For this study, a qualitative, descriptive, and contextual approach was employed, which enabled the researchers to provide a detailed description of participants’ experiences in relation to the phenomenon under examination (26). In addition, this research design prompted the researchers to bracket their own views and beliefs as participants shared their experiences of providing culturally competent care in primary healthcare facilities (27).

The participants were recruited by the primary researcher through purposive sampling, using the snowball method. The snowball sampling method enabled the primary researcher to ask participants who consented and participated in the study to refer other relevant individuals who met the study’s criteria (28, 29). Moreover, Tornava et al. (30) found that the snowball method was suitable for research perceived as sensitive and that participants needed to trust the researchers. In addition to recruiting relevant participants, the researchers utilized social media platforms, including Facebook. The primary researcher’s contact information was provided to those interested in the study who met the study’s criteria. The inclusion criteria required participants to be employed at primary healthcare facilities in the Gauteng province, South Africa (City of Ekurhuleni, Sedibeng, Tshwane, City of Johannesburg, and Westrand). Malematja et al. (31) advise that primary healthcare facilities provide services such as maternal and child health, reproductive health, chronic disease management, and acute care. These healthcare services are provided to individuals at no cost by skilled professional nurses (32–34). In addition, participants had to have been employed at a primary healthcare facility for more than 2 years and to have provided healthcare services to LGBTQI+ persons within the past 6 months, to ensure that the experiences shared were current and meaningful. Data collection was conducted from 2 December 2023 to 15 March 2024, through two independent focus groups. FG1 consisted of seven (7) participants, and FG2 also consisted of seven (7) participants, yielding a total of 14 participants. Data saturation occurred when no new themes or subthemes emerged; thus, the two independent focus groups appeared adequate to meet the study’s objective, as the participants (professional nurses) were from all five districts in the Gauteng province. These focus groups were deemed the most suitable option compared to individual interviews, as they encouraged shared reflection on collective norms among professional nurses.

The demographic information of the participants is provided in Annexure A. The two focus groups were conducted in English by the primary researcher and transcribed verbatim, and all participants were fluent in spoken English. The focus groups lasted 60–90 min, and one central question was asked: “How do you experience providing care to LGBTQI+ persons?” This central question allowed the participants to share their own experiences and provided the researchers with deep insight into the phenomenon. In addition, communication skills, such as clarification, probing, silence, and questioning, enabled the primary researcher to ask follow-up questions, which assisted in developing the interview guide in Annexure B.

The researchers employed thematic analysis for this study (35). Wæraas (36) advises that thematic analysis is helpful for analyzing qualitative data, in which themes are refined systematically to derive meaning from the data. Ahmed et al. (37) share that Braun and Clarke’s six-phase analysis includes the following:

The primary researcher reviewed the field notes and all transcripts and listened to all voice recordings to make sense of the collected data.

This was a manual process in which the primary researcher systematically reviewed data collected from the two focus groups to identify and establish meaningful features.

This stage required interpretive thinking, in which the primary researcher grouped similar themes. For this exercise, the primary researcher used mind maps.

The primary researcher reviewed the raw data to ensure the accuracy of the identified themes. During this process, specific themes were merged into one, divided, or even discarded, leading to theme repetition. This process promoted coherence and logic in relation to the identified themes and subthemes.

All the themes were described, and the primary researcher reflected on their relevance to the research question. In addition, direct verbatim quotes were linked to themes to promote clarity and enhance relevance.

The primary researcher presented a detailed data analysis report to the secondary researcher, who served as the supervisor. This report included the themes, subthemes, and their interpretation. After the secondary research provided additional insights and prompted clarity-seeking questions, the identified themes and subthemes were discussed with an independent coder, an Associate Professor with extensive experience in qualitative research. The independent coder reviewed all the raw data to begin coding and consulted the primary researcher when clarification was required. In addition, regular meetings were held with the researchers and the independent coder, where any identified discrepancies were discussed and corrected, or any additional information was required, which ultimately led to the consensus or agreement on the final themes and sub-themes, as the independent coder had all the insight to determine the trustworthiness of the study and the provided information the researchers provided to the independent coder. This was done to promote transparency and prevent possible bias.

Ethical approval for this study was obtained from the Faculty of Health Sciences Research Ethics Committee at the University of Johannesburg (REC-1822-2022). In addition to gaining access to the various research sites (City of Ekurhuleni, Westrand, City of Johannesburg, Sedibeng, and Tshwane), the study had to be registered with the National Health Research Database (NHRD), and an approval reference was provided (GP_202211_014). The participants who met the inclusion criteria were invited to an information session, where the primary researcher shared the purpose of the intended research with them individually (38).

Trustworthiness in qualitative research promotes the authenticity and absolute truthfulness of the research findings (39). Trustworthiness was assessed using Lincoln and Guba’s criteria: credibility, transferability, dependability, confirmability, and authenticity (40).

From the meaningful conversations during the two independent focus groups (FG1 = 7, and FG2 = 7, total 14 participants), it became evident to the researchers that the participants felt that they were not prepared to provide culturally competent caring practices to LGBTQI+ persons when they access primary health care facilities; it sounded as if the unpreparedness was related to the knowledge deficit. The following verbatim quotes give insight into the participants’ reality:

Other participants added:

The unpreparedness to provide culturally competent care to LGBTQI+ individuals is clarified with the subtheme below.

In addition, the participants revealed that personal and systemic barriers negatively affected the care they provided to LGBTQI+ persons, which can be interpreted as internal and external factors. The following verbatim quotes illustrate how this theme was identified:

The verbatim quotes shared above are explicitly explained with the subtheme below.

The participants reported being unprepared to provide culturally appropriate care, attributing this to a lack of knowledge, skills, and values. This finding aligns with similar studies, which found that primary healthcare nurses have insufficient knowledge on how to provide culturally appropriate care to LGBTQI+ individuals (43). Inadequate knowledge, skills, and values among professional nurses regarding the healthcare needs of LGBTQI+ persons create significant barriers to the provision of appropriate healthcare services to this population (44). More than 30 independent studies have found that professional nurses are not adequately empowered to provide appropriate care to LGBTQI+ persons, which often leaves nurses feeling unprepared and contributes to ongoing healthcare disparities experienced by LGBTQI+ individuals (45). Furthermore, Klepper et al. (46) reveal that the few available textbooks contain insufficient or non-significant information to empower professional nurses to provide inclusive healthcare to LGBTQI+ people. There is a limited supply of teaching and learning material, as only three textbooks appear to include content relevant to LGBTQI+ persons, their healthcare needs, and general health disparities they experience (47).

In addition to the limited availability of textbooks that equip professional nurses to care for LGBTQI+ persons and address their healthcare needs, the current nursing curriculum also appears to lack relevant content (48). Even in instances where professional nurses have received formal or informal training to care for LGBTQI+ persons, it is still not adequate to provide culturally competent caring practices to these individuals (49, 50). To address the knowledge gap in providing culturally competent, caring practices to LGBTQI+ persons, McCann and Brown (51) state that the nursing curriculum should include content such as theoretical instruction, skills simulation, and practice-based learning, as well as relevant theories such as gender, queer, and social justice. These components will provide professional nurses with insight into the lived experiences of this population. The findings of this theme highlight the importance of empowering professional nurses to provide inclusive care, demonstrating the need to realign the current curriculum to address knowledge deficits professional nurses experience in providing care to LGBTQI+ persons.

In addition to the knowledge and skills deficit, professional nurses stated that a barrier to the provision of culturally appropriate care was the unavailability of resources. The participants shared that essential resources needed in primary healthcare facilities were not available, which led them to view the general environment as not accommodating LGBTQI+ persons. This aligns with findings indicating that healthcare facilities do not prioritize the unique sexual health needs of LGBTQI+ people, resulting in the non-provision of imperative resources such as lubricants, finger gels, and preferred condoms (52). The inability of professional nurses to provide lubricants, finger gels, and condoms contributes to the marginalization of LGBTQI+ people (53). Thus, Fu et al. (53) advocate that the non-availability of these resources often denies LGBTQI+ persons access and communicates a message that healthcare organizations do not provide healthcare services for LGBTQI+ people. The non-availability of condoms and lubrication may be the rationale for the LGBTQI+ persons being more susceptible to infections such as HIV/AIDS (54). A recent study by Gyamerah et al. (55) affirms that LGBTQI+ people in South Africa face a high infection rate, which is exacerbated not only by the lack of condoms and lubricants but also by stigma and discrimination that limit access to healthcare facilities. To address the consequences of inadequate availability of suitable or preferred condoms for the LGBTQI+ community, governments globally should consider these needs and integrate relevant information into all relevant curricula (56).

In addition to the identified barriers to providing culturally appropriate care, Seretlo, Smuts, and Mokgatle (57) note that healthcare providers recognize that healthcare institutions frequently fail to accommodate LGBTQI+ persons by not providing appropriate bathroom facilities. Colliver and Duffus (58) and Porta et al. (59) advocate that healthcare institutions should promote gender-neutral bathrooms to foster acceptability and inclusivity. The presence of gender-neutral toilets is essential to ensure that LGBTQI+ persons feel safe and comfortable, as opposed to using bathrooms designed exclusively for heterosexuals, where they may experience bullying and intimidation from heterosexual patients (60). James et al. (61) and Kosciw et al. (62) confirm that LGBTQI+ persons are harassed and attacked in heterosexual bathrooms. A study by McGuire, Okrey, Anderson, and Michaels (63) concludes that gender neutrality is imperative not only for LGBTQI+ persons but also for marginalized individuals such as people with disabilities. The findings of this subtheme demonstrate the importance of gender-neutral toilets. However, the researchers are mindful that some individuals might not be comfortable with gender-neutral toilets. Thus, the conclusion is that not all toilets should be gender-neutral, thereby giving all individuals the opportunity to choose which bathroom to use.

The participants shared with the researchers that they felt as if their belief systems had a negative impact on the care they provided to LGBTQI+ people. A recent study unveiled that professional nurses’ religious beliefs have an impact on the way they provide care to LGBTQI+ persons, which is normally embedded in discrimination and bias (64). Westwood, James, and Hafford-Letchfield (22) affirm that professional nurses confessed that, because of their religious beliefs and practices, they prefer not to engage with LGBTQI+ people. A quantitative study found that professional nurses perceived individuals classified as LGBTQI+ as having a mental illness and being possessed by evil spirits, resulting in these individuals not being accepted within healthcare environments (65). These findings are supported by Müller (66), where a patient stated, “As soon as I declared my sexuality, my physician perceived me as an ‘evil spirit’”. Another study, also within the South African context, shared a verbatim quote, “I believe God created Adam and Eve, and that’s how it should be” (67). Bumgardner et al. (68) advise that healthcare organizations need to raise awareness about how an individual’s religion can have a negative impact on the care they provide to LGBTQI+ persons. The findings of this theme indicate that professional nurses are not upholding the values and principles of the nursing profession, such as the patient rights charter, batho pele principles, caring or ubuntu, but rather their own personal beliefs.

This study was conducted to examine the barriers professional nurses experience when providing care to self-identified LGBTQI+ persons. Based on the available literature, this appeared to be the first study of its kind in the context of primary healthcare facilities, providing significant insight into the identified barriers and their negative impact on the care nurses provided. Moreover, the findings of this study may be generalized to other contexts beyond primary healthcare facilities, as the researchers provided detailed information on the research setting, participants, and the methodology used throughout the study.

This study was conducted only in primary healthcare facilities in Gauteng, which may have imposed geographical limitations. Additionally, despite employing a qualitative methodology, this study yielded relevant results. However, a quantitative methodology might have reached a larger number of participants, yielding more findings, as a larger sample size would have allowed for greater statistical power.