Date of Graduation

Fall 12-14-2018

Document Access

Project/Capstone - Global access

Degree Name

Master of Science in Nursing (MSN)


School of Nursing and Health Professions

First Advisor

Dr. Nancy Taquino


Improving Knowledge and Attitude of Primary Healthcare

Givers Towards Vulnerable Populations

Kimberly Shankel

University of San Francisco



This project aims to improve patient satisfaction for vulnerable population patients while in hospital, namely transgender and gender non-conforming people. A major roadblock for this population in seeking medical care is their fear of discrimination when accessing healthcare, resulting in a delay, or avoidance of medical care. Multiple studies agree there is a need for nursing education on cultural competence to improve care and satisfaction for vulnerable populations.


The site for this quality improvement project is a small suburban hospital within a large not-for-profit healthcare organization. The improvement team includes a CNL student, social worker, transgender educator, assistant nurse manager, RN champion, PCT champion, and quality data operations specialist. A microsystem assessment was conducted using the Dartmouth microsystem assessment tool, providing a blueprint for the project.


The intervention for this project comprises in-services for RNs, PCTs, and UAs working in the microsystem of the fifth floor. In-service presentations include short films, group activities, and panel discussions. Education focuses on recognizing bias in care, respectful and inclusive care for all vulnerable populations, including transgender and gender non-conforming patients.


Data measurement includes a pre-project survey of an adapted National LGBT Cancer Network survey for RNs, pre and post intervention Watson Caritas surveys for healthcare givers and patients, and quarterly HCAHPS scores for two nursing related questions.


Results after project implementation show a slight improvement in scores on the Watson survey for nurses and patients. Nurse self-reporting questions relating to self-care scored the lowest with the highest scoring on the question asking nurse feelings of their values and beliefs, contributing to personal success.

Interestingly, patient scoring on the Watson survey had lowest averages on questions of nurses valuing their personal beliefs and faith, allowing for hope, and nurses providing loving care. Highest scoring questions are nurses treating patients with dignity, meeting basic human needs, and fostering trusting relationships. HCAHPS scores on the microsystem unit for this project increased by 1 point each, for the two nursing focused questions. The higher score represents a significant increase in patient satisfaction.


Conclusions point towards the positive influence nursing education has on patient satisfaction. Several additional contributing factors should be noted. Hospital leadership is beginning to stabilize, the interim manager on the microsystem unit is encouraging an inclusive environment, and RNs and PCTs from other departments have been invited to attend in-services.

RNs and PCTs are increasing their dialogue around bias and how to provide respectful care for all. As we move forward, there is interest and support in spreading this program to outside inpatient hospital areas. The emergency department and perioperative services staff, who are often patients first contact with the hospital setting, have shown the most significant support for the program. They have been proactive with encouraging their leadership to bring this program to their departments. The greatest value of the project is the opportunity to improve vulnerable patient healthcare outcomes.