Racial and Ethnic Composition of Neonatal Nurse Practitioner Faculty and Students in the United States : Advances in Neonatal Care

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Ethical Issues in Neonatal Care

Racial and Ethnic Composition of Neonatal Nurse Practitioner Faculty and Students in the United States

Newberry, Desi M. DNP, NNP-BC; Bell, Tracey DNP, NNP-BC

Editor(s): Fortney, Christine A. PhD, RN, Section Editor

Author Information
Advances in Neonatal Care ():10.1097/ANC.0000000000001045, January 06, 2023. | DOI: 10.1097/ANC.0000000000001045
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Despite improvements in neonatal care, glaring health disparities still exist in the neonatal intensive care unit (NICU). Current evidence shows that Black and Latinx neonates in the NICU receive less quality care than their White counterparts with resultant disparate outcomes1; these differences persist even within the same NICU.2–5 Underrepresented minority (URM) patients receive lower quality care when cared for by a provider with a different skin color than their own.6 Research has shown that Black parents express more dissatisfaction with nursing care in the NICU.5

Underrepresented minority infants are born prematurely at higher rates and have increased rates of mortality and morbidity. The preterm birth rate for Black infants is 50% higher than infants of all other races and ethnicities,7 often resulting in lengthy NICU stays. These differences persist even after accounting for other risk factors such as maternal hypertension, smoking, and obesity.8

Minority nurses offer a valuable perspective to nursing care with shared life experiences as their patients and the ability to understand the culture and establish partnerships and communication with their minority patients.9 Increased diversity in healthcare providers has shown to increase patient satisfaction, communication, and access to care.10 In a recent statement on workforce demands of the future, the National League of Nurses called for “a clear path forward to achieve an inclusive, diverse, qualified, and competent workforce in sufficient numbers to meet the needs of the population's health care.”11 Despite these recommendations, there remains a current racial and ethnic discordance between NICU providers and patients.6

Health equity, and therefore patient/parent satisfaction, could be improved with a nursing workforce from a diverse background.12,13 Improved health equity, through the provision of equitable and fair healthcare for all, will support social justice.14 Improved cultural sensitivity could help ensure future nursing graduates treat all their patients with respect and with less implicit bias.12

According to the US Census Bureau, approximately one-third of US citizens self-identified their race as non-White. It is estimated that within the next 30 years, these numbers will continue to increase and by 2060, those who are currently the minority will be the majority. Based upon data from the 2020 U.S. Census, 60% of the US population self-identified as White. In this same database, 12% identified as Black and 19% as Latinx.15

When comparing the racial breakdown of the country to the registered nurses (RNs) in the United States, there are marked differences. The number of minority nurses remains low, with an estimated 19% of nurses identifying as having a URM background. Data from 2017 showed that White RNs accounted for 80.1%, Black 6.2%, and Latinx 5.3%, respectively.16

To address this problem, efforts must begin before nursing school. A known barrier to recruitment and retention of URM nursing students is limited diversity in the nurse faculty role.17,18 As such, URM nursing students often lack URM faculty mentors. This is problematic as URM students have improved academic outcomes when mentored by URM faculty.19

The current racial and ethnic composition of neonatal nurse practitioner (NNP) faculty in comparison to NNP students in the United States is unknown. In the NICU, NNPs have a strong presence both in management of critically ill infants and in communication and support of the infant's family. As such, NNPs are primed to lead efforts to induce change related to health disparities in the NICU. The purpose of this study was to determine and compare the racial and ethnic composition of NNP faculty, NNP students, and NICU admissions in the United States. Barriers encountered by URM nursing students and faculty and strategies to improve recruitment and retention are discussed.

The research questions were:

  1. Is there is a discordance between the racial and ethnic composition of NNP faculty in comparison to NNP students?
  2. Is there a discordance between the racial and ethnic composition of NNP students in comparison to available data for the racial and ethnic composition of neonates admitted to the NICU?

What This Study Adds

  • Provides data on the racial and ethnic composition of NNP faculty and students in the United States.
  • Demonstrates the racial and ethnic discordance between future practicing NNPs and infants in the NICU.



This cross-sectional study used a descriptive survey to describe the racial and ethnic composition of NNP faculty and NNP students in the United States. Data on the racial and ethnic composition of NICU admissions were accessed via the National Center for Health Statistics via the Center for Disease Control and Prevention's WONDER online database.20


The target population for this study was concentration directors or lead faculty for NNP programs in the United States. Inclusion criteria included accredited NNP programs in the United States. A list of accredited NNP programs was compiled by the National Association of Neonatal Nurses (NANN) NNP Faculty Special Interest Group. There are 41 known accredited NNP programs in the United States.


Study data were collected and managed using REDCap electronic data capture tools hosted at Duke University.21,22 REDCap (Research Electronic Data Capture) is a secure, web-based software platform designed to support data capture for research studies, providing (1) an intuitive interface for validated data capture; (2) audit trails for tracking data manipulation and export procedures; (3) automated export procedures for seamless data downloads to common statistical packages; and (4) procedures for data integration and interoperability with external sources.

Participation in the survey implied consent. See Table 1 for survey questions. Of note, the full survey contained additional questions related to gender and faculty rank, which were not analyzed during this phase of the research but will instead be presented separately to maintain the focus of this article on racial and ethnic diversity.

TABLE 1. - Survey Questions
Faculty Questions
How many full-time faculty teach in your program?
How many part-time faculty teach in your program?
How many faculty identify their race/ethnicity as:
African American/Black
Native American
Declined to answer
Student Questions
How many students are in your program for the year 2021? (graduated/are graduating in 2021) (2021 cohort)
How many students in the 2021 cohort identify their race/ethnicity as:
African American/Black
Native American
Declined to answer
How many students do you have in the 2022 cohort? (graduating in August or December 2022)
How many students in the 2022 cohort identify their race/ethnicity as:
African American/Black
Native American
Declined to answer


Following institutional review board exemption (obtained through Duke University), the survey was distributed to NNP program directors via email. A data sharing agreement was in place due to this joint venture between Duke University and Emory University.

Potential participants received an invitation via email with a description of the study, and a link that allowed them to log on to the REDCap study site. A verbal reminder about the survey was given at a regularly scheduled NANN NNP Faculty Special Interest Group meeting. Two email reminders were sent out at 2-week intervals. If a response was not received from the initial contact, a second contact from the site, if available, was emailed the survey. Once the survey was complete, no further data collection from the participants occurred. There was no reimbursement for study participation.

The data were analyzed using SPSS Version 28 (IBM Corp) for descriptive statistics, to describe frequencies and make comparisons between groups. Student data were collected for 2 cohorts. Cohort 2021 included all students graduating at any time during the 2021 calendar year. Cohort 2022 included all students graduating at any time during the 2022 calendar year. Data from both student cohorts were combined for purposes of comparing the NNP students to both NNP faculty and NICU admissions.


Forty-six email survey invitations were sent out. Twenty-three responses were received (50% response rate). The majority of responses were from either the Southeast or Midwest regions of the country (61%), followed by the Northeast, West, and Southwest regions (see Figure 1). The 2021 individual institution cohort size ranged from 0 to 34 NNP students, with an average cohort size of 11 and a median of 8.5. The 2022 individual institution cohort size ranged from 0 to 28 NNP students, with an average cohort size of 10 and a median of 8.5.

Neonatal nurse practitioner program respondents by region.

Faculty Data

Faculty race/ethnicity was reported for 108 NNP faculty. The majority of NNP faculty were White, followed in order by Black, Latinx, Asian, and other. There were no entries for the categories Native American or multirace/ethnicity (see Table 2).

TABLE 2. - Comparison of Race/Ethnic Composition of NNP Faculty and Studentsa
Reported Race/Ethnicity NNP Faculty (n = 108) NNP Students (n = 403)
n % n %
Black 8 7.4 26 6.5
White 90 83.3 320 79.4
Latinx 3 2.8 23 5.7
Asian 6 5.6 18 4.5
Native American 0 0.0 1 0.2
Multirace/ethnicity 0 0.0 8 2.0
Other 1 0.9 7 1.7
Abbreviation: NNP, neonatal nurse practitioner.
aχ2(6) = 3.70, P = .583.

Student Data

The 2021 cohort had a total of 267 students, with race/ethnicity data reported for 216 of the students. The majority of the 2021 cohort were White, followed in order by Latinx, Black, Asian, other, and multirace/ethnicity. There were no responses for Native American. There were 51 students from 2 universities for whom race/ethnicity was not reported; these students were not included in the percentage calculations (see Table 2).

The 2022 cohort had 242 students, with race/ethnicity reported for 187 of the students. The majority of the 2022 cohort were also White, followed in order by Black, Latinx, Asian, multirace/ethnicity, Native American, and other. There were 55 students from 3 universities for whom race/ethnicity was not reported; these students were not included in the percentage calculations (see Table 2). A χ2 test showed no statistically significant difference between the race and ethnic composition of NNP faculty (n = 108) and NNP students (n = 403), P = .583 (see Table 2).

When comparing the combined NNP student cohorts, our future NNP workforce, with the race and ethnic composition of NICU admissions, χ2(3) = 154.77, P ≤ .001; all race distributions were significantly different between NICU admissions and students. The percentage of NICU admissions that were Black (18.0%) was significantly higher than the percentage of Black students (6.5%); Latinx NICU admissions (19.5%) were significantly higher than the proportion of Latinx students (5.7%); White students made up 79.4% of sample whereas 59.1% of the NICU admissions were White. All races were significantly different between NICU admission and students at P < .05 (see Table 3).

TABLE 3. - Comparison of Race/Ethnic Composition of NNP Students and NICU Admissionsa
Reported Race/Ethnicity NICU Admissions (n = 388,976) NNP Students (n = 403)
n % n %
Black 73,444 18.9 26 6.5
White 229,964 59.1 320 79.4
Latinx 75,658 19.5 23 5.7
Other 9,910 2.5 34 8.4
Abbreviations: NICU, neonatal intensive care unit; NNP, neonatal nurse practitioner.
aχ2(3) = 154.77, P ≤ .001. All race distributions were significantly different between NICU admissions and students. “Other” included infants of more than one race or a race other than White, Black, or Latinx.


The 2020 National Nurse Practitioner Sample Survey conducted by the American Association of Nurse Practitioners (AANP) showed similar results to ours regarding the racial and ethnic composition of nurse practitioners (NPs) in the United States.23 Similar to our results for NNP students, the majority of NPs in the United States are White (79.4%). The NP nationwide trends for Black (8.1%), Latinx (5%), multirace/ethnicity (2.3%), Asian (4.3%), and Native American (0.5%) were also very similar to our results for NNP students.

Our results show significant differences in the racial and ethnic composition of NNP students and neonates admitted to the NICU. The discordance between NNP students and neonates in the NICU is important to addressing disparities in the NICU and begins in nursing school. In 2019, 64% of students enrolled in undergraduate nursing education identified as White, 10% Black, and 13% Latinx. The good news is that, of those enrolled in that same year, the graduation rates were very similar with 66.9% of White, 9.1% Black, and 11.8% Latinx graduating from the BSN program.16

The percentage of URM graduate nursing students is higher than that of URM undergraduate nursing students, with minority students comprising 34% of students in MSN programs, 34.6% in DNP programs, and 33% in PhD programs. This increase in higher education does not, however, equate to an increase in URM faculty, as nursing faculty is even less diverse with data from the National League of Nursing indicating that only 20% of full-time nursing faculty were non-White, which is consistent with our data on NNP faculty.11

Underrepresented minority faculty members can serve as role models. Faculty members from a minority background can assist with teaching culturally appropriate care plans. The lived experiences and personal backgrounds can serve as crucial aspects to understand patient issues or concerns. In addition, these lived, shared experiences can be used to educate other nursing faculty as well as students on the potential stressors experienced by URM persons.24

Our results showed the racial and ethnic composition of NNP faculty and NNP students was not significantly different; however, there is clearly underrepresentation of URM NNP faculty and students when compared with the NICU population. Lack of URM nursing faculty has been identified as a barrier to the recruitment and retention of URM nursing students.25 The perception for students could be that inclusivity is lacking in a school with minimal URM faculty.16 Underrepresented minority students are more likely to attend a university with faculty members of similar race or ethnicity.26 The identification of barriers for URM nursing students and faculty is a crucial component in establishing justice and increasing diversity in the future nursing workforce. The focus of this discussion is nursing students in general, due to the paucity of data on NNP students specifically. We believe the information can be applied to nursing students across the continuum of nursing school, from undergraduate to postdoctoral studies as the pool of graduate students must come from the pool of undergraduate students.

Barriers/Challenges for URM Nursing Students

There are numerous barriers for URM nursing students in addition to the obvious barriers of racism, bias, and cultural assumptions.9,16,17,24 Barriers for Underrepresented minority nursing students begin prior to admission and include factors such as inadequate K-12 preparation, dated admission standards/criteria, competition for admission, and cost.9,17

Barriers that exist during the nursing school experience include feelings of isolation, less support, lack of diversity in the faculty, staff, peers and in leadership, and lack of focus on diversity, and inclusion overall.9,10,17 Underrepresented minority nursing students may fear speaking up out of fear of retaliation.27 Students may also be less likely to ask for help due to concern that they will be mocked or perpetuate a commonly accepted stereotype for their particular race.28 Lack of mentors is also a challenge for URM nursing students, both undergraduate and graduate.10 Underrepresented minority nursing students may experience situations in which their cultural concerns are disrespected if faculty have a lack of cultural understanding and sensitivity.28

Barriers/Challenges for URM Nursing Faculty

There are numerous barriers for URM nursing faculty in addition to the obvious barriers of racism, bias, and cultural assumptions.9,29 Barriers for URM faculty begin during the interview process with feelings of not belonging. The lack of URM faculty members in the interview process supports the idea that diversity is not a priority for an institution.30

Barriers related to retention of URM faculty include isolation and loneliness, lack of available mentoring and support, the presence of microaggressions, and feeling overwhelmed with the role of “diversity expert.” In a study looking at nursing advancement, it was expressed that not having someone in leadership who looked like them proved a hardship for nurses with desire to advance in their career.29 Black nursing faculty are often burdened and made to feel like the token Black person, without recognition that one person does not represent the entire Black population.29 These barriers create challenges related to gaining promotions and tenure.29


An increase in faculty diversity has the potential to increase URM NNP nursing student recruitment and retention. In addition, enhancing presence with URM faculty and students has been shown to increase cultural competence and decrease implicit bias.29,31 An increase in diversity of faculty could potentially expand NNP workforce diversity, resulting in positive outcomes on neonatal morbidity and mortality. Although a thorough review of the literature on strategies to increase URM nursing student and faculty recruitment and retention is beyond the scope of this article, a broad overview of common identified themes is presented next.

Student Recruitment

Attracting URM students involves inclusive recruitment.24 Recruitment can begin in K-12 schools with exposure of students to health topics, the nurse role and nurse faculty career options to promote nursing.9,32,33 The selection of nursing students must demonstrate a school of nursing's (SON) value of equity and diversity.13 The use of a holistic admissions process is one way to accomplish this mission.17 Lastly, financial assistance is key in attracting URM students.9,24 Financial aid assistance must continue throughout the program to ensure graduation.

Faculty Recruitment

The university must show a strong commitment to diversity and inclusion with diversity, equity, inclusion, and belonging (DEIB) addressed in the SON mission statement and/or strategic plan.17,24 Assurance of URM faculty representation on the faculty search committee must be a priority.10 During the interview process, the presence of minority leaders and interview committee members can demonstrate the SON's commitment to diversity, presenting a welcoming presence to the potential new faculty member.

Student Retention

Attrition rates for Black nursing students range from 15% to 85%,8 as such, it is imperative to identify successful strategies for success in retaining URM students. The retention of URM graduate nursing students begins at orientation and does not end until graduation and beyond. Retention of URM nursing students is supported by peer support and the presence of other URM students.8 The NNP curriculum must integrate implicit bias and antiracism education and training throughout the program,14 not just presented in 1 module or course.12,16

The importance of URM representation in NNP faculty is stressed because in mentoring relationships, racial and ethnic concordance between nursing faculty and students improves success.16,27,28 Increased mentoring and support for the URM graduate nursing student may result in increased pursuit of a career in academia after advancing their education, paving the way for an increase in URM nursing faculty.34

Faculty Retention

An increased number of URM faculty could potentially expand nursing workforce diversity as more diverse faculty will assist with recruiting and retaining a more diverse student population, resulting in a positive outcome on neonatal and maternal mortality. At the SON level, establishment of DEIB committees within the SON is imperative, with DEIB issues directly stated in the university strategic plan.21 The presence of URM leaders can help negate concerns that racism will be a factor in advancement and tenure decisions.28 An anonymous reporting system should be in place for reporting microaggression and overt racism.16

Mentorship of new URM faculty with senior URM faculty supports retention of URM faculty.21 Benefits of mentoring include improved self-esteem, well-being, networking, and career coaching.20 Communication and time are 2 factors crucial to success of a mentee/mentor relationship.20 Universities must create “protected time” to foster these relationships.20 Mentoring should be included in calculating faculty workload, especially in URM faculty, who may be overburdened with mentoring responsibilities.


We must stress that race is a social category rather than a biologic category. The human genome project, completed in 2003, showed no unifying genetic identity among the so-called “races,” with genetic variability less than 0.1% among “races.”35 The current categorization by race and ethnicity is an unfortunate necessity in an attempt to promote justice for URMs and eliminate racism and health disparities in the NICU. Once justice is achieved, one could postulate/be hopeful that the categorization of human beings by skin color would not be necessary.

The term “underrepresented minorities” is generally used to refer to race or ethnicity. There is no standardization of race or ethnic categories. The categories that we used in our study are different from the categories used by the Centers for Disease Control and Prevention (CDC) WONDER Online Database.20 The CDC category of “other” included infants of more than one race or a race other than Black, White, or Latinx; whereas our study included a separate category for multirace/ethnicity. Although not all-inclusive, we also included additional categories, including Asian and Native American. A limitation to this study is the exclusion of other diverse populations, including, but not limited to gender, social, religious, and sexual orientation. Future research should focus not only on racial and ethnic diversity, but other diversity differentiations as well.

An additional limitation is the 50% survey response rate. It is not known whether the nonresponders would change the demographics of the data. It could be postulated that nonresponders do not acknowledge the lack of diversity in the NNP workforce as a problem and therefore did not see completion of the survey valuable.

Our data were compiled from self-reported surveys. Since the survey results are dependent upon the response rate, there is a possibility that some URM persons did not complete the surveys, therefore potentially changing the overall statistics. As previously discussed regarding barriers to recruitment of URM students and faculty, there is potential that if practicing NPs do not see representation from their respective specialty organizations, they may lack desire to participate in surveys or studies.

Finally, there was no standardized method of collecting this data; therefore, there could be inaccuracies in the data because each individual program supplied the information, and it was not known how this information was obtained. There may be increased risk of inaccuracy in the race and ethnicity of the students with the various methods of data collection.

What we know:
  • URM infants in the NICU receive a lower quality of care than their White counterparts.

  • URM nurses offer valuable perspectives in providing care to URM patients.

  • There is a current racial and ethnic discordance between NICU nurses and NNP students and the NICU infants they serve.

What needs to be studied:
  • The composition of other diverse populations in nursing, including (but not limited to) gender, social, religious, and sexual orientation.

  • Identification of barriers for other diverse populations in nursing.

  • Focus on strategies to increase recruitment and retention of other diverse populations in nursing.

What we can do today:
  • Begin efforts to increase diversity in NICU nurses and NNPs in nursing schools.

  • Address barriers to URM nursing students and faculty.

  • Focus on strategies to increase recruitment and retention of URM nursing students and faculty.


There is a significant difference between the racial and ethnic backgrounds of NICU RNs and NNPs and the neonates they serve. This racial and ethnic discordance begins in nursing school with a discordance between NNP students and faculty in comparison to the US population. The recognition of barriers encountered by URM nursing students and faculty is a necessary step in increasing recruitment and retention of URM NNP students and faculty. Numerous strategies exist to offset the barriers faced by URM nursing students and faculty to increase the diversity of NNP students and faculty and ultimately practicing NNPs. The ability to diversify the NNP workforce will result in improved neonatal outcomes.


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diversity; faculty; neonatal intensive care units; newborn infant; nurse practitioners; nursing students; underrepresented minority

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