Rainbow within and beyond: A qualitative study on the experiences of lesbian, gay, bisexual, and transgender staff nurses in the Philippine hospital settings

Study Design

This qualitative descriptive study employed Husserl’s Transcendental Phenomenology to extract the lived experiences of LGBT staff nurses in hospital settings, capturing the complex and varied occurrences in their lives. Through this design, researchers uncovered the participants’ pure description of their consciousness, tackling their feelings, actions, and subjective perceptions (Neubauer et al., 2019). Philosophically, the study is grounded in the constructivist research paradigm as it acknowledges the socially constructed and subjective nature of reality within their workplace experiences. Driven by a commitment to social justice, the study highlights the participants’ reflections based on their understanding of the world. Phenomenology enables a holistic understanding of these experiences, shaped by multiple influencing factors.

Participants

Eight participants were interviewed in this study, selected purposefully via exponential non-discriminative snowball sampling. Recruitment utilized the referral process, identifying key individuals likely to know potential participants. From an initial participant, referrals expanded through the other nearby Northern Luzon, Philippines regions.

The inclusion criteria were as follows: 1) lesbian, gay, bisexual, and transgender staff nurses who are willing to disclose their LGBT community membership, 2) working as a staff nurse in any department, permanent, probationary, or job-order status, with at least one year of clinical experience in any hospital and 3) voluntarily agreed to participate in the research. Nurses in managerial or supervisory positions, such as chief nurses, head nurses, nurse managers, and nurse supervisors (Kurtessis et al., 2017), were the sole exclusion criteria because they have limited patient interactions.

All categories of the LGBT community were represented, from lesbian, gay, bisexual, and transgender, with varying years of experience, workplace setting, and department. Prior to the study’s commencement, no relationships were established between the interviewers and participants. The interviewers introduced themselves as researchers in the nursing field with an academic interest in the topic. Furthermore, no participants expressed intentions to withdraw from the study.

Data Collection

Data were gathered using unstructured interviews. Three participants were interviewed face-to-face, while five were interviewed online on a schedule aligned with their day off at work. Interviews took place from March to April 2024. It is worth highlighting that before the data collection, the 3rd year Nursing student researchers underwent a series of interview simulations where the research group role-played various face-to-face and online interview scenarios to practice and refine their interviewing skills. Their research professor, a registered nurse with substantial experience conducting qualitative studies, guided the process. The researchers also underwent training on handling psychological distress, employing Swansea University’s guidelines (Swansea University, 2015) for identifying and minimizing participant distress.

All the student researchers took turns interviewing, with a pair assigned to each interview, either both males, both females, or a combination of males and females. The first researcher is the main interviewer, and the second is tasked to record the audio and observe for non-verbal cues. The interviews were conducted in English and Filipino. The same interviewers were also responsible for transcribing the interviews and checking their congruence with the recordings. After transcription, the researchers translated all verbatims into English using the back-translation method. Another member of the researcher group served as a second translator, independently translating the transcript back to the original language. The back-translated version was then compared with the original text to correct discrepancies (Ozolins et al., 2020).

It is to be noted that the participants chose the setting for face-to-face interviews, taking place in uncrowded cafes at a time when no other customers were around. Online interviews were conducted with the researchers and participants in a quiet, well-lit environment with no other people nearby. Prior to the interview, the Informed Consent and Non-Disclosure Agreement were presented on paper or using screen-sharing features. With consent, the interviews were recorded using an audio recorder. The interview sessions were initiated with an open-ended question: “What are your experiences as an LGBT staff nurse in the hospital setting?” Throughout the interviews, the researchers consciously suspended their personal biases. Engaging the participants was achieved through establishing rapport and maintaining focus. While leading questions were avoided, open-ended follow-up questions were utilized, using probes when necessary. The interview sessions were conducted for an average of 50 minutes. No repeat interviews were conducted.

Data saturation was determined by operationalizing the saturation as a proportion. This method was done by dividing the number of identified themes at a given point in analysis by the total number of participants identified; at a point where the researchers had identified seven themes, responses from eight participants reported a saturation level since at least 87.5% of themes in the dataset were already identified (Guest et al., 2006). This indicated that adequate data was collected to comprehensively answer the main research question. Pseudonyms were assigned to each participant and utilized to label their audio recordings, transcriptions, and verbatims in the manuscript.

Data Analysis

Data collection and analysis co-occurred throughout the study. Following Colaizzi’s method (Colaizzi, 1978), thematic analysis was employed to systematically interpret the data. By convening regularly, all eleven of the student researchers, including the professor, scrutinized the gathered data and addressed concerns after every interview. The researchers rigorously reviewed the interview transcripts and analyzed sentence by sentence, paying close attention to significant phrases and critical statements that illustrated the lived experiences of LGBT staff nurses in hospital settings. After identifying these elements, they were carefully categorized into clusters of meaning. These clusters were further refined and consolidated into central themes that encapsulated the core aspects of the participants’ experiences. Once the themes were established, a thorough narrative description was constructed, providing a rich and comprehensive portrayal of the phenomenon. This process ensured that the final analysis captured the commonalities and unique aspects of the participants’ lived experiences.

Trustworthiness

The researchers fulfilled the four primary criteria in ensuring the trustworthiness of qualitative studies in terms of credibility, transferability, dependability, and confirmability (Riazi et al., 2023). To ensure credibility, the researchers meticulously handled the data, capturing verbatim responses and noting participants’ moods, behaviors, body language, and tone of voice. Transcriptions were a collaborative effort, with one researcher transcribing while another cross-checked the transcription against the recordings for accuracy. A research professor with extensive experience in qualitative studies guided the data analysis. Reflexive bracketing was practiced in which the researchers deliberately set aside their biases to prevent influencing data collection and interpretation (Habibullah et al., 2023). It was coupled with reflective field notes, which enhanced the researcher’s self-awareness, documenting their thoughts and feelings during and after the research process to ensure transparency and that interpretations remain grounded in the participants’ realities (Schwandt, 2015). Participants were also reminded of their anonymity, which encouraged honesty, transparency, and trust minimizing social desirability bias.

Transferability was achieved by providing thick descriptions of participants, settings, and data collection methods, supplemented by descriptive field notes (Stahl & King, 2020). The purposeful sampling of participants and locations allowed for the gathering of specific information, enabling readers to assess the applicability of the findings to their contexts while acknowledging the study’s inherent biases. Dependability was ensured through techniques such as iterative questioning and negative case analysis to enhance the focus and depth of the data. Negative case analysis ensured that all insights, even those contradicting initial themes, were carefully considered to avoid confirmation bias (Hanson, 2017). Confirmability was maintained through a transparent audit trail, supported by member-checking (Stahl & King, 2020). The researchers created a pre-publication write-up to solicit feedback so they could review the findings and enhance their accuracy and relevance. Peer debriefing sessions with experts unaffiliated with the study and critiques from other research groups during defense sessions provided constructive feedback. Their recommendations helped reduce redundancy and refine the methodology, strengthening the credibility of the research.

Ethical Considerations

The Saint Louis University–Research Ethics Committee approved the study on February 2, 2024 (SLU-REC 2023-074). Local regulations did not mandate further formal ethical scrutiny. Participants’ autonomy was upheld through informed consent, thorough explanations, and voluntary participation. The study prioritized comfort and trust, assuring the participants’ right to decline participation or withdraw from the study without providing a rationale. To ensure the participants’ psychological well-being, the researchers completed online courses and seminars on qualitative research and managing psychological distress. A referral to counseling services was made available if needed. Privacy and confidentiality were maintained, with a non-disclosure agreement signed by participants, referrers, and interviewers after informed consent. Pseudonyms were used to anonymize data, and materials were securely transported and stored. Interviews were promptly deleted from recording devices once securely stored.

Theme 1: Recognizing Gender Stereotypes

Recognizing gender stereotypes emerged as a double-edged sword, with stereotypes manifesting positively and negatively according to the participants’ narratives. LGBT staff nurses acknowledged the existence of gender stereotypes in the workplace, which they felt were boxed in by their sexual orientations. They observed their behavior, attitude, and personality being generalized by patients and older colleagues as they attributed certain behaviors to specific genders. They expressed sentiments that being judged based on stereotypical views of gender expression can lead to discriminatory treatment or assumptions about capability. Despite this, they did not dwell on the stereotypes due to their resilient personalities. In a contrasting viewpoint, some stereotypes pertained to flattering evaluations from their workplace interactions. This theme highlights the importance of recognizing and respecting the individual differences and complexities within the LGBT community, as evident in the participants’ statements:

“We have colleagues in the older age group who seem to be against other genders. There are those in their fifties who lean only on biologically male or female. They label the LGBT as flirtatious, and if an LGBT did something wrong, they generalize that all gays will commit the same mistake. But, I am not sensitive to those comments.” [Red]

“There is also the classification of masculine and feminine genders. At times, other patients tend to comment that females and feminine genders, like gays, are slow and weak or something like that.” [Pink]

“In our workplace, they associate being gay as being innovative and fun. They often expect that in workplace programs, there should be gays to host or entertain, which is okay for me, given my personality. But we cannot equate that all gay men are like me. Not every gay individual has the same personality. So, we cannot generalize.” [Yellow]

Theme 2: Optimizing Nursing Care

During the interview, a crucial aspect was probed into how the participants interacted with their patients in the area, revealing diverse experiences that prompted different reactions. However, their end goal remains to provide care to the best of their abilities. This theme shows that the LGBT staff nurses, no matter the hospital classification and unit they worked at, upheld nursing care standards and patient-centered care, whether the nurse-patient relationship was smooth or challenging along the way. The participants used a combination of applying standard nursing care and leveraging their unique attributes to enhance the caregiving they provide. Additionally, the nurses approached unfavorable situations by understanding the patients and following protocol. They raised how they prioritized their patients’ well-being as they never let their personal feelings interfere with their patient care. A few mentioned how they handled various patient interactions:

“If you joke around, they appreciate you more. If you make them laugh, it makes them feel more cared for compared to just giving medications. If you make them laugh with your character, as gays are happy people, they feel that they are taken cared of even more.” [Yellow]

“May it be a male or female patient, as long as you explain properly, and as long as you make them understand as to why you would do a procedure, it’s okay with them. You also ask, ‘Are you comfortable if male or female, if I am the one who would do it?’ it’s okay for them as long as proper communication is ensured.” [Orange]

“There was a patient who thought highly of himself, so he assumed that I liked him just because I’m gay. I think he does not know that it is separate from being professional at work. Still, I abided by regulations in proper conduct. I took control of that interaction. I only listened and avoided retaliating. I treated that person as I treated others.” [Yellow]

“At night, there are tons of Igorots who come drunk to the ER. I was told by one, ‘Why are you acting like a gay?’ But, well, he is drunk. They are also the ones who are strict; you know, Igorots are known to be warriors. They do not like softhearted people. But, just treat them well. Present the reality of who you are as a caring nurse. Depending on what they like or dislike, just modify your approach.” [Yellow]

“Being in pediatrics, there are kids who are not yet really aware of the LGBT concept. I had an experience with kids who mockingly called me “gay,” but I chose to understand and just do my job. Nothing changed with the quality of care I provided. Nursing is nursing.” [Pink]

“Whatever feelings you have from different interactions, do not let it affect you. You have to realize that you are working right now, so you have to do your job because it could be other patients who might suffer the effects.” [Orange]

Theme 3: Yearning for Acceptance

Acceptance refers to the extent to which the LGBT community is perceived by society in a positive and inclusive manner (Flores & Park, 2018). In the context of this study, acceptance pertains to the inclusion of groups like the LGBT who often face discrimination and recognize their individuality, feelings, and capabilities. They appealed for equal respect and opportunities to thrive and achieve their full potential. Some hoped for proactive measures to address discriminatory issues, moving beyond mere acknowledgment of the problem. This theme portrays what the participants yearn for in the LGBT community as they verbalized that the change they wanted to see was an enhanced LGBT acceptance in their workplace and the society as a whole.

“In terms of the LGBT, there will always be comments, whether it be positive or negative. As members of the LGBT, we have feelings too. That’s why I hope that we get the same level of respect.” [Orange]

“I just hope that no more LGBT members get discriminated against or embarrassed because of other people’s bullying because many are always thinking that LGBT are always marginalized. It’s as if they do not see anything good or they do not believe that a member of the LGBTQIA+ can reach anything in life.” [Green]

“But perhaps what I would like to see are improved actions that respond to instances of discrimination against the LGBT or similar situations.” [Violet]

Theme 4: Generating Meaningful Relationships

Nurses in the hospital settings do not interact solely with patients but also collaborate with healthcare team members. Their identity as a member of the LGBT community was not a hindering factor, as they were able to form meaningful relationships with their colleagues in the hospital settings. This theme highlights their experiences where they truly bonded with their workmates and shared that they felt welcomed, manifested through their colleagues’ efforts to understand their personalities, experiences, and perspectives on a deeper level. They tackled the idea that openness and understanding of each other’s personalities and experiences in each other’s lives foster the development of interrelationships among their colleagues. Moreover, it is worth noting that some colleagues who identify as straight emulate certain behaviors typically associated with the LGBT community to connect better with others. Participants happily pondered:

“As we go through the days, we get the chance to bond and get to know each other. Through that, there will be an interrelationship in which you will accept the behavior of others. Until now, my colleagues understand my whole personality as a member of the LGBT, and they are just happy about it and happy for me.” [Green]

“When I first started working there, as time went by, our closeness became more okay; it was like we did not need to have barriers between us anymore. It’s like I was brought up like this, and this is who I am, that I’m not straight, but they’re okay with it.” [Indigo]

“Some girls even act more like a gay than those who are really gay. They adopt the gay character, like, ‘Oh, you’re funnier, you’re even funnier, you’re happier.’ So, they adapt to whatever jokes you have; they’ll joke the same way. You know, they’re straight, but they’re adapting the way you speak and act.” [Yellow]

Theme 5: Battling Heteronormative Gender Norms

A common experience the participants came across is their battle against heteronormative gender norms. Heteronormativity is a concept that promotes a binary alignment of biological sex, gender identity, and gender roles (Pollitt et al., 2021). This theme describes how participants navigated encounters with gender expression, particularly how they coped and pushed forward to be able to portray their authentic selves. They shared occurrences regarding their hospital uniforms, hair color, preferred pronouns, and use of hospital restrooms.

“The expectation of my old seniors was pushing us to wear women’s uniforms even if you are a lesbian. But as an LGBT, of course, I want to wear men’s clothes. I would always wear the uniform for males, which is why my supervisors would always call me out. At first, I was always scolded but I said it’s okay, I think I can still work, I can still take their words. That’s why they got used to my clothes after weeks or months. And if they get mad, I make up for it by volunteering to do tasks they request.” [Orange]

“As part of the community, we really want to express ourselves, so I said, ‘How does my hair affect my nursing care? My nursing process? Is a patient going to die or be blinded because of my hair?’ You know, in a joking way. I still dye my hair. I don’t care. I let them be as long as my hair does not affect my relationship with patients. I just brushed it off.” [Blue]

“Like 2010, 11,12, gays were not allowed to wear makeup. Long hair is not allowed. But our gay staff did not cut their hair. We justified that there was no directive that long hair is prohibited. Even makeup. What they only want is to maintain the old fashion that men or gays should have short hair because they perceive that gays would be more respected that way. But respect is not connected to the haircut. ‘What’s the logic?’ that’s what we said to the seniors.” [Yellow]

“One challenge for me before was how would I introduce myself because sometimes there are people who call me ‘Sir.’ I prefer to be addressed by my biological gender, which is ‘Ma’am,’ but as time went by, I loosened up to either.” [Violet]

“I still use the female’s restroom. I often get called out, too. As if they are checking, saying “You seem to have entered the wrong comfort room.” But I would say, “I am a female too.” I just need to explain myself, but sometimes I get irritated. There are people who still see me as a female, yet others who perceive me as a male call me out.” [Orange]

Theme 6: Inspiring Potentials Beyond Gender and Nursing

The theme discusses how LGBT staff nurses perform their duties while transcending societal gender norms and nursing expectations. They have shared their journey of personal growth and empowerment in the clinical setting, demonstrating how they achieve their true potential, acknowledging the importance of setting boundaries and ensuring that it does not cost their sense of self in the process.

“I told myself when I started working that I won’t let anyone trample on my dignity because I am here not only as an LGBT member but also as a staff nurse, as their colleague, as a healthcare provider.” [Green]

“As an LGBT staff nurse, I always ponder that since I belong to the LGBT community, I should strive harder and excel more. It’s like I always have something to prove to myself, that I shouldn’t let myself be mistreated in the hospital and that I should always represent the LGBT and my colleagues well.” [Indigo]

“I don’t exist with my gender itself. I don’t live with my gender only. I characterize myself as someone who can do what males or females can do. You are also not limited as a nurse only or what is expected of you at the ward. So I go beyond what is expected, that I can do more. Because that is what I also perceive of myself, I don’t limit myself to nursing forever. I see myself not based on gender or relationships with men but rather on my goals in life.” [Yellow]

“Because at the end of the day or at the end of the line, it is us, the members of the LGBTQ community, who will provide clarity in our lives, in achieving our goals, and in what we want to accomplish. We stand firm. We stand tall. Because we know our strengths. We know our capabilities. And we know when to shine bright.” [Green]

Theme 7: Valuing LGBT Inclusivity

According to Megathlin (2007), an LGBT-inclusive workplace ensures fair treatment and equal opportunities for all employees, regardless of sexual orientation, gender identity, or expression, nurturing diversity effectively through various means. This was a common theme that emerged from every participant, where they acknowledged the progress of LGBT acceptance, exhibiting the presence of inclusive programs and the shift of the older generation to the present generation’s perspectives.

“In this generation, as they are also younger, the age range of my colleagues is 45 and below. Back when I was a student, they said that their seniors back then were too harsh. They scold the boys for “acting soft like gays” before, but now that doesn’t happen. That’s the difference, at least every year, they’re more open now unlike before.” [Red]

“Compared to before, I’ve heard a lot of stories of discrimination. But now, I don’t know if it’s just in our institution, but so far, it’s more welcoming. More okay, personally. I haven’t felt any discrimination from my seniors or from the staff.” [Blue]

“There are programs in our institution implemented, although they’re just for fun. For example, during December, there would be a Christmas party with Ms. Gay competitions. Everything is equal when it comes to opportunities in such programs.” [Green]

“As an LGBT, a good experience I had was joining the friendship games because my sport before was table tennis. It is only now that I was able to practice the sport I really want, which is basketball. Additionally, I was able to be with my fellow LGBT friends and see that I am not the only one. So, at least, the impact of LGBT awareness is really strong. We are gradually being accepted in the community. That “we also exist in society,” and now the hospital has implemented a gender sensitivity program.” [Orange]

“In general, they do not discriminate against who you are, especially since there may be LGBTQ staff in the hospital. They celebrate Pride Month during June so they are really LGBTQ-friendly.” [Indigo]

“Even though they know that I am part of the LGBTQ, there is no special treatment or discrimination. So my workflow was good because they were very approachable, and they don’t care about your gender; as long as you are willing to learn, they will teach you.” [Indigo]

“When it comes to the evaluation of staff nurses, we do not evaluate based on gender. We evaluate what you have done or what you have accomplished for the patient or the ward or a certain activity assigned to you.” [Yellow]

“Of course, I feel happy knowing that they know that it is not wrong to be a part of the LGBTQ community, and they respect us. And since there is no discrimination, we have the freedom to move. We are more confident with patient care. There are also patients who tell me that gays and lesbians are truly caring, so it is a compliment for me as a part of the community.” [Violet]

“I can see their acceptance, their love, their understanding, of who I really am and who I really wanted to be, that’s why I am happy and blessed that they accepted me as I am as a member of the LGBT. And then I think I am one of the lucky members of the LGBTQ community who was not bashed, not bullied, and was accepted immediately in my workplace as LGBT.” [Green]

Implications of the Study

The study has direct implications for improving the support of LGBT staff nurses. The study provides helpful information for the hospital administration to continue their diversity celebrations like Pride Month and encourage programs and support networks to enhance inclusiveness. In addition, establishing Employee Resource Groups and Allies Programs can go a long way in boosting these efforts. This study also suggests gender-sensitivity policies should be reinforced by increasing understanding of LGBT rights and anti-discrimination enforcement. Moreover, concerns with dress codes or the use of certain facilities indicate the need for policy revisions to allow LGBT staff to express themselves without fear of reprimand. Healthcare organizations can work toward creating a more inclusive, equitable, and supportive environment for LGBT staff nurses, ultimately improving both workplace culture and patient care.

Limitations

This study focuses on the experiences of eight registered staff nurses, excluding other nursing positions, from various hospitals in the Ilocos Region, Cagayan Valley, Central Luzon, and Cordillera Administrative Region. Hence, the findings cannot be applied to the entire population of LGBT staff nurses. Future studies must consider the broader demographic representation of LGBTQ employees beyond Luzon, Philippines. An exploration of how sexual orientation intersects with other social-cultural categories can also yield insight into the lived experiences of LGBTQ staff in organizations. The study used unstructured interviews, with interviewers having different proficiency levels. Due to schedule conflicts, most interviews were conducted online, with only three out of seven individuals interviewed in person. Most participants had 1-to-2 years of experience, but the data gathered remained unchanged due to the same interview method. There may be a need to include participants with a broader range of experience in nursing, especially those with over two years of experience. This would provide more diverse perspectives and help determine if experience level influences the perceptions and experiences of LGBT staff nurses. The findings should be interpreted with caution due to the limitations of the study.