Article Text
PDF
Abstract
Objective This study aimed to assess staff’s experience of wearing the Health Service Executive (HSE) Rainbow Badge, a symbol of inclusion for LGBTQ+ (lesbian, gay, bisexual, transgender, queer/questioning; + signifying inclusivity of all sexual and gender identities) people, in a paediatric hospital setting.
Design This was a cross-sectional multisite observational study. Participants completed an anonymous online survey, consisting of open and closed-ended questions covering domains of: responses to the badge from staff and patients; experience and impact of wearing the badge; and further training needs.
Setting All five sites (four clinical and one non-clinical) pertaining to the Children’s Health Ireland healthcare group.
Participants All staff, clinical and non-clinical, who had signed up the HSE Rainbow Badge initiative were eligible to participate.
Results A total of 151 eligible participants across a mix of disciplines participated, 29 (19.2%) of whom were members of the LGBTQ+ community. Over half (58.9%, n=89) of respondents said they learnt something new about barriers to care for LGBTQ+ young people from the initiative. Staff reported mostly positive responses to the badge; 5.1% reported mixed/negative responses from colleagues, 4.5% reported mixed/negative responses from young people and 3.7% reported mixed/negative responses from families. Open-ended questions were analysed using a thematic analysis framework. Five themes emerged: pride, a symbol of safety and inclusion, impact on workplace culture, awareness of LGBTQ+ issues and more to do for LGBTQ+ patients.
Conclusions This study demonstrates that the Rainbow Badge initiative increases staff awareness of LGBTQ+ issues and helps to create a safe, inclusive environment for staff, young people and families.
- Paediatrics
- Child Health
- Child Health Services
- Adolescent Health
Data availability statement
Data are available upon reasonable request. All quantitative data pertaining to the study are summarised in the article. Access to qualitative data is available upon reasonable request.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
Statistics from Altmetric.com
WHAT IS ALREADY KNOWN ON THIS TOPIC
LGBTQ+ young people experience discrimination in healthcare settings, negatively impacting their ability to receive safe care.
WHAT THIS STUDY ADDS
In the largest study of the Rainbow badge across any healthcare jurisdiction, staff reported positive interactions with patients, families, and colleagues. LGBTQ+ staff felt more accepted.
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY
The Rainbow Badge initiative supports creation of safe, inclusive environments for staff and young people in healthcare settings.
The Rainbow Badge initiative supports creation of safe, inclusive environments for staff and young people in healthcare settings.
Additional training may increase its impact.
Introduction
Self-report survey data indicate that 13% of young Irish people under 23 years identify as LGBTQ+ (lesbian, gay, bisexual, transgender, queer/questioning; + signifying inclusivity of all sexual and gender identities).1 Despite a significant shift in societal attitudes towards LGBTQ+ identities,2 this group continues to report increased levels of bullying, victimisation and discrimination.3 Increasingly, evidence suggests disparity in mental health outcomes for LGBTQ+ people relates to negative societal attitudes and behaviours.4 Young people are particularly vulnerable: the LGBTIreland Report revealed that more than half of LGBTQ+ adolescents between 14 and 25 years had self-harmed, two in three had seriously considered suicide and one-third had attempted suicide.3
LGBTQ+ people also face discrimination in healthcare settings,5 negatively impacting their ability to receive safe care. A survey of 5000 LGBTQ+ respondents in Britain found that almost a quarter had heard healthcare staff making negative comments about the LGBTQ+ community, while one in seven reported avoiding healthcare due to fear of discrimination.6 In Ireland, LGBTQ+ young people have cited fear of stigma and lack of culturally competent practitioners as barriers to accessing care.7
The need for compassionate, respectful healthcare is paramount; the Stonewall School Report showed that most LGBTQ+ adolescents did not have a supportive adult with whom they could discuss their sexuality.8 The role of social and healthcare professionals in creating a safe environment is therefore crucial to improving LGBTQ+ young people’s experiences of, and accessibility to, healthcare.9 An Irish study of paediatric emergency medicine staff indicated that despite positive attitudes towards LGBTQ+ identities, staff lacked adequate training in caring for LGBTQ+, and in particular transgender, young people.10 Positive attitudes alone are not sufficient for safe care.
The pride rainbow has been identified as a symbol of safety by the LGBTQ+ community.11 12 The Health Service Executive (HSE) Rainbow Badge is intended to be a simple visual symbol, identifying its wearer as someone an LGBTQ+ person can feel comfortable talking to about issues relating to sexuality or gender. Modelled on the NHS (National Health Service) Rainbow Badge,13 it is an opt-in initiative; staff sign up to the badge and its values, receiving education about LGBTQ+ health needs and ways in which they can overcome any perceived heteronormative barriers. Although the Rainbow Badge exists in other healthcare jurisdictions, only one other study on staff experiences has been published. In this study, 36 paediatric NHS staff reported that the badge opened conversations about LGBTQ+ issues with young people, but cited challenges of intersectionality and discussing sexuality and gender.9
This study aimed to evaluate staff experiences from a paediatric healthcare group in wearing the HSE Rainbow Badge, determine whether training needs were being met and whether staff felt adequately supported in promoting a message of inclusion for LGBTQ+ young people, parents and staff.
Methods
The Rainbow Badge initiative in Children’s Health Ireland
Staff who signed up for the badge were asked to (1) complete the HSELanD elearning module LGBT+ Awareness and Inclusion: the basics which took 40–60 min to complete; and (2) were given a leaflet modelled on the NHS Rainbow Badge leaflet which provided background information, reasons to wear a badge, ways of supporting LGBTQ+ young people, signposts to Irish organisations and signposts to further reading. The approximate reading time of the leaflet was 4 min.
Data collection and analysis
Clinical and non-clinical staff working across five sites within a regional paediatric hospital group (Children’s Health Ireland, CHI) who had signed up to the HSE Rainbow Badge initiative were invited to participate via email, between 22 July and 23 September 2022. Participants were excluded if they had never worked within CHI or had not received the badge. As no relevant validated tool existed, the study was designed with regard to the Checklist for Reporting Results of Internet Esurveys.14 The study tool is available in online supplemental file 1.
Supplemental material
The study was administered via the online platform Qualtrics,15 an electronic data capture platform, fully compliant with Good Clinical Practice (21 CFR Part 11, GDPR, 20 ISO 27001 and ISO 9001.14). Prior to beginning the survey, participants were directed to a link to download a pdf of the participant information sheet. Participants were required to confirm (via a form function) that they had read and understood the information and that they consented to participate in the study.
Participants were asked to provide demographic information and asked open and closed-ended questions about responses to the badge from staff and patients; experience and impact of wearing the badge; and further training needs. Branching logic was used to direct respondents who reported that they did not wear their badge to complete questions about the initiative, and their perceived impact of the initiative’s training element. The term Rainbow Badge initiative used in the survey and throughout the paper refers to both staff’s experience of completing the training and wearing the badge.
Demographic information and closed-ended questions were analysed using descriptive statistics in IBM SPSS V.27. Free-text responses were coded and categorised using a thematic analysis framework.16 17 The data were coded, and analytical patterns were developed using the whole dataset to allow a more cohesive pattern to emerge.17 CO’D generated initial codes and developed these into subthemes and then themes; these themes were then reviewed by AK. AK and CO’D then refined and named the themes. These themes were then checked by all authors and further refined. All authors identify as either a member or allies of the LGBTQ+ community. DH, DS, WO’B and AK were involved in promoting the Rainbow Badge initiative within CHI and it was important to be conscious of any possible biases in the analysis stage in this regard.
Results
A total of 879 CHI staff who had signed up to the Rainbow Badge were invited to complete the survey. There were 151 responses (response rate: 17.2%). Of these, 139 (92.1%) were current CHI employees, while the remaining 12 (7.9%) were former employees. Of the 151 respondents, 17 (11.3%) reported that they did not wear their badge. Reasons given were: lost or broken badge (n=10), never received a badge (n=2) and impracticality due to frequently changing in and out of scrubs (n=5). Overall, 89 respondents (58.9%) reported increased knowledge about barriers to health for LGBTQ+ young people through the initiative’s training.
Discipline and identity of respondents are represented in table 1. When asked how they identify, 72.2% (n=109) reported that they were allies of the LGBTQ+ community, 19.2% (n=29) identified as a member of the community and the remaining respondents (n=13, 8.6%) reported ‘not specified’ or ‘prefer not to answer’.
Baseline characteristics of respondents
Responses to the badge are described in table 2. Over three-quarters of respondents (n=104, 77.6%) reported positive or very positive responses about the badge from other staff. Just seven respondents (5.1%) reported mixed or negative respinses from colleagues. Half of respondents (n=64, 47.8%) received responses from young people about the badge and 60 (44.8%) from families. The majority of these responses were very positive, with the exception of six (4.5%) reporting mixed responses from young people and five (3.7%) from families.
Responses to the badge
Qualitative findings
A total of 5 themes and 17 subthemes emerged from qualitative analysis of free-text responses, illustrated in figure 1. Illustrative data for each theme are shown in table 3, and for each subtheme in online supplemental file 2.
Illustrative data by theme with quotes
Themes and subthemes emerging from thematic analysis. CHI, Children’s Health Ireland; LGBTQ+, lesbian, gay, bisexual, transgender, queer/questioning; + signifying inclusivity of all sexual and gender identities.
Pride
Overwhelmingly, respondents spoke of an experience of pride for taking part in the initiative and in wearing their badge. Many took pride in the message the badge sends to LGBTQ+ staff, patients and the wider community. LGBTQ+ staff reported feeling proud to be a representative of the community in healthcare. Respondents also reported that the initiative was contributing towards a wider societal move towards increased equality for LGBTQ+ people.
Symbol of acceptance and inclusion
In the words of one respondent, the badge represented ‘a quiet and formidable way of making a statement silently’. Many reported that although a small gesture, they felt the badge communicated a strong statement of support to young people and their families. The importance of the badge as a non-verbal symbol of support for young people was highlighted. Staff members who identified as LGBTQ+ reported feeling accepted by other members of staff when they saw them wearing the badge.
Impact on the culture of CHI
Many respondents reported a sense of pride that CHI was leading the way in terms of inclusivity for LGBTQ+ children and their families. They expressed that they felt the badge had helped to create a culture of safety, inclusion and diversity for both LGBTQ+ staff and patients. Many reported that the badge had created an openness in the workplace and led to conversations among staff about LGBTQ+ issues which were mostly positive. Two of the 151 respondents reflected that some colleagues disclosed negative reactions to the badge to them. One of these comments reflected a staff member feeling the badge was overly political, while another respondent noted that other staff have judged the badge negatively.
Increased awareness and knowledge of issues facing LGBTQ+ community
Respondents reported that the initiative helped increase their knowledge and awareness of the specific difficulties faced by LGBTQ+ young people and their families. Several reported that the badge acts as a reminder of their support for LGBTQ+ young people. In particular, staff reported that they became more aware of the language and terminology that they use and the impact this may have.
More to do to support LGBTQ+ patients
Many respondents felt that the rainbow initiative needed to be developed and extended further in CHI. A need for further training was reported, including suggestions for mandatory training for all staff, refresher training and more one-off workshops and webinars. Several requested further specific training on transgender and gender identity. Respondents reported frustration at the lack of services and resources for transgender adolescents and felt that more needs to be done to support this group. Staff reported a need for more visibility for the badge and feedback from young people on how they have experienced the initiative.
Discussion
This multisite study demonstrates that multidisciplinary clinical and non-clinical staff in a regional paediatric hospital group report positive experiences of wearing the HSE Rainbow Badge. Responses from colleagues, young people and families were overall very positive. Although staff reported increased knowledge and awareness of LGBTQ+ issues due to the initiative, the majority also identified a need for further training around providing care for LGBTQ+ young people. This mirrors previous findings in clinical paediatric emergency medicine staff in Ireland10 and in the NHS.9
The aim of the HSE Rainbow Badge initiative is to create a safer and more open environment for LGBTQ+ patients and staff. The rainbow has been identified as a symbol of safety for adult LGBTQ+ patients when accessing healthcare settings.11 12 We found that the Rainbow Badge can act as a non-verbal or visual representation of acceptance for LGBTQ+ patients in a paediatric hospital setting and thus may improve care experiences for these young people. This sense of safety is essential; adolescence is a key period in the development of sexual and gender identity,18 and many young people may not have a safe person to discuss this with elsewhere.8
LGBTQ+ staff members reported that seeing other colleagues wearing the badge allowed them to feel more accepted in the work environment. NHS data found that LGBTQ+ staff were significantly more likely to experience workplace physical violence, bullying and harassment compared with non-LGBTQ+ colleagues.19 Many of these NHS staff acknowledged that there was no visible support for LGBTQ+ identities in healthcare settings; the Rainbow Badge may help healthcare staff feel safer in their workplace.
Staff showed a desire to create an inclusive, safe atmosphere for LGBTQ+ young people in their care. Many expressed pride in their involvement in the initiative as well as pride in the culture of the organisation in embracing the Rainbow Badge, reflecting societal changes in attitudes in Ireland.2 Many staff acknowledged pride in allyship to LGBTQ+ young people, while LGBTQ+ staff reported pride in representing LGBTQ+ identities in the workplace. Similar to staff in a UK study,9 they reported that the badge was a starting point for conversations with other staff members and patients around LGBTQ+ issues which many reported they had not had previously.
Over two-thirds of staff reported learning something about the barriers to care for LGBTQ+ adolescents. Research indicates that a lack of knowledge of LGBTQ+ issues may result in implicit biases, even among staff with self-reported positive attitudes.20 Given that those who signed up to the Rainbow Badge initiative are likely to be existing allies of the LGBTQ+ community, it is possible that awareness of barriers to healthcare for this group is even lower among the general staff in CHI and this may contribute to less than ideal experiences of care for young people.
There was a strong desire that momentum for the initiative was maintained and hopes that it could be expanded to include further training on specific issues facing the LGBTQ+ community, in particular supporting transgender young people. Some staff reported not feeling fully equipped around language as well as being unsure of what supports they could direct young people towards. This reflects international research that paediatric staff feel they lack knowledge to support transgender adolescents.10 21 Lack of adequate knowledge and training can result in LGBTQ+ youth bearing the responsibility of educating staff in healthcare settings.7 Even healthcare staff who report positive attitudes towards LGBTQ+ patients may hold a higher level of implicit biases without adequate knowledge.20
How this study is unique
To our knowledge, this is the biggest dataset of healthcare staff’s experiences of wearing the Rainbow Badge. The open-text format allowed for a range of responses around experiences and further training needs. These could be further explored in future studies through more in-depth semistructured interviews or focus groups. Online open-text surveys allow for a greater diversity of responses, encourage greater disclosure on sensitive topics and are less burdensome for participants,17 which was reflected in the diversity of respondents across clinical and non-clinical roles.
Limitations and future research
The study focused on the experiences of staff who signed up for the badge; thus, the results are largely reflective of people who are more likely to be allies or members of the LGBTQ+ community. Future research could explore the experiences of those who did not wish to sign up to the initiative to identify any barriers and training needs of these staff members. Two participants reported negative reactions towards the badge from colleagues, indicating that some staff may have different views to those expressed by participants in this study. The response rate of the survey was relatively low; findings may be skewed towards staff who had either a positive or negative experience wearing the badge.
The study did not capture the experiences of LGBTQ+ young people attending CHI. Future research should explore adolescents’ and parents’ experiences and their views of the badge initiative.
Implications
Symbols of the pride rainbow across other child and adult healthcare services may help increase accessibility to services for members of the LGBTQ+ community through the creation of more safe and supportive environments.11 12 LGBTQ+ young people have reported that fear of stigma and negative responses from staff act as a barrier to care in Ireland7; the Rainbow Badge may be a first step in reducing barriers for these young people across healthcare settings.11 12
A need for further training that incorporates voices from the LGBTQ+ community, as well as more specific training around gender identity and caring for transgender young people, is needed.22 It is unclear how many hours of training will increase staff’s confidence in providing care for LGBTQ+ young people,23 and best practice indicates that training should be co-designed with the LGBTQ+ community.24
Data availability statement
Data are available upon reasonable request. All quantitative data pertaining to the study are summarised in the article. Access to qualitative data is available upon reasonable request.
Ethics statements
Patient consent for publication
Ethics approval
This study involves human participants and was granted ethical approval by the Children’s Health Ireland Research Ethics Office (REC-084-22). Participants gave informed consent to participate in the study before taking part.
Acknowledgments
We would like to acknowledge the contributions of all staff working hard to provide care to the children, young people and families who present to Children’s Health Ireland hospitals every day. We would like to recognise the contributions of the following champions of the study: Patrick Fitzpatrick, HSE Rainbow Badge Site Lead and Consultant in Emergency Medicine at Children’s Health Ireland at Temple Street; Sheena Durnin, HSE Rainbow Badge Site Lead and Consultant in Emergency Medicine at Children’s Health Ireland at Tallaght; and Jacqueline Lyons, HSE Rainbow Badge Site Lead and Quality Improvement Nurse at Children’s Health Ireland at Connolly. We would like to thank Mike Healy, Assistant Director of Nursing at Linn Dara CAMHS, for introducing the HSE Rainbow Badge to Ireland.
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
X @danihalltweets
Contributors Study conception—DH, DS and AK. Design of the study—DH, DS and AK. Acquisition, analysis and interpretation of data—all authors. Drafting of the manuscript—CO'D. Critical revision of the manuscript—all authors. Final approval of the submitted version—all authors. DH accepts full responsibility for the work and/or the conduct of the study, had access to the data, and controlled the decision to publish.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.
Author note We have chosen to use the acronym LGBTQ+; ‘lesbian, gay, bisexual, transgender; queer/questioning with + signifying we are inclusive of all sexual and gender identities not included in the LGBTQ acronym’. We have used this acronym to refer broadly to all types of sexuality and gender-diverse individuals. We acknowledge that each of these letters (and many more) represents a distinct patient population with individualised healthcare needs (as adapted by Roth et al, 2021). It must be noted that language in this area is constantly evolving and the authors have used the terms commonly used at this time and acknowledge that these terms may change over time.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.