TRANSFORMING CARE: A GENDER-AFFIRMING CARE SIMULATION STUDY A Dissertation Presented for the Doctor of Philosophy Degree The University of Tennessee, Knoxville Edward D. Petrie August 2025 DEDICATION This work is dedicated to transgender and gender non-conforming individuals—past, present, and future. I see you. I support you. I will continue to fight for you. May this work, and the collective efforts of all of us, contribute to a more just, affirming, and inclusive world. A world where your voices are heard, your identities are honored, and your healthcare reflects our humanity. ACKNOWLEDGEMENTS I want to express my deepest gratitude to my dissertation committee, Drs. Joel Anderson, Jamian Coleman, Susan Hebert, and Jennifer Smith, for their guidance, thoughtful feedback, and support throughout this journey. Your mentorship has shaped not only this work, but also the educator and scholar I continue to become. To the Advisory Board of transgender individuals: thank you for your trust, honesty, and wisdom. Your voices shaped the heart of this project. This work exists because of your courage and willingness to collaborate in the spirit of advocacy and transformation. Thank you to the clinical instructors and students who engaged with this simulation. Your insight and participation brought this work to life and grounded it in real-world impact. If you are interested in utilizing the simulation scenario and script developed through this study, I would be honored to share it. Please contact me directly for more information. ABSTRACT Transgender and gender non-conforming (TGNC) individuals experience significant health disparities, often stemming from bias, stigma, and a lack of provider education regarding gender-affirming care. Despite growing societal awareness, nursing curricula continue to under-prepare students to provide culturally congruent, gender-affirming care. This dissertation, presented in manuscript format, explores a pilot study integrating simulation-based education including TGNC standardized patients to improve nursing student attitudes and beliefs toward TGNC individuals. Chapter 1 introduces the problem, highlighting the specific gap in nursing education, which is the lack of TGNC-focused content, and the urgent need to address disparities in care for TGNC individuals. Chapter 2 presents an integrative review of the literature, revealing both the lack of TGNC-focused content in baccalaureate nursing programs and the effectiveness of simulation as an educational intervention. Chapter 3 provides an analysis of Rivera’s Gender-Affirming Nursing Care (GANC) model, a prescriptive middle-range theory grounded in cultural humility, therapeutic relationships, and inclusive engagement. This framework guided the development and implementation of the simulation. Chapter 4 describes the findings of a mixed-methods study involving thirteen nursing students who participated in a gender-affirming simulation. Quantitative data were collected using the Transgender Attitudes and Beliefs Scale (TABS) before and after the simulation. Results indicated statistically significant improvements in interpersonal comfort and sex/gender beliefs. Qualitative analysis of focus group debriefings revealed four key themes: increased comfort and confidence, power of authentic representation, enhanced empathy through lived experience, and commitment to inclusive and respectful practice. Students consistently emphasized how working with TGNC-standardized patients enhanced realism, empathy, and their commitment to inclusive care. Chapter 5 concludes by synthesizing the study’s contributions to nursing education, theory, and practice. The findings support including TGNC standardized patients in simulation to promote affirming care, deepen students’ reflections, and prepare future nurses to meet the needs of diverse populations. This work advances equitable, patient-centered nursing education and calls for broader implementation of inclusive simulation experiences grounded in relational and reflective frameworks. TABLE OF CONTENTS CHAPTER ONE: INTRODUCTION 1 Significance 1 Gaps in Knowledge 3 Purpose of the Study 4 Manuscripts 5 References 7 CHAPTER TWO: PREPARING BACCALAUREATE NURSING STUDENTS IN GENDER-AFFIRMING CARE: AN INTEGRATIVE REVIEW 9 Abstract 11 Background: 11 Purpose: 11 Method: 11 Results 11 Conclusion 11 Introduction 12 Problem 12 Methods 14 Study design 14 Search method 15 Search outcome 15 Results 15 Data evaluation 15 Data analysis 16 Current nursing curricula addressing TGNC care 16 Educational interventions 18 Discussion 23 Implications 24 Conclusion 25 References 27 Appendix 31 CHAPTER THREE: RIVERA’S GENDER AFFIRMING NURSING CARE MODEL: A MIDDLE-RANGE THEORY: ANALYSIS AND EVALUATION 36 Abstract 38 Background 38 Method 38 Conclusion 38 Introduction 39 Theory Analysis 41 Theory Scope 41 Theory Context 42 Theory Content 44 Theory Evaluation 47 Significance 47 Internal Consistency 48 Parsimony 49 Testability 49 Empirical Adequacy 49 Pragmatic Adequacy 50 Conclusion 51 References 53 CHAPTER FOUR: TRANSFORMING CARE: A GENDER-AFFIRMING CARE SIMULATION STUDY 57 Abstract 59 Background: 59 Purpose: 59 Method: 59 Results: 59 Conclusion: 60 Introduction 61 Significance 61 Theoretical Framework 63 Methods 64 Participants 64 Sample Size 64 Ethical Considerations 65 Simulation Framework 66 Instrument 68 Focus Group Debriefing 69 Data Analysis 69 Results 70 Demographics 70 TABS scores 70 Focus Group Themes 71 Increased comfort and confidence 71 Power of authentic representation 72 Enhanced empathy through lived experience 72 Commitment to inclusive and respectful practice 72 Discussion 73 Limitations 80 Conclusion 81 References 83 Appendix 87 CHAPTER FIVE: CONCLUSION 93 References 100 VITA 101 LIST OF TABLES Table 2.1. Integrative review methodology 31 Table 2.2. Data display: Summary of literature 32 Table 3.1. Theory Concepts and Relational Propositions 55 Table 3.2. Gender-Affirming Nursing Care Theory Concepts and Related Nursing Characteristics 56 Table 4.1 Theoretical Concepts and Relational Propositions 87 Table 4.2 Demographic Characteristics (N = 13) 88 Table 4.3 Paired Sample t-Test Results for TABS (N = 13) 89 Table 4.4 Wilcoxon Signed-Rank Test for TABS –Interpersonal Comfort (N = 13) 90 Table 4.5 Wilcoxon Signed-Rank Test for TABS –Sex/Gender Beliefs (N = 13) 91 Table 4.6 Wilcoxon Signed-Rank Test Human Value (N = 13) 92 iii ii CHAPTER ONE: INTRODUCTION The healthcare needs of transgender and gender-nonconforming (TGNC) individuals have historically been overlooked or inadequately addressed within the medical community (Bhatt et al., 2022; Eickhoff, 2021). This population faces significant health disparities, including higher rates of mental health issues, substance abuse, and barriers to accessing competent and respectful healthcare (Abeln & Love, 2019). A critical barrier to progress in this field is the lack of comprehensive education and training for healthcare professionals about providing gender-affirming care (Altmiller et al., 2022; Diaz et al., 2017). Nursing students often receive insufficient training in this area, leading to a gap in the knowledge and skills necessary to provide gender-affirming care (Bhatt et al., 2022; Koch et al., 2021). This dissertation addresses that gap by implementing a simulation-based training program specifically designed to enhance nursing students' levels of competence and confidence in delivering gender-affirming care to TGNC individuals. Significance The American Psychological Association (APA, 2015) defines gender as attitudes, feelings, and behaviors that a given culture typically associates with an individual’s biological sex. This definition is crucial in understanding the complex issue of gender diversity in healthcare. Health research often reinforces a binary concept of gender, which can be seen in the way sex and gender (often used interchangeably) are represented as male/female, men/women, or boys/girls in research that involves human participants (Lightfoot et al., 2021). This approach effectively erases participants who identify between or outside these binary categories, which is a growing population known as TGNC (Bhatt et al., 2022; Lightfoot et al., 2021). TGNC is an umbrella term for individuals whose gender expression, identity, and/or role differs from gender norms associated with their biological sex (APA, 2015). The marginalization of TGNC individuals in healthcare is exacerbated by cisnormativity, which is the assumption that being cisgender is what is normal and expected (Lightfoot et al., 2021). Cisgender refers to individuals whose gender expression, identity, or role matches gender norms associated with their biological sex (APA, 2015). In the United States, 1.6 million individuals 13 years of age and older identify as TGNC (Herman et al., 2022). The falsehood that TGNC individuals are uncommon leads to cisnormativivity, which can be exhibited as binary gender markers on forms, billing, and medical records (Lightfoot et al., 2021). Nurses who work within this cisnormative environment receive little to no education about providing gender-affirming care to TGNC individuals (Altmiller et al., 2022; Diaz et al., 2017). This lack of education and understanding adversely impacts the healthcare experiences of TGNC individuals, highlighting the need for change in nursing education. Gender-affirming care refers to medical, psychological, and social support provided to individuals seeking to align their gender identity with their outward appearance and lived experience (Bhatt et al., 2022; Lightfoot et al., 2021; Rivera et al., 2022). This holistic approach acknowledges the diversity of gender identities and aims to alleviate the distress often associated with gender dysphoria. By providing access to services such as hormone therapy, surgery, counseling, and support groups, gender-affirming care plays a crucial role in promoting the well-being, dignity, and autonomy of TGNC individuals. Additionally, Lightfoot et al. (2021) indicate that access to gender-affirming care correlates with significantly improved mental health outcomes, reduced rates of suicide, and enhanced overall well-being among TGNC individuals. This reassures us about the positive impact of gender-affirming care, instilling optimism about the outcomes. When individuals are supported in their gender identity, they are more likely to thrive, contributing positively to their communities and workplaces. Gaps in Knowledge Current practices in education for nursing students about gender-affirming care significantly lack depth and breadth. Despite the increasing recognition of the unique healthcare needs of TGNC individuals, many nursing programs still do not provide comprehensive training on this critical subject (Eickhoff, 2021; Koch et al., 2021). Existing curricula often fail to cover the full spectrum of gender-affirming care, from basic concepts of gender identity and expression to the specific medical and psychological needs of TGNC patients (Altmiller et al., 2022; Diaz et al., 2017; Koch et al. 2021). Additionally, traditional teaching methods that rely heavily on lectures and textbooks do not adequately prepare students to provide gender-affirming care to this population. As a result, many nursing graduates enter the workforce without the necessary knowledge, skills, and confidence to deliver effective gender-affirming care, perpetuating health disparities and contributing to suboptimal health outcomes for TGNC individuals (Bhatt et al., 2022; Eickhoff, 2021; Koch et al., 2021). Conversely, experiential learning opportunities enhance students' understanding of gender-affirming care, ensuring they are better prepared to meet the unique healthcare needs of TGNC patients. Several researchers have attempted to address the gap in education about gender-affirming care by employing various innovative methods, including virtual simulations, role-play, and hands-on simulation exercises (Altmiller et al., 2022; Diaz et al., 2017; Koch et al., 2021). These approaches have shown promise in enhancing students' clinical skills and sensitivity toward TGNC patients (Eickhoff, 2021; Diaz et al., 2017; Koch et al., 2021). However, many of these methods have been limited by the lack of direct input and participation from members of the TGNC community. Often, the role-plays and simulations featured fellow students or cisgender standardized patients portraying TGNC individuals, which can lead to inauthentic and potentially stigmatizing representations. A standardized patient is a trained individual who consistently simulates real patients' medical conditions, symptoms, and histories for educational and assessment purposes. The absence of the genuine voices and lived experiences of TGNC individuals reduces the realism of these educational interventions. Incorporating TGNC individuals as standardized patients in simulations makes the training more authentic and impactful. This inclusion ensures that scenarios accurately reflect the lived experiences, challenges, and healthcare needs of the TGNC community. Purpose of the Study This dissertation study aimed to improve gender-affirming care education for nursing students by incorporating TGNC individuals into every stage of the simulation process. While previous efforts have introduced role-play, virtual simulations, and standardized patient encounters to teach gender-affirming care, those efforts have often lacked authentic representation of TGNC individuals. Without this firsthand perspective, students may not gain the depth of understanding needed to provide gender-affirming care. To address this gap, this dissertation study ensured that voices of TGNC individuals played a central role in developing, implementing, and evaluating the simulation experience. TGNC individuals helped co-design the case scenario to ensure its accuracy and relevance, served as standardized patients to provide realistic interactions, and participated in debriefing sessions to offer direct feedback to students. They also participated in post-simulation discussions, helping to refine and improve future simulations through structured reflection. Ultimately, we sought to determine whether including TGNC individuals in simulations enhanced the overall authenticity and effectiveness of gender-affirming care education, better preparing future nurses to meet the needs of TGNC patients. Manuscripts This dissertation consists of three manuscripts that together provide a thorough exploration of gender-affirming care education in nursing. Each manuscript serves a distinct purpose: identifying gaps in current nursing education, analyzing a theoretical model that supports gender-affirming nursing practice, and evaluating the outcomes of a simulation-based learning approach. By addressing these areas, the dissertation aims to enhance nursing students' preparedness to provide competent gender-affirming care for TGNC patients. The first manuscript is a literature review that examines the current state of education about gender-affirming care in nursing programs. It highlights key deficiencies in existing curricula, particularly the limited involvement of TGNC individuals in teaching strategies. These gaps contribute to lower competence levels among providers and reinforce the health disparities that TGNC patients frequently experience. This literature review establishes the pressing need for nursing programs to adopt educational strategies that enable students to engage more meaningfully with gender-affirming care. The second manuscript analyzes Rivera’s Gender-Affirming Nursing Care Model (2022) and its relevance to nursing education. It examines how the theory offers a structured approach to supporting TGNC patients through affirming communication, inclusive care practices, and nurse advocacy. By applying this theory within an educational context, the manuscript demonstrates how conceptual frameworks can shape nursing curricula and better prepare students to provide competent, affirming care. The third manuscript presents the results of a gender-affirming care simulation pilot study that integrates the voices of TGNC individuals at every stage of the learning experience. Unlike previous studies that relied on role-play or cisgender standardized patients, this study involved TGNC individuals in development of the scenario, simulation sessions, debriefing discussions, and post-simulation evaluations. The findings explore how this approach influences nursing students’ attitudes, beliefs, and preparedness in providing gender-affirming care. The manuscript also examines how firsthand feedback from TGNC participants enhances student learning and highlights the importance of authentic representation in nursing education. Together, these three manuscripts provide a comprehensive perspective on gender-affirming care in nursing education. The literature review identifies the problem and illustrates the need for improved teaching methods, the theory analysis lays out a framework for implementing gender-affirming practices, and the research study evaluates the effect of a simulation model that emphasizes authenticity and lived experiences. By linking these elements, this dissertation presents both a critical examination of the current limitations in nursing education and a research-driven approach to enhancing student preparedness to care for TGNC patients. References Abeln, B., & Love, R. (2019). Considerations for the care of transgender individuals. The Nursing Clinics of North America, 54(4), 551–559. https://doi.org/10.1016/j.cnur.2019.07.005 Altmiller, G., Wilson, C., Jimenez, F. A., & Perron, T. (2023). Impact of a virtual patient simulation on nursing students' attitudes of transgender care. Nurse Educator, 48(3), 131–136. https://doi.org/10.1097/NNE.0000000000001331 American Psychological Association (2015). Guidelines for psychological practice with transgender and gender nonconforming people. The American Psychologist, 70(9), 832–864. https://doi.org/10.1037/a0039906 Bhatt, N., Cannella, J., & Gentile, J. P. (2022). Gender-affirming care for transgender patients. Innovations in Clinical Neuroscience, 19(4-6), 23–32. Díaz, D. A., Maruca, A., Gonzalez, L., Stockmann, C., & Hoyt, E. (2017). Using simulation to address care of the transgender patient in nursing curricula. BMJ Simulation & Technology Enhanced Learning, 3(2), 65–69. https://doi.org/10.1136/bmjstel-2016-000147 Eickhoff, C. (2021). Identifying gaps in LGBTQ health education in baccalaureate undergraduate nursing programs. Journal of Nursing Education, 60(10), 552–558. https://doi.org/10.3928/01484834-20210729-01 Herman, J.L., Flores, A.R., O'Neill, K.K. (2022). How many adults and youth identify as transgender in the United States?. UCLA Williams Institute http://williamsinstitute.law.ucla.edu/publications/trans-adults-united-states/ Koch, A., Ritz, M., Morrow, A., Grier, K., & McMillian-Bohler, J. M. (2021). Role-play simulation to teach nursing students how to provide culturally sensitive care to transgender patients. Nurse Education Practice, 54, 103123. https://doi.org/10.1016/j.nepr.2021.103123 Lightfoot, S., Kia, H., Vincent, A., Wright, D. K., & Vandyk, A. (2021). Trans-affirming care: An integrative review and concept analysis. International Journal of Nursing Studies, 123, 104047. https://doi.org/10.1016/j.ijnurstu.2021.104047 Rivera, D., Jukkala, A., & Rohini, T. (2022). Introduction to Rivera's Gender Affirming Nursing Care Model: A middle-range theory. Journal of Holistic Nursing, 40(3), 255–264. https://doi.org/10.1177/08980101211046747 CHAPTER TWO: PREPARING BACCALAUREATE NURSING STUDENTS IN GENDER-AFFIRMING CARE: AN INTEGRATIVE REVIEW A version of this chapter was originally submitted to the International Journal of Transgender Health by Edward D. Petrie and Joel G. Anderson. The required citation format for this journal is that of the American Psychological Association, 7th Edition. Abstract Background: The transgender and gender non-conforming (TGNC) community faces significant healthcare disparities, yet nursing and healthcare curricula fail to address the unique healthcare needs of this community adequately. As a result, nurses and other healthcare providers often lack the knowledge and skills to provide quality care for TGNC individuals. Purpose: In this integrative review, I sought to examine the literature pertaining to baccalaureate nursing students’ current curriculum and educational interventions related to TGNC care. Method: Whittemore and Knafl's updated integrative review methodology was used to offer a clear picture of the current state of the science of baccalaureate nursing students' education regarding the care of TGNC individuals. By taking an integrative approach, the full potential of the available literature can be realized by including the researcher’s findings from all types of studies and designs. Results: The analysis identified two prominent themes: the first pertaining to the adequacy of the current nursing curricula addressing TGNC care and the second regarding potential educational interventions to enhance nursing education in this area. Conclusion: Overall, the findings from this integrative review offer a valuable perspective on the literature regarding nursing education about gender-affirming care for TGNC individuals. Nursing students must receive education and exposure to provide culturally congruent and affirming care for this population. Introduction In the United States, 1.6 million individuals 13 years of age and older identify as transgender or gender-nonconforming (TGNC) (Herman et al., 2022). TGNC is an umbrella term encompassing individuals whose gender identity does not match the sex assigned to them at birth (APA, 2015). To provide holistic patient-centered care, nurses must possess competence in gender-affirming care. Gender-affirming care is a range of medical, psychological, and social services designed to support and affirm an individual's gender identity, including hormone therapy, surgeries, counseling, and social support measures (Rivera et al., 2022). Establishing nursing competence in gender-affirming care will help foster successful nurse-patient relationships by engaging in interaction without bias and affirming the patient’s identity. Future nurses will be prepared to care for TGNC individuals by including education about gender-affirming care in nursing curricula. In this integrative review, I sought to examine the literature pertaining to baccalaureate nursing students’ current curricular and educational interventions regarding TGNC care to make recommendations for future nursing education. Problem TGNC individuals face significant healthcare disparities that result in poorer health outcomes and difficulties accessing healthcare. These disparities are due to various factors, including discrimination, biases, stigma, inadequate education for healthcare providers, and limited access to affordable gender-affirming healthcare services (Bonvicini, 2017; Diaz, 2017; Eickhoff, 2021; Elertson & McNiel, 2021; Hand & Gedzyk-Nieman, 2022; Lim et al., 2015; McEwing, 2020; McKay et al., 2022; Rivera et al, 2022; & White et al., 2015). For example, researchers suggest TGNC individuals are more likely to experience mental health issues such as anxiety, depression, substance abuse, and suicide than the general population (Diaz, 2017; Elertson & McNiel, 2021; Hand & Gedzyk-Nieman, 2022; McEwing, 2020; & McKay et al., 2022). Additionally, they may face barriers to accessing essential healthcare services such as preventative screenings and routine care (Diaz, 2017; Elertson & McNiel, 2021; Hand & Gedzyk-Nieman, 2022; McEwing, 2020; & McKay et al., 2022). Addressing these disparities requires a multi-faceted approach, including improving education for healthcare providers, increasing access to gender-affirming healthcare services, and addressing systemic discrimination and stigma within healthcare and society. In recent years, there has been a concerning trend of political attacks on TGNC people, resulting in several states prohibiting or limiting access to best-practice medical care for TGNC youth (MAP, 2022). The American Nurses Association (ANA) firmly rejects any laws or policy measures that impose limitations on TGNC healthcare, or that criminalize gender-affirming care (ANA, 2022). According to Kano et al. (2019), TGNC individuals are less likely to disclose their sexual orientation and/or gender identity when uncomfortable with their healthcare providers, leading them to not seek preventative or urgent care. Therefore, it is imperative to educate future nurses on the best-practice medical care for TGNC individuals to understand how these discriminatory laws prevent holistic care for our patients. Society is progressing to the point where more individuals are comfortable talking about their sexual orientation and/or gender identity. However, Bonvicini (2017) suggests that despite the research gains in TGNC healthcare disparities made during the past fifteen years, education and training in gender-affirming care for healthcare professionals remains lacking. As a result, healthcare providers who care for TGNC individuals lack the education and training needed to reduce their bias toward the TGNC community. These biases may be either explicit or implicit. Explicit biases are attitudes and beliefs that are consciously accessible and controlled, whereas implicit biases are automatic responses that occur outside conscious awareness (Burke et al., 2015). The TGNC community faces significant healthcare disparities, yet nursing curricula fail to adequately address the unique healthcare needs of this population (Bonvicini, 2017). As a result, nurses and healthcare providers often lack the knowledge and skills needed to provide quality care for TGNC individuals (White et al., 2015). A study conducted by Lim et al. (2015) found less than one-third of nursing faculty in baccalaureate programs reported having a comprehensive understanding of TGNC health issues. This lack of preparation leaves nurse educators feeling unprepared to address the needs of the TGNC community. Therefore, it is essential to introduce education about gender-affirming care in nursing schools to ensure future nurses have the core competencies necessary to provide holistic care to individuals of all gender identities. According to White et al. (2015) and Bonvicini (2017), developing a knowledge base of health disparities experienced by the TGNC community is a critical first step in building empathy and understanding among future nurses. Methods Study design An integrative review is a specific methodology that effectively synthesizes previous empirical and theoretical literature to better understand a specific phenomenon or healthcare issue (Broome, 1993). Whittemore and Knafl's (2005) updated integrative review methodology (Table 2.1, See Appendix) was utilized to offer a clear picture of the current state of the science of baccalaureate nursing students' education regarding the care of TGNC individuals. By taking an integrative approach, the full potential of the available literature can be realized by including findings from all types of studies. Search method The search occurred in February 2024 and was limited to publications between January 2014 and February 2024 using the Cumulative Index of Nursing and Allied Health Literature (CINAHL) and PubMed databases with the following key search words and terms: “transgender,” “care,” “nursing,” and “education.” Manipulation occurred by forming Boolean building blocks “NOT surgery” and “NOT hormone” to narrow the search. Inclusion criteria comprised peer-reviewed publications in English from sources relevant to TGNC care in nursing education. Search outcome Initial searches produced 248 publications from CINAHL and 145 from PubMed, with three additional articles identified during manual investigation of references. The results from the two databases were cross-referenced for duplication, with 103 publications remaining. To further refine the search, cases involving hormone replacement and gender confirmation surgery were omitted, removing 83 publications and leaving 20 publications for screening to ensure alignment with the aim of the integrative review. Following this process, 13 publications were deemed relevant. Results Data evaluation The integrative review included 13 high-quality studies (Table 2.2, See Appendix). These studies were selected based on their relevance to TGNC care and the extent to which the findings contributed to the overall understanding of educating baccalaureate nursing students on TGNC care. Each study was subjected to a meticulous analysis, which involved identifying key themes, extracting relevant data, and synthesizing the findings to generate this integrated review. Data analysis The literature was meticulously scrutinized to ensure a rigorous analysis, identifying commonalities and patterns across the studies. By methodically grouping similar data into coherent themes, an understanding of the subject matter was attained, enabling the identification of key trends and patterns in the available literature. The analysis revealed two prominent themes: adequacy of the current nursing curriculum addressing TGNC care (n = 6) and potential educational interventions to enhance nursing education in this area (n = 7). Current nursing curricula addressing TGNC care The studies by Lim et al. (2015), Eickhoff (2021), White et al. (2015), Bonvicini (2017), Hand and Gedzyk-Niemman (2022), and McKay et al. (2022) collectively highlight significant gaps and deficiencies in current nursing curricula regarding TGNC care. Despite growing recognition of the importance of TGNC health education, these studies underscore the persistent inadequacies in preparing nursing students and educators to address the needs of TGNC patients competently. In a comprehensive national survey by Lim et al. (2015), over 1,000 nursing educators were polled to assess their perceptions of preparedness for discussing TGNC healthcare in the classroom. The results were concerning, with limited knowledge, experience, and readiness to teach gender-affirming care reported. In addition, the findings revealed that the average amount of time dedicated to lesbian, gay, bisexual, transgender, and queer (LGBTQ) community in the undergraduate nursing curriculum was just 2.12 hours, indicating a significant gap in the knowledge and skills of nurse educators when it comes to providing holistic care for TGNC individuals. In Eickhoff's (2021) study, a survey on TGNC health education was distributed to all Commission on Collegiate Nursing Education accredited schools. Using a cross-sectional descriptive design, Eickhoff found that nearly two-thirds of the responding schools felt that their graduates were unprepared to care for this population. Additionally, only 38% of the schools believed their faculty had the necessary knowledge to teach this content adequately. These results were consistent with the findings of Lim et al. (2015), which showed most nursing schools taught fewer than five hours of TGNC health-related content. Of concern, 13.3% of schools surveyed did not teach any content related to this population. White et al. (2015) conducted a large-scale online questionnaire, surveying 9,522 nursing students to evaluate their preparedness for providing care to the TGNC community. While most students felt at ease discussing HIV and sexually transmitted illnesses with this population, only a quarter felt comfortable addressing more sensitive topics such as gender transitioning or sex confirmation surgery. Moreover, most students believed there was room for improvement in TGNC-specific curricula. To supplement their findings, White et al. conducted focus group discussions using semi-structured scripts to explore the participants' preparedness and levels of comfort in caring for TGNC patients. During these discussions, most participants felt comfortable but not fully prepared to care for TGNC individuals. However, one participant expressed discomfort in caring for TGNC patients due to a lack of personal experience with the community. Bonvicini (2017) conducted a follow-up study almost 15 years after their initial research on lesbian and gay community disparities. Recognizing the need for inclusivity, Bonvicini incorporated the bisexual and TGNC community into the study, an aspect previously overlooked. Unfortunately, despite increasing TGNC-specific research over the years, nursing schools lack adequate education about TGNC healthcare. Bonvicini's review of leading nursing textbooks showed no practical discussions on sexual orientation or gender identity. Hand and Gedzyk-Niemman (2022) conducted a national survey of prelicensure nursing students to evaluate their preparedness and comfort levels while caring for LGBTQ patients. This multisite descriptive correlational study utilized a modified version of the LGBTQ Medical Education Assessment tool (Zumwalt et al., 2022) to collect data about students' perceived levels of preparedness and comfort. Results showed only 34% of the participants felt prepared to care for LGBTQ patients, while 49% felt somewhat prepared. However, 55% of the respondents attributed their preparedness to something other than their nursing education. McKay et al. (2022) conducted a pilot study to assess prelicensure nursing students' attitudes, beliefs, and willingness to provide care for TGNC individuals. Specifically, participants completed the Transgender Attitudes and Beliefs Survey (TABS) (Kanamori et al., 2017), a Willingness to Provide Care Questionnaire developed for the study, and a demographic questionnaire. The results indicate younger generations may be more accepting of TGNC individuals than their older counterparts (McKay et al., 2022), deviating from previously published research that reported increased discrimination and differential treatment of TGNC individuals. Furthermore, approximately 25% of the study participants reported providing nursing care for a TGNC client. Exposure to this content and the opportunity to care for TGNC individuals in a clinical setting may have resulted in more positive attitudes and a willingness to provide nursing care, as observed in the McKay et al. (2022) pilot study. Educational interventions The reviewed studies by McEwing (2020), Altmiller et al. (2022), Diaz et al. (2017), Elertson and McNiel (2021), Sherman et al. (2021), Koch et al. (2021), and McMillian-Bohler et al. (2022) collectively underscore the effectiveness and ongoing challenges of educational interventions aimed at enhancing nursing students' level of competency in providing care for TGNC individuals. These studies highlight innovative approaches, significant improvements in knowledge and attitudes, and the need for continuous development and evaluation of such educational programs. In 2020, McEwing designed an educational program specifically aimed at enhancing the competency of BSN students in caring for LGBTQ individuals. The program involved 124 students who participated in online modules and a simulation exercise exploring various LGBTQ-related health care topics. To evaluate the program's effectiveness, 108 participants completed surveys pre-intervention, immediately post-intervention, and one month post-intervention. McEwing's analysis showed a significant improvement in TGNC knowledge sub-scores, with scores increasing from pre- (M = 3.97) to post-intervention (M = 5.17); moreover, these scores did not decline significantly one month post-intervention (M = 4.98). A notable strength was utilizing the Sexual Orientation Councilor Competency Scale instrument, a valid and reliable measure for pre- and post-intervention assessments (McEwing, 2020). Additionally, the educational program was built on a theoretical and evidence-based framework. This framework focused on enhancing awareness, skills, and knowledge and provided a context that directly supported the educational program's goals. Despite its strengths, the project had some limitations. Firstly, it was self-contained and implemented only with two cohorts of BSN nursing students. Secondly, matching the time points for data collection was challenging due to the anonymity of the data. Consequently, the means were examined rather than individual responses. Altmiller et al. (2022) explored the impact of a virtual patient simulation (VPS) on nursing students' attitudes toward TGNC individuals compared with traditional classroom learning methods. The study utilized the TABS, a validated instrument designed to assess an individual's perspective on TGNC identity (Kanamori et al., 2017). Using a randomized controlled trial, the researchers analyzed data from 126 participants. Although the study did not yield statistically significant results regarding total TABS scores, there were significant findings in the human value subscale in the treatment group, indicating a positive effect of the VPS in affirming the value of TGNC people as individuals in the treatment group. These researchers shed light on the impact of VPS experiences on learner thinking, attitudes, and beliefs, emphasizing the potential of experiential learning in nursing education. Altmiller et al. also highlight the difference in attitudes towards TGNC individuals of senior- and junior-level nursing students, with senior students exhibiting greater receptiveness. However, further research is needed to establish the efficacy of VPS in nursing education and its potential to foster long-term attitudinal change. In Diaz et al.'s (2017) study, simulation was utilized to promote cognitive and reflective practice and investigate whether simulation could modify perceptions and attitudes toward the TGNC community. Diaz et al. revealed that despite students verbally reporting acceptance of the LGBTQ community to faculty, they often felt uncomfortable addressing sexual orientation and gender identity with patients. This highlights the need for nursing education to significantly change the future of nursing care for the LGBTQ community. Exposing nursing students to the most vulnerable populations through education and simulation could be a powerful tool for achieving this goal. In addition, given that nursing students may have limited exposure to TGNC individuals in clinical settings, simulation offers a safe space for them to examine their beliefs and attitudes toward this community and reflect on their practices. Elertson and McNiel (2021) conducted a groundbreaking pilot study aimed at enhancing nursing students' understanding and attitudes toward LGBTQ health. Their innovative approach involved the implementation of the highly regarded Students, Staff, and Faculty for Equality (SAFE) training program, which has gained nationwide recognition on college campuses for promoting inclusivity and diversity (Elertson & McNiel, 2021). A comprehensive online survey was distributed to 33 students, and reflective journal entries were shared with individual clinical course instructors, stimulating discussions about the care of LGBTQ individuals during post-clinical conference meetings. The study yielded encouraging results, with senior-level baccalaureate nursing students reporting a positive and enlightening experience accompanied by significant gains in knowledge. Sherman et al. (2021) aimed to provide an innovative solution to address the gaps in LGBTQ health education among nurse educators and nursing students at Johns Hopkins University. The study evaluated the preliminary efficacy of a TGNC-focused health curriculum using a self-administered online mixed-methods survey. The investigators analyzed pre- and post-intervention data about students’ knowledge and attitudes towards TGNC health. Survey data were collected at three crucial time points throughout the accelerated BSN program: at the program's onset, following the introductory webinar presented during the first semester, and after completing the pre-licensure program. Sherman et al. revealed a significant increase in the importance assigned by nursing students to knowing their patient's gender identity, underlining the positive impact of the TGNC health curriculum. However, the initiative faced internal and external limitations, as the researchers could not track individual student progress between time points due to the survey design, and some students may have opted out of non-required content or missed mandatory content. Additionally, the study's response rate was relatively low, highlighting the need for more focused efforts to increase retention in future studies. Koch et al. (2021) developed an interactive learning strategy to promote culturally sensitive care for TGNC individuals and their caregivers, utilizing a role-played simulation. The LGBTQ nursing student organization on campus reviewed and provided feedback on the culturally intelligent simulation scenario created by faculty, ensuring inclusive language, clarity, and cultural sensitivity. The simulation featured real people, including student volunteers and faculty, allowing participants to observe and empathize with the challenges TGNC patients and their families face when heteronormative assumptions are made, and inappropriate questions are asked. Nursing students reported that the simulation increased their empathy for patients and their understanding that "family" can be defined in various ways, including by choice rather than biology. While the study focused on one nursing school in the Southeast United States, the findings are relevant to other prelicensure and current healthcare providers. However, the study has limitations, including the lack of an assessment to compare knowledge before and after the intervention and no mention of whether the actors were TGNC or just portraying TGNC roles. Students might have benefited more if TGNC actors were used in the role-play scenario. McMillian-Bohler et al. (2022) recognized the potential benefits of sharing the lived experiences of pregnant transgender men with nursing students to increase awareness, understanding, and empathy for this underrepresented population. To achieve this, a transgender man shared his pregnancy experiences with students enrolled in a maternity course. Pre- and post-presentation surveys were administered to assess the students' perceptions of working with TGNC patients. During the seminar, the guest speaker shared his pregnancy experiences, including descriptions of inequitable treatment, invasion of privacy, disrespect, and general mistreatment. Although not explicitly stated as an objective of the seminar, most of the surveyed students reported a significant shift in their perspective about TGNC patients and an increased desire to learn more about providing quality care for pregnant TGNC individuals. Discussion TGNC individuals often face stigma and barriers nurses may not be fully aware of, resulting in their unique needs being overlooked. To provide culturally safe and affirming care, nursing students require education and exposure to best prepare them for clinical practice. This integrative review assessed the state of the science of baccalaureate nursing students’ preparedness to care for the TGNC community. This review highlighted two significant themes: the adequacy of the current nursing curriculum in addressing TGNC care and potential educational interventions to enhance nursing education in this area. Care of TGNC individuals remains an underemphasized topic in nursing curricula. Nationwide, baccalaureate nursing schools allocate fewer than five hours on average to LGBTQ health related topics (Lim et al., 2015; Eickoff, 2021), with leading nursing textbooks lacking practical discussions regarding sexual orientation or gender identity (Bonvicini, 2017). This gap not only perpetuates negative attitudes towards the LGBTQ community but also impedes the development of the necessary competencies for providing competent and compassionate care to LGBTQ individuals. Interestingly, Hand and Gedzyk-Niemman (2022) reported an increase in TGNC-related care preparedness among nursing students, but 55% of these students attributed their preparedness to something other than their nursing education. However, McKay et al. (2022) suggest that younger generations may be more accepting of TGNC individuals than their older counterparts. This leads me to believe that current nursing students are more receptive to including TGNC nursing care in the curricula. The reviewed studies collectively advocate for integrating comprehensive, evidence-based educational interventions in nursing curricula to enhance care for TGNC individuals. Several educational interventions have been explored, including online modules, SAFE seminars, virtual patient simulation, role-play simulation, and storytelling from TGNC patients. These have shown positive results in increasing nursing students' preparedness to care for TGNC patients. Educating future nurses about care for TGNC individuals directly addresses the American Association of Colleges of Nursing’s (AACN) essential domain of person-centered care by equipping them with the knowledge and skills to deliver respectful, individualized, and culturally sensitive healthcare tailored to the unique needs of TGNC individuals (AACN, 2021). Integrating these educational interventions into nursing programs would provide a more comprehensive approach to nursing education, emphasizing the importance of culturally safe and affirming care for all patients, regardless of gender identity. Implications The findings from the reviewed literature have significant implications for educating baccalaureate nursing students about gender-affirming care for the TGNC community. It is apparent that nurses often lack knowledge of the unique needs of TGNC individuals and are unaware of the stigma and barriers faced by this population. These findings suggest the need for additional education in nursing programs regarding the unique healthcare needs of the TGNC community. Exposing nursing students to the most vulnerable populations through education and simulation could be a powerful tool for achieving this goal. In addition, given that nursing students may have limited exposure to TGNC individuals in clinical settings, simulation offers a safe space for them to examine their beliefs and attitudes toward this community and reflect on their care practices. Using Rivera's Gender-Affirming Nursing Care Model, educators can effectively develop simulations tailored to gender-affirming care. By incorporating this framework, instructors can create comprehensive educational modules that cover topics such as cultural competence, hormone therapy, surgical options, and the psychosocial aspects of TGNC healthcare. Simulations can provide students with hands-on experience in providing respectful and empathetic care to TGNC patients, fostering a deeper understanding and sensitivity. This approach enhances the students' knowledge and skills and prepares them to deliver high-quality, inclusive care in their future nursing practice. Finally, nursing programs should evaluate curricula to ensure that health care topics affecting TGNC individuals are thoroughly covered and inclusively taught. These programs also should assess students' perceived preparedness to identify areas of content that require reinforcement. This, in turn, can help reduce the health disparities and discrimination faced by this vulnerable population. These findings can assist in guiding the design of faculty development programs and aligning curricula with current health priorities for the TGNC community. Additionally, nursing schools could consider collaborating with community-based organizations such as SAFE, which specialize in TGNC health, to provide students with hands-on experiences. Overall, this review emphasizes the need for nursing education to incorporate gender-affirming care for the TGNC community. As healthcare professionals, it is crucial to foster an environment that values diversity and promotes equitable healthcare for all patients, regardless of their gender identity. Conclusion Overall, this integrative review offers a valuable perspective on the literature regarding nursing education related to gender-affirming care for TGNC individuals. It highlights the critical need for nursing students to receive education about TGNC health and to interact with TGNC patients to provide culturally safe and affirming care for this population. Additionally, nursing schools should integrate educational interventions emphasizing gender-affirming care into their curricula to enhance students' preparedness for clinical practice. Furthermore, this review underscores the importance of keeping nursing curricula up to date with current health priorities for the TGNC community. Nursing schools should adopt a comprehensive approach to nursing education that includes the unique needs of TGNC individuals, addresses the gap in current nursing textbooks, and accounts for the inadequate time spent on LGBTQ-health related topics nationwide. References Altmiller, G. , Wilson, C. , Jimenez, F. & Perron, T. (2022). Impact of a virtual patient simulation on nursing students' attitudes of transgender care. Nurse Educator, Doi: 10.1097/NNE.0000000000001331. American Association of Colleges of Nursing. (2021). Welcome to the essentials. https://www.aacnnursing.org/essentials American Nurses Association. (2022). American Nurses Association opposes restrictions on transgender healthcare and criminalizing gender-affirming care. https://www.nursingworld.org/news/news-releases/2022-news-releases/american-nurses-association-opposes-restrictions-on-transgender-healthcare-and-criminalizing-gender-affirming-care Bonvicini K. A. (2017). LGBT healthcare disparities: What progress have we made?. Patient Education and Counseling, 100(12), 2357–2361. https://doi.org/10.1016/j.pec.2017.06.003 Broome M. (1993) Integrative literature reviews for the development of concepts. In B.L. Rodgers & K.A. Knafl (Eds) Concept Development in Nursing (2nd ed., pp. 231—250). W.B. Saunders Co. Díaz, D. A., Maruca, A., Gonzalez, L., Stockmann, C., & Hoyt, E. (2017). Using simulation to address care of the transgender patient in nursing curricula. BMJ Simulation & Technology Enhanced Learning, 3(2), 65–69. https://doi.org/10.1136/bmjstel-2016-000147 Eickhoff, C. (2021). Identifying gaps in LGBTQ health education in baccalaureate undergraduate nursing programs. Journal of Nursing Education, 60(10), 552–558. https://doi.org/10.3928/01484834-20210729-01 Elertson, K., & McNiel, P. L. (2021). Answering the call: Educating future nurses on LGBTQ healthcare. Journal of Homosexuality, 68(13), 2234–2245. https://doi.org/10.1080/00918369.2020.1734376 Hand, M. C., & Gedzyk-Nieman, S. (2022). Graduating nursing students' preparedness and comfort level in caring for LGBTQ+ patients. Journal of Professional Nursing, 41, 75-80. https://doi.org/10.1016/j.profnurs.2022.04.011 Herman, J.L., Flores, A.R., O'Neill, K.K. (2022). How many adults and youth identify as transgender in the United States?. UCLA Williams Institute http://williamsinstitute.law.ucla.edu/publications/trans-adults-united-states/ Kanamori, Y., Cornelius-White, J. H. D., Pegors, T. K., Daniel, T., & Hulgus, J. (2017). Development and validation of the transgender attitudes and beliefs Scale. Archives of Sexual Behavior, 46(5), 1503–1515. https://doi.org/10.1007/s10508-016-0840-1 Kano, M., Silva-Bañuelos, A. R., Sturm, R., & Willging, C. E. (2016). Stakeholders' recommendations to improve patient-centered "LGBTQ" primary care in rural and multicultural Practices. Journal of the American Board of Family Medicine, 29(1), 156–160. https://doi.org/10.3122/jabfm.2016.01.150205 Koch, A., Ritz, M., Morrow, A., Grier, K., & McMillian-Bohler, J. M. (2021). Role-play simulation to teach nursing students how to provide culturally sensitive care to transgender patients. Nurse Education Practice, 54, 103123. https://doi.org/10.1016/j.nepr.2021.103123 Lim, F. A., Johnson, M. J., & Elisason, M. J. (2015). A national survey of faculty knowledge, experience, and readiness for teaching lesbian, gay, bisexual, and transgender health in baccalaureate nursing programs. Nursing Education Perspectives, 36(3), 144–152. DOI: https://doi.org/10.5480/14-1355 McEwing, E. (2020). Delivering culturally competent care to the lesbian, gay, bisexual, and transgender (LGBT) population: Education for nursing students. Nurse Education Today, p. 94, 104573. https://doi.org/10.1016/j.nedt.2020.104573 McKay, M., De Santis, J., Valdes, B., & Salani, D. (2022). Prelicensure baccalaureate nursing students' attitudes, beliefs, and willingness to care for transgender clients. Journal of Nursing Education, 61(6), 322-325. https://doi.org/10.3928/01484834-20220404-10 McMillian-Bohler, J., Gedzyk-Neiman, S., Hepler, B., May, J. T., & Koch, A. (2022). The power of a story: Enhancing students' empathy for transgender pregnant men. Journal of Nursing Education, 61(8), 489-492. https://doi.org/10.3928/01484834-20220602-11 Movement Advancement Project (MAP). (2022). Healthcare laws and policies. https://lgbtmap.org/equality-maps/healthcare_laws_and_policies/ Rivera, D., Jukkala, A., & Rohini, T. (2022). Introduction to Rivera's Gender-Affirming Nursing Care Model: A middle-range theory. Journal of Holistic Nursing, 40(3), 255–264. https://doi.org/10.1177/08980101211046747 Sherman, A. D. F., Cimino, A. N., Clark, K. D., Smith, K., Klepper, M., & Bower, K. M. (2021). LGBTQ+ health education for nurses: An innovative approach to improving nursing curricula. Nurse Education Today, 97, 104698. https://doi.org/10.1016/j.nedt.2020.104698 White, W., Brenman, S., Paradis, E., Goldsmith, E., Lunn, M., Obedin-Maliver, J., Stewart, L., Tran, E., Wells, M., Chamberlain, L., Fetterman, D., & Garcia, G. (2015). Lesbian, gay, bisexual, and transgender patient care: medical students’ preparedness and comfort. Teaching and Learning in Medicine, (27)3, 254-263; DOI: https://doi.org/10.1080/10401334.2015.1044656 Whittemore, R., & Knafl, K. (2005). The integrative review: updated methodology. Journal of Advanced Nursing, 52(5), 546–553. https://doi.org/10.1111/j.1365-2648.2005.03621.x Zumwalt, A. C., Carter, E. E., Gell-Levey, I. M., Mulkey, N., Streed, C. G., Jr, & Siegel, J. (2022). A novel curriculum assessment tool, based on aamc competencies, to improve medical education about sexual and gender minority populations. Academic Medicine : Journal of the Association of American Medical Colleges, 97(4), 524–528. https://doi.org/10.1097/ACM.0000000000004203 Appendix Table 2.1 Integrative review methodology Stage of review Process Problem identification The review begins with clearly identifying the problem and the intended purpose. Additionally, the variables of interest, such as the target population, concepts, and healthcare problems, are carefully selected. Finally, the appropriate sampling frame is established by the type of empirical studies and the inclusion of a theoretical framework Literature Search A well-defined literature search strategy is critical for enhancing the rigor and precision of any review. Conversely, vague and biased searches can lead to an insufficient database and the possibility of inaccurate results, underscoring the necessity of a thorough search approach Data evaluation Evaluating the quality of primary sources in an integrative review is a multifaceted task that requires careful consideration. To ensure the highest level of accuracy and credibility, it is essential to address the quality of primary sources in a meaningful manner Data analysis Extracted data are compared, enabling the identification and grouping of similar data. Additionally, these grouped data are compared furthering the analysis process Presentation (Implications) The results obtained from the review encapsulate the comprehensive depth and breadth of the topic under consideration, providing new insights into the phenomenon of interest. Furthermore, the review findings emphasize the practical implications for clinical practice and the relevance for research and policy initiatives Note: Whittemore & Knafl, 2005 Table 2.2. Data display: Summary of literature Author/Year Title Objective Conclusion Altmiller, G. , Wilson, C. , Jimenez, F. & Perron, T. (2022) “Impact of a Virtual Patient Simulation on Nursing Students' Attitudes of Transgender Care” To explore the impact of a virtual patient simulation scenario involving the care of a transgender and gender nonconforming (TGNC) adult on nursing students’ attitudes, beliefs, and overall readiness to provide affirming, culturally sensitive care to TGNC individuals. The findings highlight experiential learning as an effective approach for enhancing cultural competence and sensitivity in nursing education, particularly in the care of TGNC patients. Differences were noted between junior and senior nursing students, with senior students demonstrating greater openness and acceptance toward TGNC individuals. Bonvicini, K. (2017) “LGBT Healthcare Disparities: What Progress Have We Made?” To critically examine the current state of medical and nursing education with a specific focus on the development of clinical competence in providing inclusive, evidence-based care for LGBTQ populations. Although nursing education has incorporated more content on cultural competence, significant gaps and inconsistencies remain in preparing nurses to provide effective care for LGBTQ patients. Díaz, D., Maruca, A., Gonzalez, L., Stockmann, C., & Hoyt, E. (2017) “Using simulation to address care of the transgender patient in nursing curricula” This manuscript explores nursing students’ perceptions of their professional role and responsibilities when delivering care to transgender and gender nonconforming (TGNC) patients within a simulated clinical environment. Findings indicate that many students rarely, if ever, engage in conversations about gender identity. Although they report being open and accepting of the LGBTQ community with faculty, they express discomfort in fostering an environment that supports self-identification. Table 2.2 Continued Eickhoff, C. (2021) “Identifying Gaps in LGBTQ Health Education in Baccalaureate Undergraduate Nursing Programs” Educating nurses and other healthcare professionals is essential to overcoming barriers to equitable care; however, there is limited information regarding the current state of LGBTQ health education in nursing programs. To address this gap, a survey assessing LGBTQ health content offered to undergraduate nursing students was distributed to all schools accredited by the Commission on Collegiate Nursing Education. Nearly two-thirds of participating schools reported that their graduates were not sufficiently prepared to provide care for LGBTQ populations. Additionally, only 38% of schools believed their faculty possessed the necessary knowledge to effectively teach this content. These findings highlight a dual need for enhanced LGBTQ health education for both nursing students and faculty. Elertson, K., & McNiel, P. L. (2021) “Answering the Call: Educating Future Nurses on LGBTQ HealthCare” To enhance the knowledge, attitudes, and cultural competence of senior-level baccalaureate nursing students in relation to LGBTQ health and inclusive care practices. Through this pilot training and curricular revision, baccalaureate nursing students are developing greater cultural awareness and are increasingly equipped to address the healthcare needs of the LGBTQ population. Hand, M. C., & Gedzyk-Nieman, S. (2022). “Graduating nursing students' preparedness and comfort level in caring for LGBTQ patients” To administer a nationwide survey of graduating prelicensure nursing students in order to evaluate their self-reported preparedness and comfort in delivering care to LGBTQ patients. Students reported that LGBTQ health topics were addressed within their nursing programs; however, certain areas were identified as needing additional focus. While most students expressed feeling prepared and comfortable providing care to LGBTQ individuals, they did not credit their formal education as the primary source of this readiness. Table 2.2 Continued Koch, A., Ritz, M., Morrow, A., Grier, K., & McMillian-Bohler, J. M. (2021) “Role-play simulation to teach nursing students how to provide culturally sensitive care to transgender patients.” To enhance students’ knowledge and confidence in providing affirming care to TGNC individuals, while also strengthening their ability to address and challenge culturally insensitive behaviors among peers and colleagues. Simulation has the potential to reduce discomfort and discrimination in healthcare settings for TGNC patients by preparing students with culturally sensitive, inclusive communication skills. Lim, F. A., Johnson, M. J., & Elisason, M. J. (2015) “A National Survey of Faculty Knowledge, Experience, and Readiness for Teaching LGBTQ Health in Nursing Programs” To evaluate the knowledge base and instructional readiness of faculty in baccalaureate nursing programs regarding LGBTQ health topics. These findings can inform the development of faculty training initiatives and support the alignment of nursing curricula with contemporary LGBTQ health priorities. McEwing, E. (2020) “Delivering culturally competent care to the lesbian, gay, bisexual, and transgender (LGBT) population: Education for nursing students” Although healthcare disparities within the LGBTQ community are well established, nursing education has fallen behind other health professions in advancing culturally competent care for this population. Integrating cultural competency education into nursing curricula has the potential to enhance health outcomes for individuals within the LGBTQ community. McKay, M., De Santis, J., Valdes, B., & Salani, D. (2022) “Prelicensure Baccalaureate Nursing Students' Attitudes, Beliefs, and Willingness to Care for Transgender Clients” This pilot study explored the attitudes, beliefs, and willingness of prelicensure nursing students to provide care for TGNC individuals. Most prelicensure nursing students who participated in this pilot study expressed a willingness to provide care for TGNC clients. However, further research is necessary to identify and address their specific learning needs related to delivering competent and inclusive care for TGNC individuals. Table 2.2 Continued McMillian-Bohler, J., Gedzyk-Neiman, S., Hepler, B., May, J. T., & Koch, A. (2022). “The Power of a Story: Enhancing Students' Empathy for Transgender Pregnant Men.” Amplifying the lived experiences of pregnant transgender men can foster greater awareness, deepen understanding, and cultivate empathy for this underrepresented and often overlooked population. Nursing faculty can enhance student empathy and help reduce discrimination in healthcare by creating opportunities for students to engage directly with TGNC individuals through meaningful conversations and shared experiences. Sherman, A. D. F., Cimino, A. N., Clark, K. D., Smith, K., Klepper, M., & Bower, K. M. (2021) “LGBTQ+ Health Education for Nurses: An Innovative Approach to Improving Nursing Curricula” The Johns Hopkins School of Nursing (JHSON) launched the LGBTQ Health Initiative (LHI) to implement a strategic and innovative approach aimed at addressing educational gaps in LGBTQ health content among nursing faculty and students. The JHSON LHI logic model serves as a replicable framework that equips nurse educators and students with the essential knowledge and tools needed to address the profound healthcare disparities experienced by LGBTQ populations. White, W., Brenman, S., Paradis, E., Goldsmith, E., Lunn, M., Obedin-Maliver, J., Stewart, L., Tran, E., Wells, M., Chamberlain, L., Fetterman, D., Garcia, G. (2015) “Lesbian, Gay, Bisexual, and Transgender Patient Care: Medical Students’ Preparedness and Comfort.” To examine the structure and scope of LGBTQ-related content within nursing curricula, assess students’ perceptions of their institution’s inclusivity and adequacy in this area, and evaluate their self-reported preparedness to provide care for LGBTQ patients. Expanding LGBTQ-related content within nursing curricula is recommended, particularly through increased opportunities for students to engage with LGBTQ patients in clinical practice settings. CHAPTER THREE: RIVERA’S GENDER AFFIRMING NURSING CARE MODEL: A MIDDLE-RANGE THEORY: ANALYSIS AND EVALUATION A version of this chapter was originally prepared for the Journal of Holistic Nursing by Edward D. Petrie. The required citation format for this journal is that of the American Psychological Association, 7th Edition. Abstract Background: To holistically address healthcare disparities and the potential impact on transgender and gender non-conforming (TGNC) individuals, Rivera et al. (2022) introduced a middle-range theory that focuses on addressing nursing care and outcomes for TGNC individuals. Rivera’s Gender Affirming Nursing Care Model supports developing gender-affirming knowledge and care practices within nursing to improve healthcare outcomes. Initially, her explorative work commenced as a narrative inquiry, delving into nurses' assumptions regarding TGNC patients. Gradually, this narrative evolved into a remarkable theoretical framework, which was subsequently polished and refined by the expertise and mentorship of esteemed professionals such as Drs. Lisa Goldberg, Susan Luparell, and Jean Watson. Method: In this article, Rivera’s Gender Affirming Nursing Care Model was critically appraised using criteria outlined by Fawcett and DeSanto-Madeya (2013). Conclusion: This theory equips nursing with the necessary resources to foster enhanced health outcomes for the TGNC community. While its practical application in the nursing field may be limited, the concepts embodied in the theory can potentially promote transformative social change in nursing research, education, and practice. As such, this theory represents a vital steppingstone towards realizing more inclusive and equitable healthcare practices and paves the way for a brighter future for the TGNC community. Introduction The American Psychological Association (APA, 2015) defines gender as the attitudes, feelings, and behaviors that a given culture associates with an individual’s biological sex. Health research typically reinforces a binary concept of gender, evident in how sex and gender (often used interchangeably) are represented as male/female, men/women, or boys/girls in studies involving human participants (Lightfoot et al., 2021). This effectively erases participants who identify between or outside these binary categories, a growing population known as transgender and gender non-conforming (TGNC) individuals (Clark et al.,2018). TGNC is an umbrella term for individuals whose gender expression, identity, or role diverges from the gender norms associated with their biological sex (APA, 2015). The marginalization of TGNC individuals in healthcare is worsened by cisnormativity, which is the belief that being cisgender is the norm and expectation (Lightfoot et al., 2021). Cisgender refers to individuals whose gender expression, identity, or role aligns with the gender norms associated with their biological sex (APA, 2015). The misconception that TGNC individuals are rare contributes to cisnormativity, which can manifest as binary gender markers on forms, billing, and medical records (Lightfoot et al., 2021). Nurses operating in this cisnormative environment receive little to no training about providing competent, patient-centered care to TGNC individuals (Lim et al., 2015). TGNC individuals are increasingly visible in society and healthcare settings; however, more attention is needed to their specific healthcare needs to overcome disparities this population faces. These disparities arise from various factors, including discrimination, biases, stigma, inadequate education for healthcare providers, and limited access to affordable gender-affirming healthcare services (Kano et al., 2019). For example, Lightfoot et al. (2021) concluded that TGNC individuals are more likely to experience mental health issues such as anxiety, depression, substance abuse, and suicide than the general population.  Additionally, they may encounter barriers to accessing essential healthcare services, such as preventive screenings and routine care. Addressing these disparities requires a multi-faceted approach that includes improving education for healthcare providers, increasing access to gender-affirming healthcare services, and tackling systemic discrimination and stigma. In recent years, there has been a concerning trend of political attacks on TGNC people, resulting in several states restricting or prohibiting access to best-practice medical care for TGNC youth (MAP, 2022). According to Kano et al. (2019), LGBTQ individuals are less likely to disclose their sexual orientation or gender identity when they feel uncomfortable with their healthcare providers, leading to a reluctance to seek preventative or urgent care. Therefore, it is crucial to educate future nurses on the best-practice medical care for TGNC individuals to ensure they understand how these discriminatory laws hinder holistic-centered care for patients. Rivera et al. (2022) have made significant contributions to healthcare by introducing a middle-range theory that addresses healthcare disparities holistically and improves outcomes for TGNC individuals. Their theory, the Gender Affirming Nursing Care Model (GANC), promotes gender-affirming knowledge and care practices within nursing. This approach can enhance healthcare outcomes and reduce disparities in care for this vulnerable population. However, to ensure the validity and reliability of GANC, it is essential to subject the theory to rigorous scientific scrutiny. Therefore, this article offers a comprehensive analysis and evaluation of GANC using the well-established approach proposed by Fawcett and DeSanto-Madeya (2013). Theory Analysis A theory is usually developed to articulate a unique and comprehensive concept regarding a phenomenon, addressing previously unaddressed questions and providing a fresh perspective on the nature of the phenomenon (Walker & Avant, 2019). Theory analysis involves an objective and thorough evaluation of a theory's strengths and limitations, with particular emphasis on its usefulness, clarity, relevance, and practicality in nursing practice (Walker & Avant, 2019). I used the analysis framework that Fawcett and DeSanto-Madeya (2013) developed, producing a descriptive, analytical, and critical interpretation summarized in three categories: theory scope, context, and content. Theory Scope Examining the theory's scope is crucial because it helps assess the theory's unique and distinct focus (Fawcett & DeSanto-Madeya, 2013). While nursing models are generally grounded in a broad understanding of the purpose of nursing, these models provide unique perspectives on the concepts within the nursing metaparadigm. Therefore, the scope of theory is vital in identifying the specific areas in which the authors emphasize their insights, highlighting variations in the nursing model influenced by factors such as nursing situations, client concerns, environment, nursing outcomes, and nursing therapeutics (Fawcett & DeSanto-Madeya, 2013). Rivera (2019) eloquently narrated the journey that led to the development of her groundbreaking middle-range theory. Her explorative work, initially a narrative inquiry into nurses' assumptions regarding TGNC patients, gradually evolved into a remarkable theoretical framework. This framework was then meticulously polished and refined under the mentorship of esteemed professionals such as Drs. Lisa Goldberg, Susan Luparell, and Jean Watson, ultimately resulting in a formidable middle-range theory. Rivera et al. (2022) aimed to address the marginalization and discrimination experienced by TGNC individuals in healthcare. The authors proposed that to facilitate holistic nursing practice, nurses should engage in self-reflection to enhance their personal awareness of the interconnectedness between themselves and others. This, in turn, creates opportunities for relational learning and cultural humility. As Fahlberg et al. (2016) assert, cultural humility is an ongoing process that requires maintaining an open mind and heart, recognizing that the process is never fully mastered, and constantly evolving with each encounter. This cultural humility underpins the GANC and plays a key role in promoting positive health outcomes. Middle-range theories can be classified as descriptive, explanatory, or prescriptive. In this context, Rivera et al. (2022) introduced a prescriptive theory designed to guide action in nursing education, practice, and research, with the goal of delivering holistic, patient-centered care to TGNC patients. As Fawcett and DeSanto-Madeya (2013) note, prescriptive theories are essential in guiding decision-making and action, providing clear direction on the specific steps needed to achieve a given objective. In nursing and healthcare, the GANC serves as a powerful tool for promoting positive health outcomes and enhancing the quality of care for TGNC patients. Theory Context The theory context examines the historical evolution of the nursing model and investigates the author's motivation for developing it (Fawcett & DeSanto-Madeya, 2013). The creation of a nursing model also includes the author's personal nursing philosophy, values, and beliefs, the process of knowledge acquisition used in developing the model, the influence of other nursing scholars and related fields on the author's perspective, and the worldview expressed in the nursing model (Fawcett & DeSanto-Madeya, 2013). Rivera et al. (2022) applied Fawcett's (2013) criteria to develop the GANC model. The GANC model centers on holistic patient wellness by shifting the nursing paradigm from a gender-binary framework to one of gender transcendence and affirmation fostered by gender-affirming interactions (Rivera et al., 2022). The GANC model, developed by Rivera et al., serves not just as a theoretical construct but as a transformative tool with the potential to revolutionize gender-affirming care. It incorporates elements from critical and interaction theories to achieve this phenomenon. The choice of Critical Theory (Weaver & Olson, 2006) was made due to its inclusive constructs and nurse-patient interactions, which represent a cooperative manifestation of a shared understanding of meaning that holds the potential to enhance both equality and equity. The GANC model acknowledges the crucial importance of self-reflection; thus, this theory establishes a strong foundation for developing gender-affirming therapeutic connections between nurses and patients. According to Scheel et al. (2008) and their Interactional Theory, the nursing relationships outlined in the GANC model are characterized by reciprocity and an emphasis on understanding through dialogue and action. This reciprocal interaction between nurses and patients pertains to all aspects of care. Interactional Theory is built upon principles such as Internal Good, External Good, Goals, Ethical Action, Speech Action, and Avoidance of Instrumental Strategic Action. The two theories were selected for their synergistic properties, which include being based on a view of caring within the humanistic paradigm, exhibiting a high degree of consistency and alignment that supports face validity, emerging from a collaborative inductive research process, and being informed by a synthesis of existing literature on cultural humility, caring, and the social construct of holistic nursing practice (Rivera et al., 2022). This collaborative approach is not merely a theoretical construct; it serves as a call to action for all nursing professionals, scholars, and students interested in gender-affirming care and nursing theories. These aspects ensure that the theories work cohesively while grounded in evidence-based research and practical application. Ultimately, these synergistic properties enhance the effectiveness and relevance of the theory in nursing, especially in fostering a culture of caring and humility in healthcare. Consequently, the GANC model offers a distinctive approach to cultivating culturally sensitive relationships for both TGNC and cisgender individuals (Rivera et al., 2022). Theoretical assumptions are fundamental to any theory and reflect the beliefs and values of the theorist. The GANC theory operates on the assumption that gender-affirming nursing care transcends gender, embraces an all-inclusive approach, and advocates for a paradigm shift from a gender-binary worldview to a gender-affirming one, eliminating social struggle and oppression (Rivera et al., 2022). This assumption is not just impressive, but it's a testament to the respect and value the GANC model places on all individuals, regardless of gender identity. The theory emphasizes the importance of a therapeutic relationship with the person receiving care, the acquisition of knowledge about gender transition and affirming care, and the recognition that the individual is the "owner" of their decisions (Rivera et al., 2022). Overall, these assumptions provide a strong foundation for gender-affirming nursing care and serve as an essential guide for nurses who strive to support and advocate for individuals with diverse gender identities. Theory Content A key aspect of this analysis involves examining the general concepts of the model, along with the relational propositions that define and connect those concepts. Specifically, the four metaparadigm domains of person, health, environment, and nursing are essential to this analysis. The content of the nursing model includes defining and describing each of these concepts, outlining the overarching goals of nursing, detailing the nursing practice, and exploring the relationships among the four metaparadigm domains. By undertaking this analysis, nurses can achieve a deeper understanding of the theoretical foundations of their profession and apply this knowledge meaningfully and informedly to their daily practice. Rivera et al. (2022) present the three concepts that create a comprehensive framework for nurses when caring for TGNC patients. The first concept, relationships, emphasizes the importance of establishing a strong connection between the nurse and the patient that is grounded in trust, empathy, and mutual respect (Rivera et al., 2022). This relationship-building process fosters a safe and supportive environment for the patient, which is crucial for their overall well-being. A strong relationship also allows the nurse to understand the patient's unique needs and preferences, informing their care. The second concept, knowledge, highlights the nurse's role in grasping and clarifying current and emerging TGNC care (Rivera et al., 2022). This includes understanding the patient's specific needs, medical treatments, and social and cultural factors that may influence their care. The third concept, engagement, centers around the nurse's actions within the care delivery system and society (Rivera et al., 2022). This encompasses advocating for the patient's rights, educating other healthcare providers, and addressing systemic barriers that may affect the patient's care. By engaging in these actions, the nurse can help cultivate a more inclusive and supportive healthcare environment for TGNC patients. Overall, these three concepts present a comprehensive framework for nurses to follow in caring for TGNC patients. Through building solid relationships with their patients, understanding their unique needs and preferences, and engaging in advocacy and education, nurses can deliver high-quality, patient-centered care that supports the health and well-being of TGNC individuals. The GANC model, with its potential to advance nursing science, empowers nurses by facilitating the generation and testing of hypotheses through relational propositions (Rivera et al., 2022). The information in Table 3.1 (See Appendix), which links the concepts of gender-affirming nursing care to relational propositions, serves as a guide for continued practice and research. The validation of the GANC model through scholarly exploration is crucial, as it provides empirical evidence of its impact on holistic health outcomes (Rivera et al., 2022). This validation reinforces the importance of gender-affirming nursing care and enhances the quality of nursing practice, instilling confidence and capability in nurses. Nursing characteristics are essential for delivering quality care to patients. These traits develop through a combination of formal education and clinical experiences, enabling nurses to acquire the knowledge, skills, and attitudes necessary for their role (Fawcett, 2013). As healthcare professionals, nurses must be mindful of their implicit and explicit biases to provide respectful and compassionate care to all patients, including those who identify as LGBTQ+ (Rivera, 2022). By nurturing a gender-affirming practice, nurses can deliver care that acknowledges and respects the diversity of patients' identities, enhancing health outcomes and overall patient satisfaction. Clear and concise categorization and definition of these characteristics to assist nurses in better understanding and implementing them in their practice are presented in Table 3.2 (See Appendix). Rivera's GANC theory is a holistic approach to nursing care that acknowledges the importance of the nurse's impact on the person, health, environment, and nursing domains. The theory emphasizes recognizing the interactions between GANC concepts within each domain. According to Rivera et al. (2022), the person receiving care is a unique individual or group who is continuously evolving with a sense of identity and self-worth; health is not static, but a dynamic state on an illness-wellness continuum; the environment includes all external and internal influences and forces affecting the nurse-patient (group) interaction; and the ultimate goal of gender-affirming nursing care is to achieve holistic patient wellness. This holistic approach promotes a comprehensive understanding of the patient's needs and experiences. Theory Evaluation Fawcett and DeSanto-Madeya's (2013) process of theory evaluation is a systematic approach to assessing nursing theories. The process comprises six steps: (1) significance, (2) internal consistency, (3) parsimony, (4) testability, (5) empirical adequacy, and (6) pragmatic adequacy. Each step includes specific criteria that are used to evaluate the theory in question. This process aims to assist nurses in critically examining theories and determining their relevance for guiding nursing practice and research. By employing this method, nurses can evaluate the strengths and weaknesses of a theory to make informed decisions about its application. Significance Evaluating a theory's significance involves assessing whether its concepts and propositions stem from philosophical viewpoints and whether its conceptual models are anchored in philosophical principles (Fawcett & DeSanto-Madeya, 2013). Rivera’s GANC model (2022) was developed using Fawcett’s (2013) criteria for theory development criteria, taking a holistic view of TGNC individuals with the aim of building nurse-patient relationships through gender-affirming care. Rivera et al. (2022) clearly address the person, health, environment, and nursing metaparadigm domains and their relationship with the GANC theory in the nursing discipline. The GANC model is rooted in critical and interactional theories, chosen for their synergistic properties, and reflects a caring perspective within the humanistic paradigm. Rivera et al. (2022) expressed their gratitude to Willa Starke, Trystan Reese, and Hannah Simpson for their contributions to the development and evaluation of the GANC from the TGNC patient's perspective, as well as to Dr. Lisa Goldberg, Dr. Susan Luparell, and Dr. Jean Watson for their theoretical expertise and mentorship in refining the middle-range theory. The GANC model emphasizes the importance of relationships, knowledge, and engagement for nurses to provide compassionate and effective care to TGNC patients, thereby achieving holistic patient wellness (Rivera et al., 2022). Holistic wellness is a complex concept that encompasses physical health as well as emotional and social well-being. Gender-affirming nursing actions can support this type of wellness, fostering therapeutic communication and trust between the patient and the nurse. When a caring relationship is established, it can positively affect the patient's overall well-being. Therefore, nurses who advocate for healthcare equity can contribute to improved patient outcomes; additionally, care partners who engage in lifelong learning and gain wisdom will positively impact holistic patient wellness (Rivera et al., 2022). Finally, by addressing these various aspects of care, nurses and care partners can collaborate to support their patients' holistic wellness (Rivera et al., 2022). Internal Consistency Internal consistency refers to the coherence and harmony among the components of a theory, which encompass the clarity and consistency of its concepts, propositions, and definitions (Fawcett & DeSanto-Madeya, 2013). Rivera et al. (2022) clearly describe the three concepts, four propositions (Table 3.1), and definitions of nursing characteristics (Table 3.2). Gender-affirming language is uniformly used throughout the concepts, propositions, and nursing characteristics. Structural consistency is demonstrated by Rivera et al. (2022) using Fawcett’s (2013) framework to develop the GANC. Parsimony The principle of parsimony refers to the ability of a theory to explain phenomena clearly while using as few concepts and propositions as possible. Additionally, parsimony helps reduce complexity, increase clarity, and enhance the testability of nursing theories (Fawcett & DeSanto-Madeya, 2013). In this context, Rivera’s (2022) GANC model stands out as a prime example of parsimony in action, incorporating just three concepts, four propositions, and 13 nursing characteristics. The information presented clarifies the theory, which contains a justified and essential number of concepts, propositions, and nursing characteristics, with no overlap. This carefully calibrated balance ensures the theory is both comprehensive and streamlined, with each component crucial for illuminating the complexity of caring for TGNC individuals. Testability Testability pertains to the extent to which the scientific value of a theory can be validated through empirical testing. This can be determined by examining whether the research methodology aligns with the theory, whether there are available scales to measure observable concepts, and whether the propositions of the theory can be assessed through statistical analysis (Fawcett & DeSanto-Madeya, 2013). Rivera et al. (2022) developed the GANC Nursing Characteristics Evaluation Tool to assess gender-affirming nursing practice behaviors, which includes a list of empirical indicators for model testing. They created this tool for future research. After examining the article, the tool was not located; however, this does not negate the methodology of the GANC Nursing Characteristics Evaluation Tool. Empirical Adequacy Empirical adequacy refers to the extent to which a theory or model corresponds with observed empirical data or evidence (Fawcett & DeSanto-Madeya, 2013). A theory is deemed to have empirical adequacy when it is supported by empirical evidence gathered from observations, experiments, or other forms of data collection (Fawcett & DeSanto-Madeya, 2013). A review of the literature identified two articles by Rivera conducted during the development of the GANC model. The first study aimed to explore the lived experiences of TGNC patients to inform potential nursing curricular modifications (Rivera, 2019). Through a narrative inquiry approach, the study examined the patients' perspectives on the quality of the nursing care they received. The second study aimed to create and pilot test the Transgender Fertility Preservation Knowledge Scale to support the development and assessment of health education resources (Rivera et al., 2021). Rivera's GANC model shows promise, but its applicability is limited beyond the original theorist's work. Therefore, it is crucial that future research focuses on establishing the empirical adequacy of the GANC model with greater certainty. By doing so, we can more fully comprehend potential impact of the model and identify any areas where it may need refinement or improvement to better meet the needs of TGNC patients. Pragmatic Adequacy Pragmatic adequacy refers to practical usefulness and effectiveness of a theory or model in solving real-world problems and achieving specific goals (Fawcett & DeSanto-Madeya, 2013). A theory is deemed to possess pragmatic adequacy when it can be effectively applied in various contexts and holds practical value in addressing specific issues or challenges (Fawcett & DeSanto-Madeya, 2013). Further research is necessary to evaluate the pragmatic adequacy of Rivera’s GANC model. Nevertheless, it is reasonable to assume that the concepts related to Rivera's GANC model could be integrated into nursing research and practice, offering potential practical benefits. I concur with Rivera et al.'s (2022) assertion that numerous studies illustrate the positive effects of applying the concepts associated with the GANC model on patient outcomes. The evidence supporting gender-affirming nursing care is expanding. Researchers have consistently demonstrated that this approach can improve patient satisfaction, reduce healthcare disparities, and promote better health outcomes for TGNC individuals (Clark et al., 2018; Lightfoot et al., 2021; Rivera, 2019; & Rivera et al., 2021). Specifically, the emphasis of the GANC model on fostering therapeutic relationships, acquiring knowledge about TGNC care, and advocating for patients' rights has positively influenced patient outcomes. These concepts align with the core values of the nursing profession, which include patient-centered care, respect for patient autonomy, and advocacy for social justice, and can potentially enhance the quality of care for TGNC patients. Conclusion In this comprehensive analysis, the structural and functional components of Rivera's GANC were meticulously examined and assessed using the rigorous standards established by Fawcett and DeSanto-Madeya (2013). This investigation aimed to provide insights into Rivera’s GANC that would help shape and refine the delivery of high-quality nursing care for the TGNC community. This middle-range theory generally fulfills most of the criteria, except for empirical and pragmatic adequacy. Although there is tentative support for the empirical adequacy of the theory based on Rivera's studies and the its logical coherence, it falls short in terms of pragmatic adequacy due to the lack of practical application. Despite this limitation, the relevance of the theory in addressing the persistent health disparities experienced by the TGNC community cannot be understated, making it a timely and essential contribution to the field of healthcare research. Rivera's GANC (2022) marks a significant advancement in gender-affirming care. Grounded in cultural humility and holism, this prescriptive theory delineates specific nursing actions and characteristics vital for delivering comprehensive and compassionate gender-affirming care. By integrating evidence-informed practices, gender-affirming nursing care can create synergistic effects that lead to superior health outcomes across all demographics. This holistic approach to nursing care has the potential to transform the healthcare landscape and foster a more equitable and inclusive healthcare system. However, while the evidence supporting the GANC model is promising, it's essential to acknowledge that considerable work remains in advancing inclusive and equitable healthcare for TGNC individuals. This need highlights the necessity for further research and the implementation of Rivera's GANC to enhance healthcare for TGNC individuals continuously. References American Psychological Association. (2015). Key terms and concepts in understanding gender diversity and sexual orientation among students. https://www.apa.org/pi/lgbt/programs/safe-supportive/lgbt/key-terms.pdf Clark, B., Veale, J., Townsend, M., Frohard-Dourlent, H., & Saewyc, E. (2018). Non-binary youth: Access to gender-affirming primary health care, International Journal of Transgenderism, 19:2, 158–169, https://doi/10.1080/15532739.2017.1394954 Fahlberg, B., Foronda, C., & Baptiste, D. (2016). Cultural humility: The key to patient/family partnerships for making difficult decisions. Nursing, 46(9), 14–16. https://doi.org/10.1097/01.NURSE.0000490221.61685.e1 Fawcett J. (2013). Thoughts about conceptual models, theories, and literature reviews. Nursing Science Quarterly, 26(3), 285‐288. https://doi.org/10.1177/0894318413489156 Fawcett, J., & DeSanto-Madeya, S. (2013). Framework for analysis and evaluation of nursing theories. In Contemporary nursing knowledge: Analysis and evaluation of nursing models and theories (3rd ed., pp. 311-318). F.A. Davis. Kano, M., Silva-Bañuelos, A. R., Sturm, R., & Willging, C. E. (2016). Stakeholders' recommendations to improve patient-centered "LGBTQ" primary care in rural and multicultural practices. Journal of the American Board of Family Medicine, 29(1), 156–160. https://doi.org/10.3122/jabfm.2016.01.150205 Lightfoot, S., Kia, H., Vincent, A., Wright, D. K., & Vandyk, A. (2021). Trans-affirming care: An integrative review and concept analysis. International Journal of Nursing Studies, 123, 104047. https://doi.org/10.1016/j.ijnurstu.2021.104047 Lim, F. A., Johnson, M. J., & Elisason, M. J. (2015). A national survey of faculty knowledge, experience, and readiness for teaching lesbian, gay, bisexual, and transgender health in baccalaureate nursing programs. Nursing Education Perspectives, 36(3), 144–152. doi: https://doi.org/10.5480/14-1355 Movement Advancement Project (MAP). (2022). Healthcare laws and policies. https://lgbtmap.org/equality-maps/healthcare_laws_and_policies/ Rivera, D. (2019). Care without assumptions: The perceptions of transgender persons regarding their experiences with nursing care. International Journal for Human Caring, 23(3), 242-253. DOI: 10.20467/1091-5710.23.3.242 Rivera, D., Jukkala, A., Mistretta, K., & Starke, W. (2021). Development and pilot testing of the transgender and gender diverse fertility preservation knowledge scale. Preprints 2021. https://doi.org/10.20944/preprints202107.0524.v1 Rivera, D., Jukkala, A., & Rohini, T. (2022). Introduction to Rivera's Gender Affirming Nursing Care Model: A middle-range theory. Journal of Holistic Nursing, 40(3), 255–264. https://doi.org/10.1177/08980101211046747 Scheel M. E., Pedersen B. D., & Rosenkrands V. (2008). Interactional nursing: A practice theory in the dynamic field between the natural, human and social sciences. Scandinavian Journal of Caring Sciences, 22(4), 629‐636. https://doi.org/10.1111/j.1471-6712.2007.00564.x Walker, L. O. & Avant, C. A. (2019). Strategies for theory construction in nursing. (6th Ed., pp. 210- 223). Pearson Weaver K., & Olson J. K. (2006). Understanding paradigms used for nursing research. Journal of Advanced Nursing, 53(4), 459‐469. https://doi.org/10.1111/j.1365-2648.2006.03740.x Appendix Table 3.1. Theory Concepts and Relational Propositions Concepts Relational Propositions Knowledge Engagement Relationships “If gender-affirming nursing actions foster therapeutic communication and trust, then Holistic Patient Wellness is supported.” “If a caring relationship is established, a positive effect on Holistic Patient Wellness is generated.” “If the nurse advocates for healthcare equity, then improved patient outcomes are achieved.” “If care partners engage in life-long learning (knowledge), wisdom gained will have a positive impact on Holistic Patient Wellness.” Note. Adapted from “Introduction to Rivera’s Gender Affirming Nursing Care Model: A Middle-Range Theory”, Rivera, D.; Jukkala, A.; & Rohini, T., 2022, Sage Journals, 40(3) Table 3.2. Gender-Affirming Nursing Care Theory Concepts and Related Nursing Characteristics Concept Characteristic Definition Relationships Acceptance The nurse's intentional recognition of a situation or condition as it is, without attempting to alter it or resist its presence. Compassion The nurse’s awareness of a client’s suffering, accompanied by a genuine desire to alleviate that distress. Ethical The nurse’s behaviors reflect moral integrity and align with professional codes of conduct and ethical principles. Gender-Affirming Care Refers to optimal healthcare interactions and interventions that affirm and support the identities and needs of TGNC individuals. Humility The nurse demonstrates a grounded self-awareness, acknowledging personal limitations and strengths while respecting the contributions of others and embracing shared responsibility in care. Openness The nurse demonstrates a readiness to consider diverse viewpoints, experiences, and approaches to care. Trust The nurse holds a confident belief in the reliability, honesty, and integrity of others in the care relationship. Engagement Advocacy Purposeful action taken to influence social, political, or institutional decisions in order to confront and reduce bias, stigma, and discrimination. Gender Inclusive Care that honors and reflects the full range of gender identities, ensuring respectful and affirming healthcare environments and practices. Knowledge Competence The ability to deliver knowledgeable, evidence-informed care developed collaboratively with patients to meet shared goals. Dispel Myth The act of addressing and correcting misinformation or harmful beliefs by offering clear, evidence-based education to oneself and others. Gender Inclusive Education A teaching and learning approach that incorporates gender-affirming content, promoting respect and understanding of gender diversity. Wisdom Growth in clinical judgment and insight gained through the thoughtful application of learned knowledge and experience within nursing care contexts. Note. Adapted from “Introduction to Rivera’s Gender Affirming Nursing Care Model: A Middle-Range Theory”, Rivera, D.; Jukkala, A.; & Rohini, T., 2022, Sage Journals, 40(3) CHAPTER FOUR: TRANSFORMING CARE: A GENDER-AFFIRMING CARE SIMULATION STUDY A version of this chapter was originally prepared for The International Journal of Transgender Health by Edward D. Petrie. The required citation format for this journal is