Presentation
Revealing Hidden Harms: Utilizing TGNB Patient Experience Surveys to Identify Contributors to Psychosocial Safety
DescriptionINTRODUCTION:
Stigma associated with gender nonconformity can impact psychosocial safety and well-being for transgender and non-binary (TGNB) individuals. In the healthcare context, stigmatization can lead to (1) immediate harms (e.g., medical trauma or exacerbated gender dysphoria), and (2) long-term harms (e.g., poor health outcomes due to patients’ loss of trust in the healthcare system, clinicians’ failure to adhere to screening guidelines, etc.). Thus, it is critical to understand contributors to patient safety and harm to improve care for TGNB individuals.
The aim of this study was to characterize barriers and facilitators to psychosocial safety for TGNB patients reported via patient experience surveys that were completed after receiving care at a medical center. These surveys provide an important window on the factors that play a role in the patients’ health care experience and can aid in identifying barriers to psychosocial safety and the care provided to TGNB patients, as well as interventions aimed at improving these challenges.
MATERIALS AND METHODS:
We retrieved patient experience surveys from ambulatory surgery, urgent and emergency care, outpatient and telehealth visits, imaging and testing, and pharmacy services from a single academic medical center in Southern California. The surveys were completed between July 2023 and June 2024 by patients who self-identified as genderqueer, non-binary, transgender male, transgender female, or who described their gender as “other.”
We conducted a work system analysis guided by the Systems Engineering Initiative for Patient Safety (SEIPS) model to identify barriers and facilitators to TGNB patients’ psychosocial safety. The analysis was performed by two researchers who independently reviewed and categorized the patient survey responses using the coding scheme below. Additionally, because it was important to understand how the attitudes and behaviors of health care staff affected patient care, we sought to highlight this within the analysis.
Coding scheme:
1. Staff behavior-facilitator: Healthcare staff contributed positively to the patient’s experience through their actions (e.g., the physician demonstrated compassion and support while they actively listened to their patient’s concerns).
2. Staff behavior-barrier: Healthcare staff demonstrated behavior that was perceived as rude, dismissive, or unkind, making the patient feel uncomfortable or unwelcome (e.g., nurses made inappropriate comments about the patient’s appearance or gender expression).
3. Work system-facilitator: Other features of the system that support psychological and social well-being of the patient, promoting inclusivity and respect. Features include the environment, tasks, tools/technology, and organizational management) (e.g., exam room has thick walls to promote privacy, restrooms are marked with gender inclusive markings).
4. Work system-barrier: Other features of the system that do not support psychological and social well-being of the patient, leading to discomfort or exclusion (e.g., restrooms are marked with images of a man or woman, healthcare provider seems unfamiliar with the protocols for transgender care).
Survey responses that were duplicate entries, incomplete responses, or lacked sufficient detail (e.g., one response simply stated “always amazing”) were excluded from the dataset.
Descriptive statistics were used to analyze the demographic data, staff behavior facilitators and barriers, and work system facilitators and barriers. Additionally, the barriers were further analyzed to identify how many patient survey responses mentioned challenges related to gender-affirming care (i.e., care that is affirming of one’s gender).
RESULTS:
Demographics
A total of 397 surveys were submitted between July 2023 and June 2024. After removing 29 surveys from the dataset, a total of 368 surveys were reviewed.
The sample included surveys from transgender women (n=141, 38.3%), non-binary individuals (n=128; 34.8%), transgender men (n=79; 21.5%), other (n=15, 4.1%), and genderqueer (n=5, 1.4%). The top three care settings for which surveys were submitted included office visits (n=193, 52.5%), imaging and testing (n=53, 14.4%), and telehealth visits (n=44, 12%).
Barriers and Facilitators
400 barriers and facilitators were extracted from the final dataset of 368 surveys and included 289 (72.3%) staff behavior-facilitators, 43 (10.8%) staff behavior-barriers, 18 (4.5%) work system-facilitators, and 50 (12.5%) work system-barriers.
Office visits accounted for 210 (52.5%) patient experience factors. Of the 210 patient experience factors, 159 (75.7%) were categorized as staff behavior-facilitators, 18 (8.6%) as staff behavior-barriers, 9 (4.3%) as work system-facilitators, and 24 (11.4%) as work system-barriers. The common barriers occurring during office visits included challenges with appointment scheduling or appointment availability, wait times, and experiencing rude or dismissive behavior by clinic staff.
Imaging and testing visits accounted for 55 (13.8%) patient experience factors. Of the 55 patient experience factors, 43 (78.2%) were categorized as staff behavior-facilitators, 5 (9.1%) as work system-facilitators, and 7 (12.7%) as work system-barriers. Staff behavior was not described as a barrier in this setting. Some work system-barriers included equipment and technology issues and difficulty obtaining care information.
Telehealth visits accounted for 49 (12.3%) patient experience factors. Of the 49 patient experience factors, 31 (63.3%) were categorized as staff behavior-facilitators, 6 (12.2%) as staff behavior-barriers, 1 (2%) as work system-facilitators, and 11 (22.5%) as work system-barriers. The barriers included use of the patient’s deadname or incorrect pronouns, dismissive behavior demonstrated by staff, and referral challenges.
Sub-Analysis on Barriers
A total of 93 work system and staff behavior factors were categorized as barriers. Seventy-two (77.4%) patients mentioned general challenges experienced during their visit, while 21 (22.6%) mentioned barriers specific to gender-affirming care (use of deadname or incorrect pronouns, incorrect name or sex marker in the chart).
CONCLUSIONS:
This preliminary analysis of TGNB experience survey data demonstrates that both the behavior of staff and the design of the work system contribute to psychosocial safety, though to differing degrees across care settings. Although an overwhelming majority of the patient responses were positive (n=307 (76.8%) staff behavior and work system facilitators), it is important to recognize where improvements can be made to further promote psychosocial safety for TGNB patients. Future work should explore the differences in contributors to psychosocial safety between care settings as well as patient identities, to inform targeted re-design of tools, technologies, workflows, and policies to ensure high-quality care for TGNB people.
This study was funded by the Agency for Healthcare Research and Quality (5R18HS029299-02).
Stigma associated with gender nonconformity can impact psychosocial safety and well-being for transgender and non-binary (TGNB) individuals. In the healthcare context, stigmatization can lead to (1) immediate harms (e.g., medical trauma or exacerbated gender dysphoria), and (2) long-term harms (e.g., poor health outcomes due to patients’ loss of trust in the healthcare system, clinicians’ failure to adhere to screening guidelines, etc.). Thus, it is critical to understand contributors to patient safety and harm to improve care for TGNB individuals.
The aim of this study was to characterize barriers and facilitators to psychosocial safety for TGNB patients reported via patient experience surveys that were completed after receiving care at a medical center. These surveys provide an important window on the factors that play a role in the patients’ health care experience and can aid in identifying barriers to psychosocial safety and the care provided to TGNB patients, as well as interventions aimed at improving these challenges.
MATERIALS AND METHODS:
We retrieved patient experience surveys from ambulatory surgery, urgent and emergency care, outpatient and telehealth visits, imaging and testing, and pharmacy services from a single academic medical center in Southern California. The surveys were completed between July 2023 and June 2024 by patients who self-identified as genderqueer, non-binary, transgender male, transgender female, or who described their gender as “other.”
We conducted a work system analysis guided by the Systems Engineering Initiative for Patient Safety (SEIPS) model to identify barriers and facilitators to TGNB patients’ psychosocial safety. The analysis was performed by two researchers who independently reviewed and categorized the patient survey responses using the coding scheme below. Additionally, because it was important to understand how the attitudes and behaviors of health care staff affected patient care, we sought to highlight this within the analysis.
Coding scheme:
1. Staff behavior-facilitator: Healthcare staff contributed positively to the patient’s experience through their actions (e.g., the physician demonstrated compassion and support while they actively listened to their patient’s concerns).
2. Staff behavior-barrier: Healthcare staff demonstrated behavior that was perceived as rude, dismissive, or unkind, making the patient feel uncomfortable or unwelcome (e.g., nurses made inappropriate comments about the patient’s appearance or gender expression).
3. Work system-facilitator: Other features of the system that support psychological and social well-being of the patient, promoting inclusivity and respect. Features include the environment, tasks, tools/technology, and organizational management) (e.g., exam room has thick walls to promote privacy, restrooms are marked with gender inclusive markings).
4. Work system-barrier: Other features of the system that do not support psychological and social well-being of the patient, leading to discomfort or exclusion (e.g., restrooms are marked with images of a man or woman, healthcare provider seems unfamiliar with the protocols for transgender care).
Survey responses that were duplicate entries, incomplete responses, or lacked sufficient detail (e.g., one response simply stated “always amazing”) were excluded from the dataset.
Descriptive statistics were used to analyze the demographic data, staff behavior facilitators and barriers, and work system facilitators and barriers. Additionally, the barriers were further analyzed to identify how many patient survey responses mentioned challenges related to gender-affirming care (i.e., care that is affirming of one’s gender).
RESULTS:
Demographics
A total of 397 surveys were submitted between July 2023 and June 2024. After removing 29 surveys from the dataset, a total of 368 surveys were reviewed.
The sample included surveys from transgender women (n=141, 38.3%), non-binary individuals (n=128; 34.8%), transgender men (n=79; 21.5%), other (n=15, 4.1%), and genderqueer (n=5, 1.4%). The top three care settings for which surveys were submitted included office visits (n=193, 52.5%), imaging and testing (n=53, 14.4%), and telehealth visits (n=44, 12%).
Barriers and Facilitators
400 barriers and facilitators were extracted from the final dataset of 368 surveys and included 289 (72.3%) staff behavior-facilitators, 43 (10.8%) staff behavior-barriers, 18 (4.5%) work system-facilitators, and 50 (12.5%) work system-barriers.
Office visits accounted for 210 (52.5%) patient experience factors. Of the 210 patient experience factors, 159 (75.7%) were categorized as staff behavior-facilitators, 18 (8.6%) as staff behavior-barriers, 9 (4.3%) as work system-facilitators, and 24 (11.4%) as work system-barriers. The common barriers occurring during office visits included challenges with appointment scheduling or appointment availability, wait times, and experiencing rude or dismissive behavior by clinic staff.
Imaging and testing visits accounted for 55 (13.8%) patient experience factors. Of the 55 patient experience factors, 43 (78.2%) were categorized as staff behavior-facilitators, 5 (9.1%) as work system-facilitators, and 7 (12.7%) as work system-barriers. Staff behavior was not described as a barrier in this setting. Some work system-barriers included equipment and technology issues and difficulty obtaining care information.
Telehealth visits accounted for 49 (12.3%) patient experience factors. Of the 49 patient experience factors, 31 (63.3%) were categorized as staff behavior-facilitators, 6 (12.2%) as staff behavior-barriers, 1 (2%) as work system-facilitators, and 11 (22.5%) as work system-barriers. The barriers included use of the patient’s deadname or incorrect pronouns, dismissive behavior demonstrated by staff, and referral challenges.
Sub-Analysis on Barriers
A total of 93 work system and staff behavior factors were categorized as barriers. Seventy-two (77.4%) patients mentioned general challenges experienced during their visit, while 21 (22.6%) mentioned barriers specific to gender-affirming care (use of deadname or incorrect pronouns, incorrect name or sex marker in the chart).
CONCLUSIONS:
This preliminary analysis of TGNB experience survey data demonstrates that both the behavior of staff and the design of the work system contribute to psychosocial safety, though to differing degrees across care settings. Although an overwhelming majority of the patient responses were positive (n=307 (76.8%) staff behavior and work system facilitators), it is important to recognize where improvements can be made to further promote psychosocial safety for TGNB patients. Future work should explore the differences in contributors to psychosocial safety between care settings as well as patient identities, to inform targeted re-design of tools, technologies, workflows, and policies to ensure high-quality care for TGNB people.
This study was funded by the Agency for Healthcare Research and Quality (5R18HS029299-02).
Event Type
Oral Presentations
TimeMonday, March 2310:30am - 10:52am EDT
LocationMurray Hill East
Patient Safety Research and Initiatives