According to the Centers for Disease Control (CDC), racial and ethnic minority individuals continue to experience a disproportionate burden of most health conditions, including coronary heart disease, stroke, diabetes, hypertension, HIV, preterm births and obesity.1 The Institute of Medicine (IOM) recommends increasing racial diversity in the healthcare workforce as an important strategy for improving the nation's health and reducing health disparities.2 Research has shown that patients’ trust and satisfaction increase when their providers are of similar racial or ethnic backgrounds.3 It is thought that in such encounters patients gain better understanding and are more likely to follow treatment plans.4 Additionally, research findings suggest that healthcare providers from underrepresented groups are more likely than others to serve those from minority and economically disadvantaged backgrounds and to practice in areas that have a shortage of healthcare providers.5 Hospitals can advance the health of the populations they serve by having a documented plan to recruit and retain a workforce that reflects the organization's patient population.
As nursing continues to advance healthcare in the 21st century, the current shift in demographics, coupled with the ongoing disparities in healthcare and health outcomes, challenge the profession to recruit and retain a racially diverse workforce that mirrors the nation's changing demographics. From 2008 to 2010, there were 2.8 million registered nurses (RN) (including advanced practice RNs) in the United States (US) nursing workforce.6 However, nurses from minority racial and ethnic groups represented only 16.8% of that number, although individuals of racial and ethnic minority backgrounds made up 34.4% of the US population.6
Several professional nursing organizations have called on nurse educators and nurse leaders of healthcare institutions to increase the diversity of the nursing workforce.7 In response to the need for increased racial and ethnic diversity in the nursing profession, one school of nursing created a program aimed at expanding nursing education opportunities for economically disadvantaged underrepresented minority students.8 Specifically the goal of this program was to provide minority students with advanced knowledge and leadership skills needed to address health disparities. The program admitted 10 scholars in the 2011 cohort, four of whom successfully graduated. Some of the challenges identified by the scholars included insufficient financial support, lack of emotional and moral support, feelings of isolation and loneliness, discrimination, need for advicing and academic support, shortage of minority faculty to serve as mentors and role models, little sense of professional socialization, limited computer access and technology competence, and deficiency in cultural competence among nonminority peers.8 Similarly nurse leaders at a children's hospital in Boston piloted a two-year program for employees that aimed to eliminate barriers faced by individuals of color in becoming nurses as a way to increase diversity in nursing.9 When the program ended, seven employees were enrolled in a nursing school and three employees had graduated from a nursing program. Nursing programs have made some progress in increasing the number of racial and ethnic minority students enrolled in nursing schools to meet the diversity needs of the workforce.10
The majority of research on diversity in nursing focuses on education programs and recruitment, even though addressing minority nurses’ job satisfaction and turnover might be a more worthwhile way to design and research effective institutional recruitment and retention strategies. Once in the workforce, racial and ethnic minority nurses face a number of challenges that contribute to job dissatisfaction and turnover.11 Seago and Spetz found that minority nurses face more barriers to promotion and advancement in their careers than white nurses.12 Qualitative evidence reveals that minority nurses face the following issues: feelings of being overlooked and undervalued, having to prove competency, and living with “only-ness”.13 Research also indicates that minority nurses employed in the hospital setting earn less than their white counterparts.14 Orientation programs and career mentoring structures can have widespread effects on broadening options and fine-tuning skills over the course of a nurse's career.15
If the nursing workforce is to be adequately diversified, there is a critical need for key stakeholders, such as schools of nursing and healthcare institutions, to develop strategies to recruit and retain underrepresented minority groups into the nursing field. Some healthcare institutions have implemented interventions and support for the newly graduated nurse.16,17 However, it is unknown what, if any, strategies are focused on the recruitment and retention of the minority nurse. Even if they have been implemented, the impact of these strategies is also unknown.
A preliminary search of the JBI Database of Systematic Reviews and Implementation Reports, CINAHL and PubMed revealed that no available systematic reviews on this topic exist. However a systematic review protocol on a similar topic was identified. That protocol focused on the effect of orientation programs on competence and organizational commitment of newly graduated nurses in specialized healthcare.18 This systematic review however will focus on interventions specific to recruiting and retaining the minority nurse. Conducting a systematic review to identify institutional practices that positively correlate with influencing a diverse workforce can lead to the development of the best available guidelines and practices for healthcare institutions to adopt in attracting and retaining racial and ethnic minority nurses.
The current review will consider all studies that include minority nurses. The study participants will include:
- Adult (18 years and over) participants who self-identify as African-American/Black or Hispanic/Latino.
- Nurses (bachelor or associate degree).
The current review will consider studies that evaluate any institutional strategies or interventions that aim to recruit and/or retain minority nurses including but not limited to the following: nurse extern/intern programs, orientation programs, mentoring programs, preceptorships, nurse residency programs and/or career guidance.
The current review will consider studies that compare institutional interventions to standard practice or no specific strategy or intervention.
The current review will consider studies that include the following outcome measures:
- Primary outcomes: recruitment, typically measured by the number hired in a fiscal year; and retention, typically measured by the number who actively resigned divided by number on board in a fiscal year.
- Secondary outcomes: minority nurses’ job satisfaction and turnover intention, measured with objective quantitative instruments.
Types of studies
This review will consider experimental study designs including randomized controlled trials, non-randomized controlled trials, quasi-experimental, before and after studies, prospective and retrospective cohort studies, case control studies, and analytical cross sectional studies for inclusion.
The search strategy aims to find both published and unpublished studies. A three-step search strategy will be utilized in this review. An initial limited search of MEDLINE and CINAHL will be undertaken followed by analysis of the text words contained in the title and abstract, and of the index terms used to describe article. A second search using all identified keywords and index terms will then be undertaken across all included databases. A full search strategy for CINAHL is detailed in Appendix I. Thirdly, the reference list of all identified reports and articles will be searched for additional studies. Studies published in English or Spanish will be considered for inclusion in this review. No date limits will be placed on database searches.
The databases to be searched include: CINAHL, MEDLINE, PsycINFO, ERIC, Academic Search Premier and Health Source: Nursing.
The search for unpublished studies will include: ProQuest Dissertations and Theses, Virginia Henderson Library and Google Scholar.
Following the search, all identified citations will be collated and uploaded into EndNote bibliographic software19 and duplicates removed. Titles and abstracts will then be screened by two independent reviewers for assessment against the inclusion criteria for the review. Studies that meet and could potentially meet the inclusion criteria will be retrieved in full and their details imported into Joanna Briggs Institute System for the Unified Management, Assessment and Review of Information (JBI SUMARI).20 The full text of selected studies will be retrieved and assessed in detail against the inclusion criteria. Full text studies that do not meet the inclusion criteria will be excluded and reasons for exclusion will be provided in an appendix in the final systematic review report. Included studies will undergo a process of critical appraisal. The results of the search will be reported in full in the final report and presented in a PRISMA flow diagram. Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer.
Assessment of methodological quality
Quantitative papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using the standardized critical appraisal instruments from the Joanna Briggs Institute for randomized controlled trials, quasi-experimental, case control, cohort or analytical cross sectional studies.21,22 Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer. Due to the possibility of a limited number of studies on this topic, all studies, regardless of their methodological quality, will undergo data extraction and synthesis (where possible). The quality of the studies will be taken into account and reported on in this review.
Quantitative data will be extracted from papers included in the review using the standardized data extraction tool available in JBI SUMARI21,22 by two independent reviewers. The data extracted will include specific details about the interventions, populations, study methods and outcomes of significance to the review question and specific objectives. Any disagreements that arise between the reviewers will be resolved through discussion or with a third reviewer. Authors of papers will be contacted to request missing or additional data where required.
Quantitative data will, where possible, be pooled in statistical meta-analysis using JBI SUMARI. All results will be subject to double data entry. Effect sizes expressed as either odds ratios (for dichotomous data) or weighted (or standardized) mean differences (for continuous data) and their 95% confidence intervals will be calculated for analysis. Heterogeneity will be assessed statistically using the standard Chi-square and I squared tests. The choice of model (random or fixed effects) and method for meta-analysis will be based on the guidance by Tufanaru et al.23 Subgroup analyses will be conducted where there is sufficient data to investigate, such as type of institution strategy/intervention, type of healthcare institution or size of healthcare institution. Where statistical pooling is not possible the findings will be presented in narrative form including tables and figures to aid in data presentation where appropriate.
A Summary of Findings will be created using GRADEPro GDT software.24 The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach for grading the quality of evidence will be followed.25 The Summary of Findings will present the following information where appropriate: absolute risks for treatment and control, estimates of relative risk, and a ranking of the quality of the evidence based on study limitations (risk of bias), indirectness, inconsistency, imprecision and publication bias.
Funding has been provided by a Purdue University Northwest Catalyst Grant.
Appendix I: Search strategy (CINAHL)
S1 (MM “Minority Groups”) OR TI Minorit∗ OR AB Minorit∗
S2 (MH “Nurses, Minority”)
S3 (MH “Blacks”) OR TI Blacks OR AB Blacks OR TI “African American” OR AB “African American”
S4 (MH “Hispanics”) OR TI Hispanics OR AB Hispanics
S5 TI Latino OR AB Latino
S6 S1 OR S2 OR S3 OR S4 OR S5
S7 (MM “Nurses”) OR TI Nurs∗ OR AB Nurs∗
S8 (MH “Personnel Recruitment”) OR TI Recruitment OR AB Recruitment
S9 (MH (“Personnel Retention”) OR TI Retention OR AB Retention
S10 (MH “Employee Orientation”) OR TI Orientation OR AB Orientation
S11 (MH “Transitional Program”) OR TI “Transition∗ Program” OR AB “Transition∗ Program”
S12 (MH “Preceptorship”) OR TI Precept∗ OR AB Precept∗
S13 (MH “Mentorship”) OR TI Mentor∗ OR AB Mentor∗
S14 (MH “Internship and Residency”) OR TI “Nurse Residency” OR AB “Nurse Residency”
S15 TI “Nurse Externship” OR AB “Nurse Externship”
S16 TI “Career Support” OR AB “Career Support”
S17 TI “Career Guidance” OR AB “Career Guidance”
S18 S8 OR S9 OR S10 OR S11 OR S12 OR S13 OR S14 OR S15 OR S16 OR S17
S19 S6 AND S7 AND S18
1. Centers for Disease Control and Prevention. CDC health disparities and inequalities report-U.S. 2013. [internet]. [cited July 5, 2017]. Available from: http://www.cdc.gov/minorityhealth/CDHIReport.html.2013
2. Institute of Medicine. In the Nation's Compelling Interest: Ensuring Diversity in the Health Care Workforce. [internet]. [cited May 31, 2017]. Available from: http://www.nap.edu/openbook.php?isbn=030909125X.2004
3. Sullivan LW, Mittman IS. The state of diversity in the health professions a century after Flexner. Acad Med
2010; 85 2:246–253.
4. Cooper LA, Roter DL, Johnson RL, Ford DE, Steinwachs DM, Powe NR. Patient-centered communication, ratings of care, and concordance of patient and physician race. Ann Intern Med
2003; 139 11:907–915.
5. UCOP (University of California Office of the President). Special Report on Medical Student Diversity. Medical Student Diversity Task Force, Office of Health Affairs, University of California. Oakland, CA: UCOP.2000;1–75.
6. Health Sources and Services Administration. The U.S. Nursing Workforce: Trends in Supply and Demand. 2013. [internet]. [cited May 31, 2017]. Available from: https://bhw.hrsa.gov/sites/default/files/bhw/nchwa/projections/nursingworkforcetrendsoct2013.pdf
7. Banister G, Bowen-Brady HM, Winfrey ME. Using career nurse mentors to support minority nursing students and facilitate their transition to practice. J Prof Nurs
2014; 30 4:317–325.
8. Carter B, Powell D, Derouin A, Cusatis J. Beginning with the end in mind: Cultivating minority nurse leaders. J Prof Nurs
2015; 31 2:95–103.
9. Sporing E, Avalon E, Brostoff M. A nursing career lattice pilot program to promote racial/ethnic diversity in the nursing workforce. JONA
2012; 42 3:138–143.
10. Phillips JM, Malone B. Increasing Racial/Ethnic Diversity in Nursing to Reduce Health Disparities and Achieve Health Equity Public Health Rep. 2014; 129:45–50.
11. Doede M. Race as a predictor of job satisfaction and turnover in US nurses. J Nurs Manag
2017; 25 3:207–214.
12. Seago JA, Spetz J. Minority nurses’ experiences on the job. J Cult Divers
2008; 15 1:16–23.
13. Moceri JT. Hispanic Nurses’ Experiences of Bias in the Workplace. J Transcult Nurs
2014; 25 1:15–22.
14. Moore J, Continelli T. Racial/Ethnic Pay Disparities among Registered Nurses (RNs) in U.S. Hospitals: An Econometric Regression Decomposition. Health Serv Res
2016; 51 2:511–529.
15. Institute for Diversity in Health Management. Diversity and Disparities: A Benchmark Study of U.S. Hospitals in 2013. 2014. [internet]. [cited September 17, 2017]. Available from: http://www.diversityconnection.org
16. Evans J, Boxer E, Sanber S. The strengths and weaknesses of transitional support programs for newly registered nurses. Aust J Adv Nurs
2008; 25 4:16–22.
17. Park M, Jones CB. A retention strategy for newly graduated nurse: A integrative review of orientation programs. J Nurs Staff Dev
2010; 26 4:142–149.
18. Linfors K, Juntilla K. The effectiveness of orientation programs on professional competence and organizational commitment of newly graduated nurses in specialized healthcare: a systematic review protocol. JBI Database System Rev Implement Rep
2014; 12 5:2–14.
19. Clarivate Analytics. EndNote [Computer software]. Philadelphia: Clarivate Analytics; 2016.
20. The Joanna Briggs Institute. The System for the Unified Management, Assessment and Review of Information (SUMARI). 2017. Available from: https://www.jbisumari.org
21. The Joanna Briggs Institute. Joanna Briggs Institute Reviewers’ Manual: 2017 edition. Australia: The Joanna Briggs Institute; 2017.
22. Tufanaru C, Munn Z, Aromataris E, Campbell J, Hopp L. Chapter 3: Systematic reviews of effectiveness. In: Aromataris E, Munn Z (Editors). Joanna Briggs Institute Reviewer's Manual. The Joanna Briggs Institute, 2017. Available from: https://reviewersmanual.joannabriggs.org/
23. Tufanaru C, Munn Z, Stephenson M, Aromataris E. Fixed or random effects meta-analysis? Common methodological issues in systematic reviews of effectiveness. Int J Evid Based Healthc
2015; 13 3:196–207.
24. GRADEpro GDT: GRADEpro Guideline Development Tool [Software]. McMaster University, 2015 (developed by Evidence Prime, Inc.). Available from: gradepro.org.
25. Schünemann H, Brożek J, Guyatt G, Oxman A, editors. GRADE handbook for grading quality of evidence and strength of recommendations. Updated October 2013. The GRADE Working Group, 2013. Available from: guidelinedevelopment.org/handbook.