Undergraduate Nursing Students' Experiences of Gender Inclusive and Affirming Practices

“It's Very Cisnormatively Structured”: An Interpretive Description of Undergraduate Nursing Students' Experiences of Gender Inclusive and Affirming Practices

This study explores the experiences of Canadian undergraduate nursing students learning about transgender and gender diverse (TGD) health. In this paper, we outline that, like other health professional education programs, nursing education contributes to harm and invisibility of TGD people, including through maintaining gender norms (called cisnormativity). In addition, TGD nursing students experience harms while navigating nursing education. 

To understand these experiences, I spoke with 18 undergraduate nursing students in focus groups or interviews, with 13 participating in follow-ups. Of these students, 8 (44%) identified as TGD. 

Three key themes emerged: 

1. Gender norms in nursing education - Nursing education was described as reinforcing gender norms in multiple ways, including in the classroom (formal learning), social interactions (informal learning), and institutional practices and policies (hidden learning).
2. “The Trans Problem” - TGD people, including patients and nursing students, were often left out of nursing education.
3. Welcoming the other – Highlights the importance of individual nurse educators in supporting TGD students and learning environments. 

The paper concludes with recommendations from students on how to improve nursing education to be more inclusive and affirming for TGD people.

The full paper is available here. 

The headings and subheadings of key findings are outlined below. See the article for a visual representation of the thematic diagram. 

Theme 1. Cisnormativity prevails across the three levels of curriculum through three subthemes (a) informational power and norms (“It's very rarely trans”), (b) relational power imbalances and norms (“As students, you feel really powerless”), and (c) institutional power and norms (“It's all words... well, it's a little bit of actions”). 

Theme 2. Othering of TGD people, called “The Trans Problem.” Nursing students expressed concern that (a) they “don't feel like I've been taught to care for people that may need gender affirming care.” In addition, (b) TGD nursing students felt like “tokenized encyclopedias of trans knowledge,” experiencing tokenism, erasure, and discrimination in their education. 

Theme 3. Students expressed positive regard for individual educators who were doing the work, saying “It just affirms that there's somebody on my side.”

Recommendations: Students requested (a) more formal training on TGD people and care, (b) improved accountability from their schools of nursing, (c) improved TGD representation across their school of nursing, and (d) larger nursing changes (e.g., licensure, accreditation).

Positionality: This study was conducted by white settler academics, three of whom are queer, including the lead who is gender diverse. 

Methods: A qualitative interpretive description was used to explore student experiences. Eligibility included undergraduate nursing students enrolled in a Canadian nursing program, second year or beyond. Students were invited to partake in initial and follow-up focus groups, or interviews by request. Data collection and analysis were co-occurring. Queer theory and Hafferty’s three levels of curriculum framework guided all steps of the research process. 

This work is directly applicable to nursing education in Canada, however, has implications for other levels of nursing programs; nursing programs in other countries; and other disciplines. Additionally, it has contributed to the development of national nursing guidelines through the Canadian Association of Schools of Nursing: Advancing sexual orientation, gender identity and expression, and sex characteristics (SOGIESC) Equity and Success. This underscores its relevance not only for nursing accreditors but also as a valuable resource for informing nursing practice requirements.

In the nursing literature, student learning experiences related to LGBT health have been explored primarily within formal education. However, the ways in which students engage with and learn from the informal and hidden curricula remain largely unexamined.  Our work has thus highlighted a crucial gap – the experiences of TGD nursing students – which has yet to be reported in nursing research. 

Cisnormativity must be challenged in undergraduate nursing education to ensure students develop the knowledge and skills needed for culturally safe, life-saving gender-affirming care.

Beyond formal learning, attention to informal and hidden curriculum experiences and conditions - which often perpetuate cisnormativity – needs to be challenged. Individual nurse educators can address these issues by embedding gender diversity across curricular content, inviting and meaningfully compensating TGD guest speakers and community organizations, and actively addressing microaggressions to foster inclusive learning environments. Additionally, nursing schools, licensing bodies, and accreditors have a responsibility to uphold accountability for gender-inclusive and affirming practices, including advancing TGD representation and safety within the profession.

Jess Crawford
College of Nursing, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada

Marnie Kramer
College of Nursing, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada

Janice Ristock
Women's and Gender Studies, Faculty of Arts,University of Manitoba, Winnipeg, Canada

Annette S. H. Schultz
College of Nursing, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada

Crawford, J., Kramer, M., Ristock, J. and Schultz, A.S.H. (2025), “It's Very Cisnormatively Structured”: An Interpretive Description of Undergraduate Nursing Students' Experiences of Gender Inclusive and Affirming Practices. Nursing Inquiry, 32: e12701. https://doi.org/10.1111/nin.12701