpose statement

The aim of this DNP project was to create an educational toolkit for culturally safe transgender client care informed by TGNB voices. The short-term goal was to identify provider knowledge gaps in culturally safe care and examine the existing patient experiences. The long-term goal is to improve satisfaction and healthcare outcomes for TGNB clients who receive healthcare in the community health services clinics within KCPH.


The outcome of this project was piloting an educational toolkit in two community health services clinics within KCPH. The educational toolkit was guided by evidence based data and the evaluation of current understandings reported by providers and patient satisfaction reported by TGNB individuals. To best evaluate gaps in quality of care, a needs assessment was conducted towards patients (Group A), and a pre and post survey was conducted towards physicians (Group B). The pre and post surveys were used to evaluate provider knowledge, attitudes, and beliefs towards facilitating care for the TGNB community. The conduction of the surveys were based on a 5-point Likert scale and had optional open-ended questions for participants to expand on their answers. The data from the surveys were used to inform the development of the clinical toolkit for providers and axillary staff.


To evaluate the effectiveness of the intervention piloted, data was compared from the provider surveys before intervention implementation and post-implementation. To help categorize the data, four themes were used: understanding of vocabulary, clinical guidelines, treatment, and cultural safety. Overall, there was an increase of knowledge and understanding reported by providers.


The goal of this project was to build a foundation of culturally safe patient care for TGNB patients that could be sustained within the organization. This quality improvement project revealed, that achieving patient satisfaction and practicing culturally safety is an effort that is evolving on a continuum. Further, the evaluation reaffirmed the need to continue working towards building a strong rapport with clients and fostering patient-driven conversations and care. Discovering comfortable ways to allow transgender and gender diverse patients to share their thoughts as well as ways providers can improve their communication will be helpful for all vulnerable populations. It is highly recommended this organization continues to evaluate patient feedback biannually to assess satisfaction and uphold culturally safe practices.

Practice Implications

The findings of this QI project show patient engagement and educational toolkits with evidence-based practice guidelines for providers can positively impact provider comfortability and knowledge. Hearing the voices of clients may be applicable for other vulnerable populations and should be priority in health care settings.


Grant, J., Mottet, L., Tanis, J., Harrison, J., Herman, J., & Keisling, M. (2011). Injustice at every turn: A report of the National Transgender Discrimination Survey. Washington, DC: National Center for Transgender Equality and National Gay and Lesbian Task Force; 2011. https://dataspace.princeton.edu/jspui/handle/88435/dsp014j03d232pexternal icon.

Grummel, J. & Collins, J. (2021). An assessment of Community Health Needs Assesment (CHNA) Data Collection Related to Building Capacity for Sexual and Gender Marginalized (SGM) Individuals in Health Care Organizations. Journal of Management Policy and Practice 22(2), 14-23. Retrieved from https://ezproxy.spu.edu/login

Jabson, J., Mitchell, J., & Doty, B. (2016). Associations between non-discrimination and training policies and physicians’ attitudes and knowledge about sexual and gender minority patients: A comparison of physicians from two hospitals. BMC Public Health, 16(256). DOI: 10.1186/s12889-016-297-y

Korpaisarn, S. & Safer, J. (2018). Gaps in transgender medical education among healthcare providers: A major barrier to care for transgender persons. Review of Endorcrine Metabolism Disorders. 19(3), 271-275. DOI: 10.1007/s11154-018-9452-5

Selix, N. & Rowniak, S. (2016). Provision of Patient-Centered Transgender Care. Journal of Midwifery & Women’s Health, 61(6), 744-751. https://doi-org.ezporxy.spu.edu/10.1111/jmwh.12518

Healthy People 2030. (2020). U.S. Department of Health Services. Retrieved from https://health.gov/healthypeople/objectives-and-data/browse-objectives/lgbt

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