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A More Diverse Nursing Workforce

Villarruel, Antonia PhD, RN, FAAN; Washington, Deborah PhD, MS, RN; Lecher, William T MS, MBA, RN, NE-BC; Carver, Nefertari A.

AJN, American Journal of Nursing: May 2015 - Volume 115 - Issue 5 - pp 57-62
doi: 10.1097/01.NAJ.0000465034.43341.b1
Advancing Health Through Nursing, Progress of the Campaign for Action

Greater diversity is good for the country's health.

This last article in a series examining the impact of the Institute of Medicine's 2010 report, The Future of Nursing: Leading Change, Advancing Health, describes the ongoing progress and challenges in meeting the report's call for more racial, ethnic, and gender diversity among nurses.

Antonia Villarruel is a professor and the Margaret Bond Simon Dean of Nursing in the University of Pennsylvania School of Nursing, Philadelphia, and a cochair of the Future of Nursing: Campaign for Action Diversity Steering Committee. Deborah Washington is the director of diversity for Patient Care Services at Massachusetts General Hospital, Boston, and a cochair of the Future of Nursing: Campaign for Action Diversity Steering Committee. William T. Lecher is the senior clinical director of the Specialty Resource Unit at the Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, and the immediate past president of the American Assembly for Men in Nursing. Nefertari A. Carver is a project manager at the Center to Champion Nursing in America, Washington, DC. Contact author: Nefertari A. Carver, ncarver@aarp.org. The authors have disclosed no potential conflicts of interest, financial or otherwise.

Our nation is becoming increasingly diverse. Yet the U.S. nursing workforce has historically been—and continues to be—predominantly white and female.1 In its landmark report, The Future of 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.1

The Future of 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 is2

“to narrow the health care disparities gap, to support the importance of a diverse workforce and to help prepare the discipline of 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. ”

The Diversity Steering Committee is composed of organizations that represent groups who are underrepresented in nursing, such as Latinos, blacks, Native Americans, Asians, and men. By working together, these groups can bolster efforts to diversify the nursing workforce and recruit and retain more nursing students from underrepresented groups.

As a result of these and other national and state-level efforts, the nursing workforce is evolving—and the historic diversity gap is beginning to close. However, more work needs to be done to ensure that the U.S. nursing workforce reflects the rich and growing diversity of the U.S. population. Every nurse has a role to play in achieving this goal.

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PROGRESS AND CHALLENGES

There is progress for the Campaign for Action to build on. In recent decades, the nursing 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.3 The percentage of men in nursing has increased from 8.7% in 2010 when the Future of Nursing report was released to 10.7% in 2013—an increase of 70,000 men during this time period.3 Men in nursing 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.3

The diversity of the nursing 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.4 By 2043, the United States will become a majority–minority nation, which means that whites will make up less than half the population.4 The nursing 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 in nursing and other health professions has been well documented and may be best summarized in the Sullivan Commission on Diversity in the Healthcare Workforce report, Missing Persons: Minorities in the Health Professions.5

The Future of Nursing 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 in nursing (BSN) to 80% by 2020 calls for “strategies to increase the diversity of the nursing workforce in terms of race/ethnicity, gender, and geographic distribution.”1 The report urges academic leaders not only to recruit but also to retain nursing 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 “the diversity of nurse faculty, scientists, and researchers.”1

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 nation's colleges and universities to take a more focused approach to enhancing the diversity of the nursing workforce if they are to catch up to, and keep pace with, the country's demographic changes. Nationwide, racial and ethnic minority students represent more than 30% of students in entry-level baccalaureate programs.6 Men compose just 11% of baccalaureate and graduate nursing students, despite making up nearly half of the U.S. population.6 Furthermore, only 12% of full-time nursing school faculty members are from racial and ethnic minority groups, and only 5.4% are men.7

A 2013 survey of nursing schools by the National League for Nursing found slightly more progress. One-third (33%) of students enrolled in baccalaureate RN programs in 2012 were from racial or ethnic minority groups,8 and 14% were male.9

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 in nursing 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 in nursing live, work, and play.

The IOM's recommendations about practice, leadership, and data collection also offer opportunities to improve diversity within the nursing 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.

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BUILDING PARTNERSHIPS

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 organizations—connections that support the campaign's vision for diversity. Another key allied organization is the American Assembly for Men in Nursing (AAMN).

All of these organizations support the health of their respective communities, help minority nurses and men in nursing 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.

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THE DIVERSITY STEERING COMMITTEE

The creation of the Campaign for Action and its Diversity Steering Committee presented an opportunity to go beyond the IOM's recommendations by integrating other initiatives that are important to nursing 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 minority nursing organizations and the AAMN to serve as committee member organizations because of their impressive track records and long-standing commitment to promoting diversity in nursing and advancing health in their respective communities (see The Campaign for Action's Diversity Steering Committee Member Organizations). Although there was an initial discussion of a broader constituency—including interdisciplinary and advocacy organizations concerned with diversity, for example—the committee members wanted to clarify the priorities and direction related to the IOM's Future of Nursing report recommendations on race, ethnicity, and gender before engaging others.

The Diversity Steering Committee was charged with laying the groundwork for the campaign's national and state-level strategies to address the complexities associated with bringing attention to diversity and advancing the IOM report'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 campaign's initiatives. For example, in collaboration with the RWJF, the committee recommended that all state action coalitions receiving grants from the Academic Progression in Nursing (APIN) program and the State Implementation Program (SIP) develop plans to address nursing 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, “Nursing Education Transformation,” April.)

The action coalitions receiving funds from APIN had been using diversity-related strategies, including exploring diversity in nursing leadership, developing partnerships with minority nursing 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 “line of sight” (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 states’ population and demographic needs.

* Efforts should be data based and data driven. The committee recommends that an action coalition's plans begin by determining baseline data regarding the state'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.

Through APIN and the SIP combined, 42 action coalitions are now working on diversity initiatives, and nearly all have incorporated the Diversity Steering Committee's recommendations.

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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. The nursing shortage is expected to be especially severe in Rhode Island because of the state's growing population of older adults.10 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 on nursing and health care. The curriculum is designed so that students can earn high school diplomas and certified nursing 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.11

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,12 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.12 The first class graduated in June 2014 and included 59 students.12 Policastro attributes her vision for the school to the IOM's Future of Nursing recommendations.

New Mexico Nursing Education Consortium. For many students in rural states, access to a university education is out of reach because of geographic barriers. Realizing this, the New Mexico Nursing Education Consortium implemented a statewide nursing curriculum that will soon make BSN degrees available at publicly funded community colleges throughout the state.

By the 2017–2018 academic year, through partnerships between community colleges and universities, New Mexico nursing 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 associate's degree and baccalaureate nursing 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 to http://bit.ly/1DlNMbo.)

Wisconsin Action Coalition. 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 academic–practice partnerships).

* create direct outreach approaches that engage diversity groups and stakeholders. This may include conferences such as the statewide Cultivating a Diverse Nursing Workforce conference, or online efforts such as the Wisconsin Center for Nursing's Web page highlighting “stellar students” from traditionally underrepresented populations (see http://bit.ly/1IgffJe).

The Cultivating a Diverse Nursing 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 for Nursing, its purpose was to address the critical need for greater diversity in the nursing workforce. During the summit, the Wisconsin Center for Nursing released findings from its Diversity Taskforce, which included several recommendations, among them to “develop a standardized system with agreed upon benchmarks for tracking data on under-represented populations in nursing programs [and] health systems throughout the state” and to “join forces for a statewide initiative to increase funding for nursing scholarships for under-represented populations.”13 The Wisconsin Center for Nursing also released an infographic highlighting results from the task force's report, as well as a diversity assessment tool and tool kit.13-16 The reports and infographic helped to raise awareness about health care disparities and the need for increased workforce diversity in the state.

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NATIONAL SUCCESS STORIES

Like the state examples, the national success stories reflect a commitment both to advancing diversity in the nursing workforce and to the IOM's call for greater diversity.

American Organization of Nurse Executives. As the voice for nursing 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.17 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 force'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 pre– and post–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.17

Such appointments will occur for a limited number of years and be discontinued when the organization'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 professional nursing organizations can follow.

American Assembly for Men in Nursing. In an effort to address gender diversity in the nursing workforce, the AAMN established a program called Excellence in Nursing Education Environments Supportive of Men. This program recognizes nursing education initiatives that demonstrate gender competence in

* recruitment and retention, with explicit efforts to increase the number of men enrolled in nursing schools and the retention of male students through graduation.

* inclusivity and affirmation.

* intentional integration of diversity into the day-to-day operations of nursing 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. Nursing 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 other nursing schools to learn from and replicate these schools’ experiences. (For more information on this program, go to http://bit.ly/1KYXTq0.)

National Association of Hispanic Nurses: Phoenix Chapter. 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.18

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.18 State action coalitions and other minority nursing associations can follow this example, working at the state and local levels to improve health outcomes.

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THE NEED FOR CHANGE

The nursing workforce is not nearly as diversified as the U.S. population, and this must change. Long-standing barriers to diversity in nursing education and in all aspects of the profession must be removed.

Everyone has a role to play in advancing reforms that will diversify the nursing workforce. Much can be achieved simply by sharing tips, tools, and successful experiences—learning important facts and relaying them to colleagues and key stakeholders, sharing this article, attending a meeting of one of the professional nursing associations working on this issue, or visiting the Web site of the Campaign for Action (http://campaignforaction.org) or another nursing organization and leaving comments or suggestions about diversity. Identify steps that can make the profession more welcoming to racial and ethnic minorities and to men—and ask others to help you take those steps.

It is important to evaluate any actions taken to diversify the nursing 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 competent nursing 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 campaign's work to promote diversity, and nurse leaders must completely embrace this goal. Only then will the country finally have a nursing workforce that reflects the population it serves and all communities will have the improved health and health care they need and deserve.

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REFERENCES

1. Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing, at the Institute of Medicine. The future of nursing: leading change, advancing health. Washington, DC: National Academies Press; 2010. http://www.nap.edu/openbook.php?record_id=12956.
2. Future of Nursing Campaign for Action. Diversity steering committee. Center to Champion Nursing in America. 2014. http://campaignforaction.org/whos-involved/diversity-steering-committee.
3. Buerhaus P, et al. Current trends of men in nursing. Nashville, TN: Center for Interdisciplinary Health Workforce Studies; 2014 Sep. Research brief no. 4. http://healthworkforcestudies.com/news/current-trends-of-men-in-nursing-2.
4. U.S. Census Bureau. U.S. Census Bureau projections show a slower growing, older, more diverse nation a half century from now [press release]. 2012 Dec 12. http://www.census.gov/newsroom/releases/archives/population/cb12-243.html.
5. Sullivan Commisson on Diversity in the Healthcare Workforce. Missing persons: minorities in the health professions. Atlanta; 2004. http://www.aacn.nche.edu/media-relations/SullivanReport.pdf.
6. American Association of Colleges of Nursing. The changing landscape: nursing student diversity on the rise. Washington, DC; 2014 Jul. Policy brief; http://www.aacn.nche.edu/government-affairs/Student-Diversity-FS.pdf.
7. American Association of Colleges of Nursing. Enhancing diversity in the workforce [press release]. 2014 Jan 21. http://www.aacn.nche.edu/media-relations/fact-sheets/enhancing-diversity.
8. National League for Nursing. Nursing education statistics: percentage of minority students enrolled in basic RN programs by race-ethnicity and program type, 2012 [slide F23]. Washington, DC; 2013. NLN DataView; http://www.nln.org/researchgrants/slides/index.htm.
9. National League for Nursing. Nursing education statistics: percentage of students enrolled in basic RN programs by sex and program type, 2012 [slide F29]. Washington, DC; 2013. NLN DataView; http://www.nln.org/researchgrants/slides/index.htm.
10. Special Senate Commission to Undertake a Comprehensive Study of the Projected Nursing Shortage in the State of Rhode Island. Findings and recommendations. Report submitted to the Rhode Island State Senate. Providence, Rhode Island; 2009.
11. Rhode Island Nurses Institute Middle College. About the Rhode Island Nurses Institute Middle College charter high school: fast facts. 2014. http://www.rinimc.org/about.html.
12. Asinof R Building a local talent pipeline for nurses in a patient-centric world. ConvergenceRI 2013 Oct 7. http://www.convergenceri.com/stories/Building-the-local-talent-pipeline-for-nurses-,88.
13. Wisconsin Center for Nursing. Enhancing diversity in the nursing workforce. A report by the Wisconsin Center for Nursing Diversity Taskforce. 2013. http://entech-dev.cuir.uwm.edu/wcfn/documents/2013%20WCN%20DiversityReport_final.pdf.
14. MacWilliams B, et al. The Wisconsin diversity assessment tool (WI-DAT): a vision for sustainable change. Oshkosh, WI: University of Wisconsin—Oshkosh; 2015. http://www.wisconsincenterfornursing.org/documents/Diversity%20product/WI%20Diversity%20Assessment%20Tool%20FINAL%201_30_15.pdf.
15. Wisconsin Center for Nursing. Diversity in nursing: a solution for Wisconsin. 2006. http://www.wisconsincenterfornursing.org/documents/Diversity%20product/WI%20Diversity%20Infographic_FINAL%20062814.pdf.
16. Wisconsin Center for Nursing. Diversity toolkit for recruitment and retention of minority nursing students. Taking the LEAD for nursing in Wisconsin: leadership, educational advancement, and diversity. Milwaukee, WI; 2015 Jan 20. http://www.wisconsincenterfornursing.org/documents/Diversity%20product/Diversity%20Toolkit%20FINAL%20Jan%202015.pdf.
17. American Organization of Nurse Executives (AONE). AONE president appoints four members to the board of directors [press release]. 2014 Feb. http://www.aone.org/membership/about/press_releases/2013/02.20.2014.shtml.
18. Health Resources and Services Administration. Nurses matter: national nursing call: national nursing call transcript. Rockville, MD: U.S. Department of Health and Human Services; 2014 Jan 23. http://www.hrsa.gov/affordablecareact/nursesmatter.html.
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