Nursing educators agree that Latinos are underrepresented in the nursing workforce. The U.S. Census Bureau estimates that the Latino population will grow from 55.4 million in 2014 to 119 million by 2060 (17.4% and 28.6% of the total U.S. population, respectively)1; therefore, nursing education programs and institutions will want to engage that growing population so that Latinos are adequately represented in the nursing workforce. Future efforts in program planning for that engagement may benefit from an understanding of demographic complexities in the current Latino nursing population. This article provides initial data toward that end.
National nursing organizations and governmental bodies have called for greater diversity in the nursing workforce. In its First Report to the Secretary of Health and Human Services and the Congress, issued in 2001, the National Advisory Council on Nurse Education and Practice (NACNEP) stated its position on diversity in the nursing workforce in clear terms: “Increasing numbers of RNs from minority backgrounds is a prime consideration in reducing the substantial racial and ethnic disparities in health.”2 More than a decade later, NACNEP's 11th report, Achieving Health Equity Through Nursing Workforce Diversity, reminded policymakers that while some progress had been made, the nursing workforce still did not fully reflect the diversity of the nation's population.3 The report identified barriers to increased diversity, including “weak representation of minorities among nursing faculty and within healthcare organizations, especially in leadership roles; and admissions policies and practices that fail to encourage and support underrepresented minority students and applicants to health professional education institutions.” The American Association of Colleges of Nursing echoed this concern in a recently released fact sheet: “Nursing's leaders recognize a strong connection between a culturally diverse nursing workforce and the ability to provide quality, culturally competent patient care.”4
In 2006 the Health Resources and Services Administration (HRSA) published The Rationale for Diversity in the Health Professions: A Review of the Evidence, a landmark literature review that pointed to two key substantive ways in which health provider diversity increased the quality of care for underserved patient populations5:
“[G]reater health professions diversity will likely lead to improved public health by increasing access to care for underserved populations, and by increasing opportunities for minority patients to see practitioners with whom they share a common race, ethnicity or language. Race, ethnicity, and language concordance, which is associated with better patient–practitioner relationships and communications, may increase patients’ likelihood of receiving and accepting appropriate medical care.”
Among organizations dedicated to the formation of the U.S. nursing workforce, the consensus is that diversity will be an increasingly important characteristic of the nursing workforce, which does not yet adequately reflect the increasing diversity of the U.S. population. In particular, Latino representation in the nursing workforce trails far behind Latino representation in the population. In 2015 the National Academies of Sciences, Engineering, and Medicine (NASEM) pointed out that while Latinos constituted 15.5% of the U.S. working-age population (16 years old or older), they made up only 5.4% of RNs.6
The purpose of this article is to assist in strategic planning to promote greater diversity by providing detailed information on the Latino RN workforce from 1980 to 2010; we present data at the national level and at the state level for the five states with the largest Latino population: California, Florida, Illinois, New York, and Texas. We also provide information on the number of RNs per 100,000 people in the general population and on the language ability and nativity (U.S. born or born abroad) of non-Latino white (NLW) and Latino RNs.
While some Latinos are recent arrivals in the United States, many Latino families have been here for generations, and Latino nurses have cared for this population for more than two centuries.7 In 1803, King Carlos IV of Spain financed a smallpox vaccination campaign, the “Expedición Sanitaria,” to reduce the effects of the disease in the Americas. Twenty-two orphans between the ages of eight and 10 years were exposed to the virus through a scratch on the arm as a means of prophylaxis. These children were sent with the expedition from Spain to the Americas, where they served as a kind of human chain, inoculating others from arm to arm.8 Isabel Zendela y Gómez had responsibility for the well-being, education, and health of the orphans and their safe arrival in the Americas. She also served those in the region that's now the southwestern United States and today is considered the first Spanish-speaking public health nurse.8 Thanks to her two years of service, the inoculation campaign ultimately reached Spanish-speaking populations in California, New Mexico, and Texas.9
We used U.S. Census Bureau data for the period from 1980 to 2010, in the form of the Integrated Public Use Microdata Series (IPUMS-USA) provided by the Minnesota Population Center at the University of Minnesota.10 We chose these data for our analyses instead of the National Sample Survey of Registered Nurses because the latter was discontinued after the survey conducted in 2008.11 IPUMS-USA combines both decennial census long-form survey data from 1980 to 2000 and data from the American Community Survey (ACS), an annual survey used after the 2000 census that samples 1% of the national population to collect demographic, housing, social, and economic data (the Census Bureau replaced the decennial long-form survey with the ACS in 2010). The major advantage of the IPUMS-USA database is that, where possible, the Minnesota Population Center assigns uniform codes across all the samples and brings relevant documentation into a coherent form to facilitate analysis of social and economic change.
In this article, we compare trends for Latino and NLW populations. The basic unit of analysis is the proportion of RNs per 100,000 persons in the population, with both numbers drawn from the census data. While the decennial census data for 1980, 1990, and 2000 were based on 5% samples, the ACS data for 2010 were based on a 1% sample. The reader should bear in mind that the 2010 ACS estimates are slightly less robust. Personal information, including occupation, contained in census data is self-reported. The ACS asks respondents to describe their occupation in their own words (the first example given is, in fact, “registered nurse”) and then to describe the job's “most important activities or duties.” The Census Bureau then postcodes the open-ended responses into specific occupational categories. While the categorical designations have changed somewhat over the three decades covered in this study, the changes did not interfere with our ability to accurately count those who had described themselves as RNs. However, because we're not counting currently licensed nurses, the census totals reported in this article will probably differ slightly from totals reported by state licensure groups. The respondents’ race, Hispanic or non-Hispanic ethnicity, Spanish-language ability, and nativity (U.S. born or born abroad) are also self-reported. (The ACS asks for both the respondent's race and ethnicity [Hispanic or non-Hispanic]; census tables note “Hispanics may be of any race.” We use “Hispanic” and “Latino” interchangeably in this article.)
Population trends. The Latino and NLW populations have shown two markedly different growth trends from 1980 to 2010. During that period, the NLW population showed a modest growth of 11%, from 180.6 million to 200.3 million. In the same period, the Latino population showed marked growth, rising from 14.8 million to 50.7 million, a 243% growth rate. In terms of representation in the total U.S. population, the NLW population fell from 80% in 1980 to 65% in 2010. In the same period, the Latino population grew from 7% to 16%. Table 1 provides comparable population figures for the five states under analysis, and they show similar trends: modestly growing NLW populations and rapidly growing Latino populations.
RNs per 100,000 population national trends. In 1980, at the national level, there were 750 NLW RNs for every 100,000 NLWs in the general population. The number of RNs increased every decade, reaching 1,186 NLW RNs per 100,000 NLWs in 2010. In marked contrast, the number of Latino RNs did not show such growth. In 1980, there were 213 Latino RNs per 100,000 Latinos; three decades later, in 2010, there were only 311 Latino RNs per 100,000 Latinos. (See Figure 1, which also includes the 30-year trends for African American and Asian/Pacific Islander RNs.) By far, Latinos have had the lowest number of RNs per 100,000 population of any group over the 30-year period.
The number of Latino RNs in the five states with the largest Latino populations in 2010 varied somewhat from the national pattern in that year (see Figure 2). While the national average was 311 Latino RNs per 100,000 population, individual states had higher or lower numbers of Latino RNs. Florida had the most Latino RNs (510 per 100,000 population), whereas California and Illinois were lower than the national average (at 248 and 146 per 100,000 population, respectively). While the number of Latino RNs in each of the five states was significantly lower than the corresponding NLW number, the degree of disparity varied. For example, in Florida there were nearly half (45%) as many Latino RNs as NLW RNs. There were slightly less than one-third as many Latino RNs as NLW RNs in New York and Texas (30% and 29%, respectively), and California had approximately one-quarter (26%) of the number of Latino RNs as NLW RNs. The numbers were most disparate in Illinois, with Latino RNs at 13% of the number of NLW RNs.
Spanish language ability. The HRSA's 2006 report on the rationale for diversity in the health professions emphasized the need for language concordance between health care providers and the patient populations they serve. Table 2 provides data from 1980 to 2010 on the percentage of NLW and Latino RNs in the United States and in each of five states with the largest Latino populations who speak Spanish. In a remarkably stable pattern, only 1% of U.S. NLW RNs spoke Spanish over those three decades, while roughly two-thirds of Latino RNs spoke Spanish. However, note that in 2010, in the five states under consideration, there was considerable variation in the Spanish-language ability of Latino RNs. Only in California did the percentage of Spanish-speaking Latino RNs match the national average (62%). Latino RNs in Florida had the highest rate of Spanish-speaking ability (80%), and their counterparts in Illinois had the lowest rate (43%). Spanish language ability among NLW RNs in the five states was more consistent with the national average, with only a very small percentage (from 1% to 3%) being Spanish speakers.
Nativity trends. Latinos have been arriving in waves of immigration to what is now the United States since 1526.12 The wave of immigration from 1965 to approximately 2005 is only the most recent of many.13 The Pew Research Center recently reported that since 2005, net migration from Mexico has been negative, driven largely by the effects of the Great Recession.14
The NLW population began arriving from Great Britain in 1607, with the founding of Jamestown, and thereafter, came in successive waves from Britain and other parts of Europe, the most recent large wave ending in 1890. In 1919, 88% of immigrants to the United States were of European origin. However, between 1965 and 2015, only 12% of U.S. immigrants were European, while 76% came from Latin America and Asia.15 Census data allow us to distinguish between U.S.-born RNs and those who were born abroad but provide no information on the country where RNs received their nursing education; RNs who were born abroad may have immigrated to the United States as children and been educated here. We offer data on the nativity of both NLW and Latino RNs, but caution the reader not to assume that an RN who has immigrated to the United States is necessarily a graduate of an international nursing education program.
Table 3 provides data on U.S. NLW and Latino RN nativity from 1980 to 2010, which shows remarkably little change over that period. A very low percentage of NLW RNs (3% to 4%) were born abroad. Latino RNs were far more likely to have been born abroad, but immigrants were a minority of all Latino RNs. During the three decades under analysis, the percentage of Latino RNs who were immigrants dropped slightly, from 35% to 30%. Figure 3 shows significant state-by-state variation from 1980 to 2010 in the number of Latino nurses who had been born abroad. Florida experienced a precipitous drop in the percentage of Latino RNs born abroad; in 1980, they were a majority (68%) but by 2010 had dropped to a minority (46%). Illinois showed a similar decline in Latino RNs born abroad, from 46% to 23%, over the same period. California and New York showed small declines; about one-third of Latino RNs in each state were born abroad. Texas showed considerable stability, with less than one-fifth of Latino RNs having been born abroad over three decades.
The aim of this study is to provide a metric (the number of Latino RNs per 100,000 Latino population) that can inform solutions to a problem in nursing: the need to increase the diversity of the workforce so that it adequately reflects the diversity of patient populations. Between 1980 and 2010, the number of RNs nearly doubled while the number of Latinos in the general population nearly tripled. If nursing education had kept pace with the increasing Latino population, we would expect the number of Latino nurses to have grown by a factor of at least two, if not three or four, which would have resulted in closing the gap between the numbers of NLW and Latino RNs per 100,000 population. However, the opposite occurred. Instead of mirroring the growth of the population and tripling the 1980 figure (to 639 RNs per 100,000 population), the number of Latino RNs grew by an anemic one-third, from 213 to 311 per 100,000—only half of what we would expect if it were true that, in this regard, a rising tide lifts all boats. Instead, the gap between the numbers of Latino and NLW RNs widened. By 2010, the number of Latino RNs per 100,000 population was only about one-quarter of the number of NLW RNs per 100,000 population (311 and 1,186, respectively).
This metric indicates that U.S. nurse education has not responded to significant national demographic changes. While the overall number of Latinos has grown dramatically, the number of Latino nurses has not. Some states may be in even more urgent need of corrective policy measures to increase the number of Latino RNs; for example, among the five states with the largest Latino populations, Illinois, which had the fewest Latino RNs per 100,000 population (148) in 1980 had even fewer (146) in 2010.
QUALITY OF NURSE EDUCATION
The census data do not provide information about Latino nurses’ educational experience. One of us (TMH-B) has gathered numerous anecdotal accounts of roadblocks in California nurse education, which may serve to indicate areas for additional research as well as educational policy activity.
- In California in 2012, community colleges were the point of entry to postsecondary education for 69% of Latino students.16 Yet students have reported that their community colleges only offer prerequisite courses once or twice a year, making it difficult to complete their required courses in a timely fashion.
- Students may be forced to patch together coursework at multiple community college campuses simultaneously (two to six campuses have been mentioned) in order to complete nursing prerequisites.
- Students who have invested up to six years completing prenursing requirements may still be turned away from associate's degree programs because there are too many applications for too few slots. Moreover, some students report being told, upon requesting admission, that because they had repeated courses during their community college careers they were considered less eligible. According to one associate's degree program administrator, a repeated course was, from the program's perspective, a predictor of future academic difficulties in completing the associate's degree courses successfully.
- Students, desperate to continue their education, report being lured by slick advertising to for-profit schools, which seem to offer a viable alternative to community college associate's degree programs; however, these schools are much more expensive than community colleges and their marketing practices have attracted scrutiny by government regulators.17 A Los Angeles Times report on the bankruptcy and closure of one of the nation's largest for-profit schools, Corinthian Colleges, noted that the institution's failure most affected the nontraditional students it targeted for recruitment—“people raising children, juggling full-time jobs and struggling to pay bills,” a description that fits many Latino students.18 Yet in the end, students also report having found it difficult to graduate from these programs, and often find themselves heavily loaded with educational loan debt. Thus, the promises for-profit institutions proffer, of career success and an entrée to the American dream, often prove elusive.
Recommendations for nurse education. Improvement is possible. While the number of Latino RNs relative to the Latino population lags, there has been a modest increase in the number of Latino nurses. We make three recommendations for nursing education, to help move the U.S. health care system toward providing improved patient-centered care for the nation's increasingly diverse population.
The first recommendation is to increase the number of Latino students admitted to nursing schools. This may require modifications to existing recruitment, admissions, and retention strategies, so that they better serve Latino nursing student populations. Some schools of nursing and other health professions have already developed “holistic review” admissions processes that give weight to an applicant's life experience (for example, family, professional, or educational experiences) and attributes (such as being a first-generation college student, having multilingual ability, or demonstrating resilience), along with the classic metrics such as grades and standardized test scores.19
Furthermore, many paths to the RN degree are difficult financially, especially for low-income students. Rising tuition and other costs at public universities now leave the average four-year graduate saddled with $25,600 in student debt.20 Organizations such as the Hispanic Scholarship Fund (https://hsf.net) are attempting to address the financial barriers Latino students face in obtaining a higher education.
The second recommendation is to reconsider the role of internationally educated nurses in providing culturally competent, patient-centered care to racially, ethnically, and linguistically diverse U.S. populations. While internationally educated nurses generally tend to move from less-developed to more-developed countries, the United States has a higher-than-average concentration of immigrant nurses in its workforce, as compared with the Organization for Economic Cooperation and Development's 34 member states (11.9% and an average of 10.7%, respectively).21 Internationally educated nurses play an important role in the nursing supply in a few U.S. states: 25% of the internationally educated nurses in this country practice in California alone.
In 2010 the World Health Organization created guidelines for voluntary use by countries in developing bilateral agreements for recruiting health personnel, in which it urged its member states to strive to meet their health care needs with their own human resources.22 For a number of reasons, however, internationally educated nurses tend not to come from Spanish-speaking areas. Slightly more than three-quarters of internationally educated nurses in the United States come from the Philippines, Canada, India, and the United Kingdom.23 Nursing education programs exist in most Latin American countries; and with changes in immigration policy, their graduates could alleviate the Latino RN shortage. However, any program seeking to use nurses educated in Latin America to alleviate the U.S. nursing shortage would be advised to consult Prescott and Nichter's conceptual framework, global nurse care chains. This model goes beyond the traditional push–pull models to a more nuanced analysis that takes into account variables ranging from state policies in a globalized context to the nurse's self-determination in making the nurse's decision to practice in her or his country of origin or in a new destination country.24
The third recommendation is to prepare non-Latino RNs to engage the Latino patient population for effective patient-centered care. Training in communication skills is fundamental and should include at least minimal Spanish language skills for those who wish to care for such patients. Nursing education on patient-centered care for U.S. Latinos should also include science-based information on the key epidemiologic and demographic trends in this population. A basic knowledge of the Latino sociohistorical experience—including an understanding of how the U.S. Census Bureau and the legal and health care delivery systems have created differing versions of the “Latino” social construct over the past two centuries, for the purposes of including or excluding Latinos from U.S. society—may help RNs frame their interaction with Latino patients for better patient-centered care.
Latino RNs and patient-centered care. The lack of Latino nurses weakens quality of care. In its 2001 report Crossing the Quality Chasm: A New Health System for the 21st Century, the Institute of Medicine (IOM) identified patient-centered and equitable care as two of six aims for improvement “to continually reduce the burden of illness, injury, and disability, and to improve the health and functioning of the people of the United States.”25 Patient-centered health care is supposed to be “respectful of and responsive to individual patient preferences, needs, and values.” This orientation would ensure that “patient values guide all clinical decisions.”25 Many Latino RNs have personal experience with cultural matters that can be valuable to other providers in creating patient-centered care appropriate for Latino patients.
Language concordance, a key feature of patient-centered care, is more difficult to achieve when there are relatively few Spanish-speaking RNs to care for a large, primarily Spanish-speaking Latino patient population. The HRSA based its 2006 report on the rationale for diversity on a review of the extensive literature citing language concordance as a key factor in the provision of quality services to non-English-speaking patients.5 Spanish-speaking nurses have provided care to Latino communities for generations,9 and it's likely that the need for Spanish-speaking health care providers will only grow for many years to come. Our findings indicate that Latino RNs in the United States are between 60 and 70 times more likely to speak Spanish than NLW RNs.
In its 2010 report The Future of Nursing: Leading Change, Advancing Health, the IOM stated: “To better meet the current and future health needs of the public and to provide more culturally relevant care, the current nursing workforce will need to grow more diverse.”26 In December 2015, the NASEM released Assessing Progress on the Institute of Medicine Report The Future of Nursing.6 The report reiterates the call to make “diversity in the nursing workforce a priority” and recommends special efforts for “African Americans, Hispanics/Latinos, and other underrepresented groups in nursing.” The NASEM urges that the Future of Nursing: Campaign for Action—the initiative to help implement the Future of Nursing report's recommendations—develops a “specific diversity plan with actionable steps,” and “compare[s] the representation of minorities in each state with their representation in the state's general population.”6 This article provides a three-decade, longitudinal view of the Latino nursing shortage to complement the NASEM recommendations and assist nursing education programs and institutions as they create strategic plans to engage the growing Latino population.
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10. Ruggles S, et al. Integrated public use microdata series: version 5.0 [machine-readable database]. Minneapolis: University of Minnesota 2010
12. Fernández-Armesto F Our America: A Hispanic history of the United States. New York, NY W.W. Norton; 2014
13. Hayes-Bautista DE El Cinco de Mayo: an American tradition. 2012 Berkeley and Los Angeles University of California Press
19. Addams AN, et al. Roadmap to diversity; integrating holistic review practices into medical school admission processes. Washington, DC Association of American Medical Colleges; 2010.
24. Prescott M, Nichter M. Transnational nurse migration: future directions for medical anthropological research Soc Sci Med. 2014;107:113–23
Keywords:Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
Latino; nurses; nursing shortage; nursing workforce