Best Nursing Practice: Safe and Inclusive Healthcare Environments for Transgender People: A Systematic Review

Round 1

Reviewer 1 Report

The study design is appropriate to answer the research question,  and the conclusions are supported by the evidence presented. The presentation of the work is clear, the stientific methods are described suciently.  The authors could supplement the manuscript with a description of the study's limitations.

The study design is appropriate to answer the research question,  and the conclusions are supported by the evidence presented. The presentation of the work is clear, the stientific methods are described suciently.  The authors could supplement the manuscript with a description of the study's limitations.

Author Response

The study design is appropriate to answer the research question,  and the conclusions are supported by the evidence presented. The presentation of the work is clear, the stientific methods are described suciently.  The authors could supplement the manuscript with a description of the study's limitations.

Thank you for your comments, we have added a paragraph in the discussion section indicating the main limitations of the study (lines 327-335). We have taken into account selection biases, methodological quality and the difficulty in generalising the results due to the heterogeneity of the articles found.

We hope that our changes and new contributions will be appropriate.

Reviewer 2 Report

I appreciate the authors' efforts to explore and address an important issue in healthcare. However, I have identified several points of weakness that, in my opinion, need to be addressed for the paper.

Introduction:

The authors may consider incorporating an overview of the diverse situations of transgender individuals across different countries. Given the variability in social and cultural contexts, it would add depth to the paper and enhance its applicability.

The inclusion criteria for articles specify a preference for those written in Spanish and/or English. It would be helpful if the authors provided a rationale for this language preference, especially considering the global nature of the issue.

Results:

The paper cites a study by Russell et al., stating that using the preferred name decreases suicidal ideation and behavior. While this finding is compelling, it may be beneficial for the authors to acknowledge the potential cultural and social variations in the impact of such interventions.

The discussion on guidelines (lines 171-174) should recognize the importance of considering social and cultural contexts in implementing trans-inclusive care. Acknowledging the diversity of experiences can strengthen the paper's applicability.

In section 3.3, the authors discuss the role of nurses as facilitators but provide limited information on how nurses can assume this role. More concrete examples or specific actions that nurses can take to facilitate understanding and acceptance would enhance the clarity of this section.

The statement "It is also inappropriate to ask about their genitalia" might be oversimplified. Considering the delicate balance nurses must strike between providing comprehensive healthcare and respecting patients' gender identity, a more nuanced discussion on this topic is warranted.

Discussion and Conclusions:

The discussion and conclusions sections appear to be summaries of the findings.

I recommend reorganizing the paper to delve deeper into specific case studies and research during the findings section, allowing the discussion to synthesize more general considerations, and the conclusions to focus on future directions and bridging the gap between theory and practice.

Thank you for your time and attention.

Author Response

Introduction:

The authors may consider incorporating an overview of the diverse situations of transgender individuals across different countries. Given the variability in social and cultural contexts, it would add depth to the paper and enhance its applicability.

Agreed, 2 new citations have been introduced (lines 66-84) reporting the current state of trans people's rights in the European Union. The data has been extracted from the organisation Transgender Europe (TGEU), the reference body in this regard.

The inclusion criteria for articles specify a preference for those written in Spanish and/or English. It would be helpful if the authors provided a rationale for this language preference, especially considering the global nature of the issue.

We share their reflection and have indicated the justification in the design section of material and methods (lines 92-95). We have also added the limitations of the study (lines 327-335). 

Results:

The paper cites a study by Russell et al., stating that using the preferred name decreases suicidal ideation and behavior. While this finding is compelling, it may be beneficial for the authors to acknowledge the potential cultural and social variations in the impact of such interventions.

One more reference has been added, and a paragraph under discussion has been added, indicating that the study of suicidal ideation should be approached taking into account the intersectionality of variables such as: age, ethnicity, religion and psychiatric comorbidities (lines 272-278).

The discussion on guidelines (lines 171-174) should recognize the importance of considering social and cultural contexts in implementing trans-inclusive care. Acknowledging the diversity of experiences can strengthen the paper's applicability.

Agreed, a new reference has been introduced discussing the need to incorporate cultural competence for sexual and gender minorities as an essential component of nursing education (lines 292-296). A reflection has also been included in the conclusions (lines 337-341).

In section 3.3, the authors discuss the role of nurses as facilitators but provide limited information on how nurses can assume this role. More concrete examples or specific actions that nurses can take to facilitate understanding and acceptance would enhance the clarity of this section.

Agreed, examples have been incorporated into the paragraph such as: community diversity workshops, patient school talks, and offering psychological support and counseling in associations (lines 210-214)

The statement "It is also inappropriate to ask about their genitalia" might be oversimplified. Considering the delicate balance nurses must strike between providing comprehensive healthcare and respecting patients' gender identity, a more nuanced discussion on this topic is warranted.

Agreed, the paragraph has been rewritten to have the same meaning but using simpler and more respectful wording (lines 255-258).

Discussion and Conclusions:

The discussion and conclusions sections appear to be summaries of the findings.

I recommend reorganizing the paper to delve deeper into specific case studies and research during the findings section, allowing the discussion to synthesize more general considerations, and the conclusions to focus on future directions and bridging the gap between theory and practice.

Thank you for your time and attention.

Agreed, the text of the discussion has been reorganised. With the new references we believe that the text now has a common thread and can be easily understood, synthesising the more general considerations.

The conclusions have been rewritten according to your indications. The main ideas have been synthesized and new recommendations for future research have been described.

We hope that our changes and new contributions will be appropriate.

Reviewer 3 Report

Dear Authors

Please find my comments bellow:

Abstract:Background

• Made the study's purpose clearer and more precise.
• Methods

• Clarified the purpose of the exploratory search.
• Mentioned the use of inclusion and exclusion criteria.
• Specified the number of reviewed articles.

Results

• Provided clear headings to categorize findings.
• Emphasized the importance of specific healthcare professional training.
• Highlighted the lack of necessary resources.

Conclusions

• Reiterated key points about competent trans-inclusive care.
• Clarified the study's registration status.

Introduction:

• Clarified changes in the classification of transsexuality as a mental disorder over time.
• Ensure relevant citations are added before publication.
• Used consistent terminology for "transgenderism" and "transgender people."
• Specified sources for prevalence estimates.
• Presented healthcare barriers in bullet points for clarity.
• Emphasized the role of nurses in creating inclusive healthcare environments.
• Mentioned sources of scientific evidence and briefly described the methods.
• Clarified the term "trans" and explained its inclusive usage.

Materials and Methods:

• Specified adherence to the PRISMA statement.
• Clarified the time frame for "published in the past five years."
• Mentioned any language restrictions in the search.
• Organized the search strategy with bullet points.
• Clarified the number of articles identified and included.
• Discussed tools or software used for data extraction.
• Describe the role of the third researcher in case of disagreements.

Results:

• Provided context for studies on the training of health professionals.
• Explained the significance of "2+" and "2++" in the table.
• Specify the studies or sources for creating safe spaces.

Discussion:

• Included specific examples or case studies to illustrate challenges faced by trans people.
• Clarified the alternatives trans people resort to outside health services.
• Explained the benefits of nurses creating safe and inclusive spaces.
• Highlighted key findings or statistics from studies addressing healthcare barriers.
• Expanded on the need for training nurses and healthcare workers.
• Discussed the limitations of the database search and potential areas for future research.
• Provided more context on various aspects mentioned in the last paragraph.

Conclusions:

• Emphasized the pivotal role of nurses and provided case study scenarios.
• Discussed the components of being a competent nurse in trans care.
• Included specific examples of effective communication and collaboration.
• Highlighted the importance of ongoing education and professional development.
• Considered the role of healthcare institutions in supporting nurses.

Registration:

• Explained the importance of registering a systematic review.
• Provided information on commonly used systematic review registries.

As a revision for this manuscript, I would like to draw the editors' attention to a critical concern that needs immediate consideration. The absence of a detailed protocol and registration for the systematic review presented in this manuscript is a substantial issue that necessitates major revisions before publication. Protocols and registration are fundamental for ensuring transparency, rigour, and credibility in systematic reviews. Their omission raises concerns about potential bias, a need for clarity regarding methodology, and impediments to readers' ability to evaluate the study's validity. Therefore, I recommend that this manuscript undergo major revisions, focusing on creating a comprehensive protocol and registering the systematic review on a recognized platform. Once these and other essential revisions are made (as sent previously), we can revisit the manuscript for further evaluation and consideration for publication.

Author Response

Abstract:Background

• Made the study's purpose clearer and more precise

That's right, thank you for your feedback.

Methods

• Clarified the purpose of the exploratory search.
• Mentioned the use of inclusion and exclusion criteria.
• Specified the number of reviewed articles.

Thank you for your feedback.

Results

• Provided clear headings to categorize findings.
• Emphasized the importance of specific healthcare professional training.
• Highlighted the lack of necessary resources.

Thank you for your feedback.

Conclusions

• Reiterated key points about competent trans-inclusive care.
• Clarified the study's registration status.

Thank you for your feedback.

Introduction:

• Clarified changes in the classification of transsexuality as a mental disorder over time.
• Ensure relevant citations are added before publication.

We have checked all citations and they are correct. Thank you.

• Used consistent terminology for "transgenderism" and "transgender people."
• Specified sources for prevalence estimates.
• Presented healthcare barriers in bullet points for clarity.
• Emphasized the role of nurses in creating inclusive healthcare environments.
• Mentioned sources of scientific evidence and briefly described the methods.
• Clarified the term "trans" and explained its inclusive usage.

Thank you for your feedback.

Materials and Methods:

• Specified adherence to the PRISMA statement.
• Clarified the time frame for "published in the past five years."
• Mentioned any language restrictions in the search.
• Organized the search strategy with bullet points.
• Clarified the number of articles identified and included.
• Discussed tools or software used for data extraction.
• Describe the role of the third researcher in case of disagreements.

That's right, thank you. We have added the role of the third investigator in case of discrepancies (lines 126-130). We have also added the limitations of the study stemming from the language restriction (lines 327-335).

Results:

• Provided context for studies on the training of health professionals.
• Explained the significance of "2+" and "2++" in the table.
• Specify the studies or sources for creating safe spaces.

Thank you for your feedback, studies that talk specifically about creating safe spaces have been included in section 3.2. entitled "Creating Safe Spaces" are citations: 11, 45-48.

Discussion:

• Included specific examples or case studies to illustrate challenges faced by trans people.
• Clarified the alternatives trans people resort to outside health services.
• Explained the benefits of nurses creating safe and inclusive spaces.
• Highlighted key findings or statistics from studies addressing healthcare barriers.
• Expanded on the need for training nurses and healthcare workers.
• Discussed the limitations of the database search and potential areas for future research.
• Provided more context on various aspects mentioned in the last paragraph.

That's right, thank you for your feedback.

Conclusions:

• Emphasized the pivotal role of nurses and provided case study scenarios.
• Discussed the components of being a competent nurse in trans care.
• Included specific examples of effective communication and collaboration.
• Highlighted the importance of ongoing education and professional development.
• Considered the role of healthcare institutions in supporting nurses.

That's right, thank you for your feedback.

Registration:

• Explained the importance of registering a systematic review.
• Provided information on commonly used systematic review registries.

As a revision for this manuscript, I would like to draw the editors' attention to a critical concern that needs immediate consideration. The absence of a detailed protocol and registration for the systematic review presented in this manuscript is a substantial issue that necessitates major revisions before publication. Protocols and registration are fundamental for ensuring transparency, rigour, and credibility in systematic reviews. Their omission raises concerns about potential bias, a need for clarity regarding methodology, and impediments to readers' ability to evaluate the study's validity. Therefore, I recommend that this manuscript undergo major revisions, focusing on creating a comprehensive protocol and registering the systematic review on a recognized platform. Once these and other essential revisions are made (as sent previously), we can revisit the manuscript for further evaluation and consideration for publication.

Thank you for your consideration, we fully agree.  As researchers we know that the ultimate aim of any research is to create rigorous, valid and transparent scientific evidence.

However, due to our inexperience in the registration system at the time of registering the search, the PROSPERO team did not allow the registration of our research claiming that we already had results. A record of the pre-registration is attached.

As you have indicated in your assessments, we understand that you consider our review to be adequate and relevant and that it meets all the requirements of a good systematic review. Please consider that it has taken a lot of work to conduct and that the error in the registration is due to inexperience in doing so before results were available.

Author Response File: Author Response.pdf

Round 2

Reviewer 2 Report

I appreciate the authors' efforts to improve the paper, according to my suggestion.

I believe that in the revised form, the paper is ready to be published.

Author Response

I appreciate the authors' efforts to improve the paper, according to my suggestion.

I believe that in the revised form, the paper is ready to be published.

Thank you for your consideration.

Reviewer 3 Report

Thank you for your response and additional context regarding the registration issue. We appreciate your commitment to conducting rigorous and transparent research.

Given your explanation about the registration problem with PROSPERO due to inexperience, we understand the situation better. In light of this, I would suggest the following steps:

1. Attempt to Register on PROSPERO Again: If the only issue was that the registration was rejected due to having results already, you could try contacting PROSPERO's support team or reattempting the registration, ensuring that you indicate that this is a pre-registration and no results have been obtained yet. If this is successful, it would be the ideal solution.

2. Use Alternative Platforms: You mentioned the Open Science Framework (OSF), which is a reputable pre-registration platform. You could consider registering your systematic review protocol there to ensure transparency and credibility. If you choose this route, please provide the link or details of the registration in your manuscript.

3. Mention Pre-Registration: In your manuscript, make sure to explicitly state that your systematic review protocol was pre-registered but encountered an issue due to inexperience, leading to the rejection by PROSPERO. This can help address concerns about transparency and intent.

4. Reiterate Commitment to Transparency: Emphasize your commitment to transparency and rigour in your research. You can highlight your willingness to share the pre-registration details upon request and ensure that the methodology adheres to the best practices of systematic reviews.

5. Seek Clarification from the Journal Editors: Given the circumstances, it may be beneficial to communicate with the journal editors about your situation and seek their guidance on how best to proceed.

By taking these steps, you can demonstrate your dedication to maintaining high research standards despite the registration hiccup and effectively address the concerns the revisor raises.

Minor editing of English language required

Author Response

Thank you for your response and additional context regarding the registration issue. We appreciate your commitment to conducting rigorous and transparent research.

Given your explanation about the registration problem with PROSPERO due to inexperience, we understand the situation better. In light of this, I would suggest the following steps:

Attempt to Register on PROSPERO Again: If the only issue was that the registration was rejected due to having results already, you could try contacting PROSPERO's support team or reattempting the registration, ensuring that you indicate that this is a pre-registration and no results have been obtained yet. If this is successful, it would be the ideal solution.

After contacting the PROSPERO support team, they confirmed that once we have obtained results, it is not possible to register the search protocol.

Use Alternative Platforms: You mentioned the Open Science Framework (OSF), which is a reputable pre-registration platform. You could consider registering your systematic review protocol there to ensure transparency and credibility. If you choose this route, please provide the link or details of the registration in your manuscript.

Agreed, we have registered our systematic review in the Open Science Framework on 01/09/2024. It can be checked at the following link: https://doi.org/10.17605/OSF.IO/RPJ6A (osf.io/rpj6a). The indication of registration has been incorporated in the abstract (lines 24-25).

Mention Pre-Registration: In your manuscript, make sure to explicitly state that your systematic review protocol was pre-registered but encountered an issue due to inexperience, leading to the rejection by PROSPERO. This can help address concerns about transparency and intent.

The recommendation has been incorporated in the text (lines 107-111).

Reiterate Commitment to Transparency: Emphasize your commitment to transparency and rigour in your research. You can highlight your willingness to share the pre-registration details upon request and ensure that the methodology adheres to the best practices of systematic reviews.

Agreed, the Data Availability Statement has been added: The submitted data and pre-registration details of this study are available upon request from the corresponding author (lines 414-415).

Seek Clarification from the Journal Editors: Given the circumstances, it may be beneficial to communicate with the journal editors about your situation and seek their guidance on how best to proceed.

We have contacted with the journal editors and explained the situation and the problem that has occurred with the pre-registration. Evidence of pre-registration with PROSPERO has been sent.

By taking these steps, you can demonstrate your dedication to maintaining high research standards despite the registration hiccup and effectively address the concerns the revisor raises.

We hope so, thank you very much for your understanding and your indications. We also hope that you will find the new contributions appropriate.

Finally, the language has been checked again with a specialised translator. The language editing certificate is attached.

Round 3

Reviewer 3 Report

Dear Authors

I am grateful for your correction in response to my earlier comments.  I thank you for your tremendous commitment to improving the work, 

Best Regards