Clinical Care

The Denial of Care Rule, the Equality Act, and Nursing Ethics

The U.S. Department of Health and Human Services (HHS) Office of Civil Rights has released what they are referring to as “the final conscience rule protecting health care entities and individuals.” This rule is more broadly being referred to as the Denial of Care Rule, as it prohibits the government from penalizing practitioners or organizations for refusing to provide health care based upon religious conscience.

The president of GLMA, Gal Mayer, MD, has spoken out against this rule in no uncertain terms. In particular, he noted that, “The Denial of Care rule also stands in direct conflict with the Joint Commission and the major medical and health professional associations representing physicians, nurses, nurse practitioners, physician assistants, psychologists, social workers and other healthcare providers that have adopted standards to ensure all patients, including LGBTQ patients, are treated with respect and without bias and discrimination in all healthcare settings.”

The GLMA Nursing Section is in full agreement with President Mayer’s statement. It is absolutely unacceptable that HHS, whose mission is “to enhance and protect the health and well-being of all Americans” would issue a rule that facilitates denial of care for, among others, LGBTQ people.

The Code of Ethics for Nurses states in its first provision that “[t]he nurse practices with compassion and respect for the inherent dignity, worth, and unique attributes of every person.” It also states in provisions two and three that nurses prioritize the health and safety of the patient, both in terms of promoting health and safety and advocating for patients. Provision eight speaks to nurses’ obligation to protect human rights and reduce health disparities, and provision nine speaks to the importance of integrating social justice into both nursing and health policy.

In short, the American Nurses Association has made clear in over half the provisions of the Code that it is the responsibility of nurses to not only provide care to their patients based on their unique needs, but also to advocate for policies that ensure patients’ health and safety are protected. The Denial of Care rule, as Dr. Mayer stated in more general terms, is in direct conflict with the Code of Ethics for Nurses, and, in fact, requires nurses to speak out against this rule.

So, what can nurses do?  Plenty, at many different levels.  Talk about this rule with policy-makers in your workplace.  Bring it up with any of your professional organizations.  And most importantly, call your representative and ask them to support the Equality Act (HR 5/S 788).

Working Towards LGBTQ Health Equity

In health care, we inherently understand that care must be tailored to individuals, as patients have different needs. For example, if a patient walks in with an ear infection and another patient comes in with a broken arm, we treat each patient differently, according to their needs, in order to provide the best care possible.

For some reason this logic fails us when we are working with patients across marginalized identities, including lesbian, gay, bisexual, transgender, and queer (LGBTQ) individuals. This, mostly unconscious, bias in favor of majority identities perpetuates health disparities. For example, LGBTQ individuals are “significantly less likely than others to have health insurance, are more likely to report unmet health needs, and, for women, are less likely to have had a recent mammogram or Papanicolaou test.”

When training health professionals, I’ve heard folks at various levels (medical assistants, nurses, providers, etc.) say that they don’t need training on LGBTQ patient care, because they treat all patients “equally.” Yet this equality framework fails to acknowledge that LGBTQ patients have different needs than cisgender and straight patients and that we cannot provide excellent care without adjusting appropriately.

Instead of continuing to use the equality framework, I propose we utilize a health equity approach to care, which simply means that we tailor our care to our patients needs. Equitable care is provided when we adjust our care appropriately so LGBTQ individuals have equal outcomes compared to their straight/heterosexual and cisgender counterparts.

IISC_EqualityEquity

Image credit: Interaction Institute for Social Change

Learn more about the fascinating history of this image here!

How can we improve health equity for LGBTQ patients?

Providing equitable care for LGBTQ individuals means health care professionals need to know who their patients are, how they identify, who their support systems are, and how their relationships and identities impact their well-being.

As a health professional, the only way to improve care for LGBTQ patients is to understand how their lived experiences differ from straight and cisgender patients. LGBTQ identity/ies can impact:

  • Access to Care
  • Preventative Services
  • Family Building
  • Relationships
  • Family Support
  • Safety (Intimate Partner Violence and Domestic Violence)
  • Work
  • HIV Exposure
  • and more!

The first step towards providing equitable care for your LGBTQ patients is to simply identify who they are. Here are a few ways you can identify LGBTQ patients and make them feel safe and comfortable in clinical spaces.

Don’t assume the name in the chart is the name your patient wants you to use.

Your initial introduction can make or break the entire encounter. Transgender and gender non-binary patients in particular will take note if you make assumptions about their name and/or pronouns, as electronic medical records may or may not align with the name they use and their gender.

Here’s an example of an inclusive introduction:

You: “Hi, I’m [insert your name] and I will be working with you today. How would you like me to address you today?”

Patient: “Hi, [your name].  Please call me [patient’s name].”

You: “Lovely to meet you, [insert patient’s name here]. What pronouns do you use? For example, I use [insert your pronouns, ex: she/her].”

Do ask about sexual orientation and gender identity (SOGI).

The only way to find out who your LGBTQ patients are is to ask.

In addition to typical medical and social health history questions, ask every patient the following:

  • “How do you identify your sexual orientation?”
  • “What was your sex assigned at birth?”
  • “What is your gender/gender identity?”

If your straight and/or cisgender patients are uncomfortable with these questions, take a teaching moment to share why these are important questions for all patients.

Trust your patients and learn from them.

Our patients know themselves and their lives best. Believe what they tell you and take the time to learn about their identities and their health care needs between visits. Self-reflection and cultural humility are critical skills when working with all patient populations. Remember that working towards equitable and inclusive care is an ongoing process, so be patient with yourself and expect to make mistakes as you learn.

I have an LGBTQ patient! Now what do I do?

Great question! The next step in providing equitable care is to critically assess how your patient’s identity/identities impact their health needs.

Keep following this series and the GLMA Nursing blog to learn more about how to assess your patients’ needs and improve your clinical management of LGBTQ individuals.

Can’t wait? Check out GLMA’s archived webinars to learn more about providing LGBTQ-inclusive care.

CookTiffanyETiffany E. Cook is the Training and Professional Development Program Coordinator at NYU School of Medicine’s Office of Diversity Affairs. She received her undergraduate degree in General Studies with a minor in Women’s and Gender Studies from the University of Idaho and is currently applying to nursing school with plans to become a Family Nurse Practitioner. She serves on the GLMA Nursing Section’s Web Team and can be found on Twitter at @TiffanyECook.