A More Diverse Nursing Workforce
A More Diverse Nursing Workforce
Our nation is becoming increasingly diverse. Yet the U.S.Â nursingÂ workforce has historically beenâ€”and continues to beâ€”predominantly white and female.Â In its landmark report,Â The Future ofÂ Nursing: Leading Change, Advancing Health, the Institute of Medicine (IOM) called for more racial, ethnic, and gender diversity among nurses in order to improve quality of care and reduce health disparities.
The Future ofÂ Nursing: Campaign for Action, a collective effort supported by the Robert Wood Johnson Foundation (RWJF) and AARP, is working to implement this and other IOM report recommendations in all 50 states and the District of Columbia. Diversity has long been a core value of the RWJF and AARP, and this commitment extends to the Campaign for Action. The mission of its Diversity Steering Committee is
â€œto narrow the health care disparities gap, to support the importance of a diverse workforce and to help prepare the discipline ofÂ nursing to care for an increasingly diverse population [in an effort] to ensure that all Americans, regardless of race, religion, creed, ethnicity, gender, sexual orientation, or any aspect of identity, will have access to high quality, patient-centered care in a health care system where nurses contribute as essential partners in achieving success. â€ A More Diverse Nursing Workforce
The Diversity Steering Committee is composed of organizations that represent groups who are underrepresented inÂ nursing, such as Latinos, blacks, Native Americans, Asians, and men. By working together, these groups can bolster efforts to diversify theÂ nursingÂ workforce and recruit and retain moreÂ nursing students from underrepresented groups. A More Diverse Nursing Workforce
As a result of these and other national and state-level efforts, theÂ nursingÂ workforce is evolvingâ€”and the historic diversity gap is beginning to close. However, more work needs to be done to ensure that the U.S.Â nursing workforce reflects the rich and growing diversity of the U.S. population. Every nurse has a role to play in achieving this goal. A More Diverse Nursing Workforce
PROGRESS AND CHALLENGES
There is progress for the Campaign for Action to build on. In recent decades, theÂ nursingÂ profession has begun to evolve from being predominately white and female. The proportion of nurses from racial and ethnic minority groups has increased in the last two decades, from less than 15% in 1995 to more than 20% in recent years.Â The percentage of men inÂ nursingÂ has increased from 8.7% in 2010 when theÂ Future ofÂ NursingÂ report was released to 10.7% in 2013â€”an increase of 70,000 men during this time period.Â Men inÂ nursingÂ are slightly more likely than women to be from a minority group: approximately 25% of male RNs are nonwhite compared with about 20% of female RNs, underscoring the need to focus on both gender inclusion and racial and ethnic diversity in the profession.
The diversity of theÂ nursingÂ workforce still lags far behind that of the general population. According to the U.S. Census Bureau, people from racial and ethnic minority groups account for more than one-third (37%) of the U.S. population.Â By 2043, the United States will become a majorityâ€“minority nation, which means that whites will make up less than half the population.Â TheÂ nursingÂ workforce is not diversifying at nearly the same pace, and there is an urgent imperative to expedite progress. The adverse impact on patient outcomes caused by the lack of diversity inÂ nursingÂ and other health professions has been well documented and may be best summarized in the Sullivan Commission on Diversity in the HealthcareÂ Workforce report, Missing Persons: Minorities in the Health Professions.
TheÂ Future ofÂ NursingÂ report noted the need for change and included a call for action regarding diversity in several of its recommendations. For example, the recommendation to increase the proportion of nurses with a bachelor of science inÂ nursingÂ (BSN) to 80% by 2020 calls for â€œstrategies to increase the diversity of theÂ nursingÂ workforce in terms of race/ethnicity, gender, and geographic distribution.â€Â The report urges academic leaders not only to recruit but also to retainÂ nursingÂ students from diverse backgrounds. Similarly, the recommendation to double the number of nurses with doctorates suggests funding strategies to increase not only the number but also â€œthe diversity of nurse faculty, scientists, and researchers.â€
Since the release of the IOM report and the formation of the Campaign for Action, many colleges and universities have stepped up efforts to increase the diversity of BSN graduates through recruitment and retention programs. However, despite progress, there is considerable work to do. There is still a compelling need for the nationâ€™s colleges and universities to take a more focused approach to enhancing the diversity of theÂ nursingÂ workforce if they are to catch up to, and keep pace with, the countryâ€™s demographic changes. Nationwide, racial and ethnic minority students represent more than 30% of students in entry-level baccalaureate programs.Â Men compose just 11% of baccalaureate and graduateÂ nursingÂ students, despite making up nearly half of the U.S. population.Â Furthermore, only 12% of full-timeÂ nursingÂ school faculty members are from racial and ethnic minority groups, and only 5.4% are men.
A 2013 survey ofÂ nursingÂ schools by the National League forÂ NursingÂ found slightly more progress. One-third (33%) of students enrolled in baccalaureate RN programs in 2012 were from racial or ethnic minority groups,Â and 14% were male.
Given the imperative to accelerate progress, the Campaign for Action has an opportunity not only to implement but also to build on the IOM recommendations. For example, the campaign can facilitate interest inÂ nursingÂ by helping to develop partnerships between nurses and schools, churches, and community-based organizations in minority communities that provide education and career advice. This also helps many nurses who are not from minority groups to better understand the communities in which people underrepresented inÂ nursingÂ live, work, and play.
The IOMâ€™s recommendations about practice, leadership, and data collection also offer opportunities to improve diversity within theÂ nursingÂ profession. Many states with restricted scope-of-practice laws and shortages of primary care providers, for instance, also have large racial and ethnic minority populations (for example, Texas, Alabama, and Mississippi). By including people from minority, rural, and other affected communities in its advocacy efforts, the campaign can help to ensure that diverse voices are heard in state-level discussions.
For the Campaign for Action, a key component in building partnerships with minority communities has been to work with organizations such as the National Black Nurses Association, the National Association of Hispanic Nurses, the Asian American/Pacific Islander Nurses Association, and the National Alaska Native American Indian Nurses Association. These groups have strong ties to minority communities and relationships with other local and national minority organizationsâ€”connections that support the campaignâ€™s vision for diversity. Another key allied organization is the American Assembly for Men inÂ NursingÂ (AAMN).
All of these organizations support the health of their respective communities, help minority nurses and men inÂ nursingÂ to advance in the profession, and address social determinants of health. In addition, they provide minority nurses with critical leadership opportunities and experience, as well as mentorship and educational opportunities.
THE DIVERSITY STEERING COMMITTEE
The creation of the Campaign for Action and its Diversity Steering Committee presented an opportunity to go beyond the IOMâ€™s recommendations by integrating other initiatives that are important toÂ nursingÂ and also support the report. The Diversity Steering Committee is led by cochairs (and coauthors of this article) Antonia Villarruel and Deborah Washington, who are from the academia and practice environments, respectively.
The Campaign for Action invited six minorityÂ nursingÂ organizations and the AAMN to serve as committee member organizations because of their impressive track records and long-standing commitment to promoting diversity inÂ nursingÂ and advancing health in their respective communities (seeÂ The Campaign for Actionâ€™s Diversity Steering Committee Member Organizations). Although there was an initial discussion of a broader constituencyâ€”including interdisciplinary and advocacy organizations concerned with diversity, for exampleâ€”the committee members wanted to clarify the priorities and direction related to the IOMâ€™sÂ Future ofÂ NursingÂ report recommendations on race, ethnicity, and gender before engaging others.
The Diversity Steering Committee was charged with laying the groundwork for the campaignâ€™s national and state-level strategies to address the complexities associated with bringing attention to diversity and advancing the IOM reportâ€™s recommendations. The campaign seeks to be all-inclusive and views diversity in terms of race, ethnicity, gender, disability, geographic location, age, and sexual orientation. Therefore, the committee adopted a concept of diversity that was broad in scope and definition.
The Diversity Steering Committee used several strategies to integrate its work into the campaignâ€™s initiatives. For example, in collaboration with the RWJF, the committee recommended that all state action coalitions receiving grants from the Academic Progression inÂ NursingÂ (APIN) program and the State Implementation Program (SIP) develop plans to addressÂ nursingÂ workforce diversity in their states. (The APIN program and the SIP, both RWJF projects, focus on education and other campaign initiatives. For more information on these programs, see the previous article in this series, â€œNursingÂ Education Transformation,â€ April.)
The action coalitions receiving funds from APIN had been using diversity-related strategies, including exploring diversity inÂ nursingÂ leadership, developing partnerships with minorityÂ nursingÂ organizations, supporting appointments of nurses from minority groups to advisory boards, and auditing Web sites for the presence of diversity. Although these strategies were a good beginning, there remained a need for more comprehensive, integrative, and outcome-oriented strategies. To further guide the action coalitions, the Diversity Steering Committee outlined criteria for effective diversity action plans, considering priority areas identified by the IOM report but also broadening the criteria.
The committee created benchmarks for state diversity plans that included the following:
- Strategies should be developed at the right â€œline of sightâ€ (focusing not only on process but on outcomes), targeted to the state level, and grounded in the IOM recommendations. The committee encourages action coalitions to focus on their statesâ€™ population and demographic needs.
- Efforts should be data based and data driven. The committee recommends that an action coalitionâ€™s plans begin by determining baseline data regarding the stateâ€™s population and workforce.
- Choice of focus, direction, and strategies should be evidence based. The committee encourages action coalitions to use lessons learned from other state-level coalitions, institutions, and minority organizations that implemented successful programs aimed at increasing diversity.
- The emphasis should be on sustainability and a credible infrastructure for continuous work. The committee wants to ensure that efforts can be sustained over time, and that plans can be replicated or adopted by other organizations or states.
- Diversity should be thoroughly embraced by each action coalition. The committee wants to ensure that the coalitions are addressing the diversity of their leadership, as well as using diversity strategies in regard to education progression, removing barriers to practice and care, interprofessional collaboration, and data collection initiatives. A More Diverse Nursing Workforce
Through APIN and the SIP combined, 42 action coalitions are now working on diversity initiatives, and nearly all have incorporated the Diversity Steering Committeeâ€™s recommendations.
STATE SUCCESS STORIES
Moving from planning to action takes courageous leadership. Diversity planning needs to be intentional and include metrics to monitor progress and ensure accountability. Several state examples of diversity programs demonstrate, and have benefited from, courageous action.
Rhode Island Nurses Institute Middle College.Â TheÂ nursingÂ shortage is expected to be especially severe in Rhode Island because of the stateâ€™s growing population of older adults.Â Donna Policastro, RNP, executive director of the Rhode Island State Nurses Association, took action, opening the Rhode Island Nurses Institute Middle College Charter High School (RINI-MC) in Providence in 2011.
This program serves students who are 15 to 20 years old. It allows those in grades 10, 11, 12, and beyond to focus their studies onÂ nursingÂ and health care. The curriculum is designed so that students can earn high school diplomas and certifiedÂ nursingÂ assistant credentials; they are also prepared to pursue BSNs. The student population of the RINI-MC is 45% Latino, 36% black, 16% white, and 3% Asian; 87% of students meet federal low-income guidelines for free and reduced-price lunches.
The results to date are notable. In 2013, the RINI-MC was ranked as one of the top 10 high schools in Rhode Island by RI-CAN,Â a branch of 50CAN: The 50-State Campaign for Achievement Now, a national network of state advocacy groups. RI-CAN ranked the school fourth in low-income and African American student performance and fifth in Hispanic student performance, noting that 58% of students were at or above proficiency.Â The first class graduated in June 2014 and included 59 students.Â Policastro attributes her vision for the school to the IOMâ€™sÂ Future ofÂ NursingÂ recommendations.
New MexicoÂ NursingÂ Education Consortium.Â For many students in rural states, access to a university education is out of reach because of geographic barriers. Realizing this, the New MexicoÂ NursingÂ Education Consortium implemented a statewideÂ nursingÂ curriculum that will soon make BSN degrees available at publicly funded community colleges throughout the state.
By the 2017â€“2018 academic year, through partnerships between community colleges and universities, New MexicoÂ nursingÂ students will be able to pursue a BSN at one of 17 locations. Previously, they had just two options: the University of New Mexico in Albuquerque or New Mexico State University in Las Cruces.
The consortium program provides for seamless transfers, allowing students to retain credits when they attend another school. The curriculum will be implemented in every state-funded associateâ€™s degree and baccalaureateÂ nursingÂ program in New Mexico by 2018, providing students from minority groups with greater access to baccalaureate completion programs.
The consortium is also exploring and participating in approaches to reach previously underrepresented minority communities. These include several high school academies that provide opportunities to strengthen math, science, and ACT scores, as well as a chance for students to be exposed to information about various health professions.
Because of the consortium, students from diverse backgrounds, particularly those who are Hispanic and Native American, will have access to a BSN education in their local communities. (For an informational video, go toÂ .)
Wisconsin Action Coalition.Â Using guidelines set forth by the Diversity Steering Committee, the Wisconsin Action Coalition created an operational framework for ensuring that its work focuses on diversity. The framework states that the action coalition will
- collect, analyze, integrate, and utilize data to develop evidence-based strategies for all project goals.
- build partnerships across multiple and diverse stakeholder groups (among them health care organizations and minority associations, such as the Milwaukee Chapter of the National Black Nurses Association and the Southeastern Wisconsin Chapter of the National Association of Hispanic Nurses).
- promote, target, and sustain diversity efforts across educational and practice settings (such as use of academicâ€“practice partnerships).
- create direct outreach approaches that engage diversity groups and stakeholders. This may include conferences such as the statewide Cultivating a DiverseÂ NursingÂ Workforce conference, or online efforts such as the Wisconsin Center forÂ Nursingâ€˜s Web page highlighting â€œstellar studentsâ€ from traditionally underrepresented populations (seeÂ ).
The Cultivating a DiverseÂ NursingÂ Workforce conference was held in June 2013 and was attended by 120 participants, 14% of whom were minorities. Hosted by the Wisconsin Action Coalition, in partnership with the Wisconsin Center forÂ Nursing, its purpose was to address the critical need for greater diversity in theÂ nursingÂ workforce. During the summit, the Wisconsin Center forÂ NursingÂ released findings from its Diversity Taskforce, which included several recommendations, among them to â€œdevelop a standardized system with agreed upon benchmarks for tracking data on under-represented populations inÂ nursingÂ programs [and] health systems throughout the stateâ€ and to â€œjoin forces for a statewide initiative to increase funding forÂ nursingÂ scholarships for under-represented populations.â€Â The Wisconsin Center forÂ NursingÂ also released an infographic highlighting results from the task forceâ€™s report, as well as a diversity assessment tool and tool kit.Â The reports and infographic helped to raise awareness about health care disparities and the need for increased workforce diversity in the state.
NATIONAL SUCCESS STORIES
Like the state examples, the national success stories reflect a commitment both to advancing diversity in theÂ nursingÂ workforce and to the IOMâ€™s call for greater diversity.
American Organization of Nurse Executives.Â As the voice forÂ nursingÂ leadership, the American Organization of Nurse Executives (AONE) convened a task force in 2013 to develop recommendations to improve the diversity of its board of directors in terms of race, ethnicity, gender, age, and practice setting.Â This was in response to a 2012 analysis of a survey of AONE members that found that respondents were primarily female, white, employed in acute care, working as directors or in more advanced positions, and older than 40.
The board of directors adopted the task forceâ€™s recommendations, including one that called for the creation of four appointed positions on the board, at least two to be filled by racial or ethnic minority nurses and the rest by men, nurses working in preâ€“ and postâ€“acute care settings, nurses working in education or academia, and nurses considered to be early career leaders. In 2014, four people were appointed to the AONE board, including nurses who are Hispanic, Filipino, male, employed across the continuum of care and academia, and leaders early in their careers.
Such appointments will occur for a limited number of years and be discontinued when the organizationâ€™s nominations committee can present a slate of electable diverse and inclusive candidates for officer and board member positions. This was a historic move by the AONE that establishes a framework other professionalÂ nursingÂ organizations can follow.
American Assembly for Men inÂ Nursing.Â In an effort to address gender diversity in theÂ nursingÂ workforce, the AAMN established a program called Excellence inÂ NursingÂ Education Environments Supportive of Men. This program recognizesÂ nursingÂ education initiatives that demonstrate gender competence in
- recruitment and retention, with explicit efforts to increase the number of men enrolled inÂ nursingÂ schools and the retention of male students through graduation.
- inclusivity and affirmation.
- intentional integration of diversity into the day-to-day operations ofÂ nursingÂ schools.
Three schools are piloting this program, a process that includes preparing for recognition, applying for recognition, and navigating the review process. The program will then be open to schools throughout the country.Â NursingÂ schools that excel in recruiting, retaining, and graduating male nurses, as well as in providing an education environment supportive of men, will be recognized. The goal is for otherÂ nursingÂ schools to learn from and replicate these schoolsâ€™ experiences. (For more information on this program, go toÂ .)
National Association of Hispanic Nurses: Phoenix Chapter.Â The IOM report emphasized that nurses should have a role in improving access to care in underserved communities. In response, the National Association of Hispanic Nurses: Phoenix Chapter developed a training model with AARP Arizona called Educating Multicultural Communities on the Patient Protection and Affordable Care Act.
Members of the National Association of Hispanic Nurses: Phoenix Chapter received training in the basic provisions of the Affordable Care Act and then used this information to educate members of multicultural communities. In just five months, these nurses reached 1,400 people through 56 community forums targeting hard-to-reach populations.Â State action coalitions and other minorityÂ nursingÂ associations can follow this example, working at the state and local levels to improve health outcomes.
THE NEED FOR CHANGE
TheÂ nursingÂ workforce is not nearly as diversified as the U.S. population, and this must change. Long-standing barriers to diversity inÂ nursingÂ education and in all aspects of the profession must be removed.
Everyone has a role to play in advancing reforms that will diversify theÂ nursingÂ workforce. Much can be achieved simply by sharing tips, tools, and successful experiencesâ€”learning important facts and relaying them to colleagues and key stakeholders, sharing this article, attending a meeting of one of the professionalÂ nursingÂ associations working on this issue, or visiting the Web site of the Campaign for Action () or anotherÂ nursingÂ organization and leaving comments or suggestions about diversity. Identify steps that can make the profession more welcoming to racial and ethnic minorities and to menâ€”and ask others to help you take those steps.
It is important to evaluate any actions taken to diversify theÂ nursingÂ workforce so we can determine which actions are most effective. We must always lead with facts. Set benchmarks for actions to promote diversity and consider whether the actions meet the urgent imperative for change.
The Campaign for Action is playing a critical role in helping to recruit and prepare a more diverse and culturally competentÂ nursingÂ workforce that is poised to provide care in a variety of settings to an aging and more diverse population. However, more nurses and other stakeholders must support the campaignâ€™s work to promote diversity, and nurse leaders must completely embrace this goal. Only then will the country finally have aÂ nursingÂ workforce that reflects the population it serves and all communities will have the improved health and health care they need and deserve.