The Affordable Care Act1 was promulgated to ensure access to healthcare for all, expanding the racial, ethnic, and social diversity of the patient care population. With that ruling came an increased need for an expansion of diversity among healthcare providers, individuals who can deliver culturally appropriate care.2 In 2014, the Surgeon General identified the importance of hiring and educating qualified staff from underrepresented racial and ethnic backgrounds, offering it as a strategy to reduce health disparities.3 Yet, expansion of diversity among nurses has not kept pace with the expansion of diversity among the patient population.
According to the National Nursing Workforce Study,4 83% of the nursing workforce is white, non-Hispanic, compared with 62.1% of the US population. In Massachusetts, 89.8% of the nursing workforce is white, non-Hispanic5 compared with 74.3% of the general population.6 African American (AA) nurses are underrepresented in the nursing profession. The disparity is even greater in traditional nursing leadership positions.7 A recent national survey8 revealed that AA nurses accounted for only 3.4% of incumbents in nursing leadership positions (Figure 1), showcasing the scarcity of diverse role models and mentors for future AA healthcare leaders.
Nurse-patient communication is fostered when both share an understanding of the patient's culture. Nursing knowledge of and sensitivity to patients' culture, customs, and religious views helps to establish interpersonal trust to enhance quality of care and health outcomes. The demographic mismatch between nurse providers and their diverse patients can yield suboptimal patient outcomes and deter effective and relevant policy development. Developed between an urban baccalaureate nursing program and a large healthcare system in the northeast United States, the Clinical Leadership Collaborative for Diversity in Nursing (CLCDN) was established to empower minority nurses to seize opportunities to lead. This article describes the outcomes of CLCDN interventions, shedding new light on what it means to lead as an AA nurse.
The CLCDN Program was established in 2007 by the Partners HealthCare (PHC) Chief Nurse Council in collaboration with the University of Massachusetts at Boston. Student applicants were competitively selected for inclusion of the CLCDN Program in the 3rd year of their undergraduate program. They remained in the program through their 1st postgraduate year. Criteria for program inclusion were grade point average and applicants' personal statements reflecting leadership capacity. Program administrators reviewed applications, considering applicants' future leadership potential. Accepted participants received 4 semesters of full tuition, academic tutoring and mentoring, and preferential clinical placement support within PHC. Each student participant was paired with a nurse mentor who represented diverse populations. Guided by diverse mentors, participants were challenged and inspired to envision themselves as future leaders.
A total of 94 diverse students participated in the program between 2007 and 2017; 50 self-identified as AA (53%). One hundred percent of all participants successfully graduated from the baccalaureate program and passed the NCLEX-RN examination. Little is known about the long-term impact programs such as the CLCDN have on AA nursing retention rates or professional advancement. Nor is the influence of these programs on developing and sustaining leadership skills well understood. Data such as these are essential for strengthening new and existing nurses' transition to practice and leadership programs, especially programs that focus on supporting, increasing, and retaining the number of diverse nurses in leadership positions.
As part of a larger study, this qualitative descriptive study
- described the demographics, employment status, cultural factors, and leadership activities among AA nurse participants of the CLCDN Program; and
- explored the sustained impact of the CLCDN Program among AA nurses 1 to 6 years post participation in the program.
The investigators used a qualitative descriptive design using in-depth, responsive interviewing to explore the sustained impact of the CLCDN Program on AA graduates' leadership experiences. Because black feminist theory9,10 places AA women's experiences at the center and empowers them to interpret their own reality, the investigators used it to fully explore and give meaning to the participants' words. Interview techniques followed the recommendations of Rubin and Rubin,11 chosen intentionally to emphasize the importance of building and developing the interviewer-interviewee relationship. Institutional review board approval was obtained at PHC. The investigators used email to recruit study participants who had completed the CLCDN Program.
A total of 19 CLCDN graduates (38%) agreed to participate in the study, constituting the convenience sample. Consenting participants engaged in 1 of 7 focus groups. Focus group interviews followed a semistructured interview guide developed by the investigative team. Focus group sessions lasted 1 or 1.5 to 2 hours. Interviews, structured to facilitate social exchange and participant voice, were audiotaped and transcribed, serving as the source of data for the study.
To ensure study rigor, the investigative team developed detailed records of the data collection process and examined coding accuracy, sharing interpretations among team members. Their approach was consistent with criteria established by Lincoln and Guba.12 Research team members independently reviewed each focus group transcription and identified themes independently,12 thus facilitating the trustworthiness and authenticity of study results. They shared their findings to confirm themes across focus groups. Finally, team members conducted NVivo qualitative software analysis13 to triangulate study findings. This secondary data analysis process further verified study results.12 Additional demographic information can be found in a supplemental file (http://links.lww.com/JONA/A765).
Sixteen of the 19 study participants were female (84%), with an average age of 34 years. Most participants (63.2%, n = 12) were born outside the United States. Ten participants (52.6%) reported another language as their primary language. Most participants (89.5%, n = 17) reported being from an economically disadvantaged background.
Most participants (78.9%, n = 15) had secured nursing positions at a PHC institution and at the time of the study. Fifteen participants (78.9%) continue to work in their 1st RN role. Although the participating nursing program was a traditional BSN program, half of the participants in this study had nonnursing degrees before matriculation in the nursing program. All but 3 of the participants (15.7%) were pursing or planning to pursue an advanced degree in nursing; of those 3, 1 had completed a graduate degree. One is currently pursuing a nonnursing graduate degree.
Six themes emerged from the original study, 2 of which demonstrated the program's impact on participants' visions of leadership and their leadership abilities. These themes are presented here. They are “I'm going to be one of them” and “Leadership. I think it's a big word.”
Theme 1: I'm Going to Be One of Them
For participants, the CLCDN provided an opportunity to meet and interact with minority nurses who were successful, were role models, and inspired confidence in them as individuals and as nurses. African American participants in a previous qualitative study14 reported that role models who resembled them afforded greater comfort, improved their communication, assisted them with gaining cultural competence, and allowed them to envision themselves as successful.15-17 For AA nurses, in particular, role models who can relate to their lived experiences and, thus, truly understand them support their success in assuming new roles. As 1 participant noted, “…being able to know that I could be a leader someday, because somebody that looks like me did it.” Another participant stated, “I said, I'm going to be one of them, until I leave this world, I will one of these people.”
Theme 2: Leadership. I Think That's a Big Word
African American nurses, like all nurses, should consider themselves as leaders, responsible for influencing and improving the practice environment. Nurses are recognized authorities in the clinical arena; the nurse is a leader to patients and clients.18 Therefore, leadership and professional development were essential components of the CLCDN Program. Leadership in nursing and healthcare is associated with quality patient care and improved outcomes; positive, healthy work environments; job satisfaction; and decreased turnover rates.19-22
Participants in this study spoke to the importance of developing leadership qualities and skills as they sought leadership opportunities. One said, “I worked extremely hard, outworked my coworkers, any leadership opportunities I made sure I did not shy away from it. I faced it head-on…. they instilled that leadership component in me. I did not think I had it, to be honest with you. But because they invested in me, I felt like it wasn't an option I had to face it head-on.” Another described the program's influence on her leadership: “…I do not think you have too much expectation when you come in. You just want to come in and get a job…. And then after I started at the CLC[DN] and I learned about leadership, …I think now I can go anywhere and I feel like, OK, I can be over there where you are. You're not better than me…. Because if you want to be a leader, you can, you just have to work hard on it.”
Nurses represent the greatest number of healthcare providers in the United States. They are critical to leading and influencing the healthcare environment. Equally critical is the need to enhance the diversity of the nursing workforce. As the US population becomes increasingly diverse, the need for strong, culturally sensitive, and diverse nurses has grown. Yet, established educational and practice systems may not fully address the specific needs of diverse, nonmajority nurses, especially in regard to encouraging their involvement in leadership.
Relf23 addressed the importance of public relations campaigns and key, national-level policy reports to strengthening diversity in the nursing workforce. The CLCDN, a collaborative leadership development program aimed to support the professional development of underrepresented nurses, extended the goal of strengthening nursing workforce diversity. Its aim was to enculturate AA nurses into the practice environment in support of strengthening their nursing leadership, whether at the bedside or in advanced practice or administrative roles. Findings of this study suggest that the CLCDC aim was achieved, as study participants described program benefits as they enhanced their active engagement in personal and professional nursing leadership activities.
Implications for Practice
Leadership development must be intentional if we are committed to advancing diversity in nursing leadership roles. As the patient population becomes increasingly diverse, minority patient needs will continue to impact and influence healthcare systems. Clinical Leadership Collaborative for Diversity in Nursing Program graduates are in the unique position of addressing these minority patient needs and transcending traditional care, serving as advocates for the minority patient and demonstrating the added value of their personal backgrounds as well as cultural and linguistic skills. Furthermore, embedding leadership education and training into the CLCDN Program, which was one of the foundational elements, created a dynamic in which graduates are poised to exercise their leadership skills in future roles that will address not only local and national but also global health challenges.24 This study demonstrates that there are potential implications for how academic/service partnerships could enhance the leadership development and the retention of diverse nurses. Examining and understanding the impact and effectiveness of this program creates the evidence needed to replicate this program in other hospitals and health systems across the country. In addition to developing academic/service partnership, nursing leaders within healthcare systems need to influence human resource practices, educate hiring nurse managers, and evaluate departmental diversity compared with the population served.
The results of this study are limited. The literature on student success suggests that social determinants such as these are significantly associated with nursing school attrition.25 Although this study was localized to a large metropolitan area and its results may not be immediately generalizable, findings support trends that are apparent in published literature.
Opportunities exist to recognize and promote diverse nurses in leadership roles and professional activities. Ultimately, effective leadership experiences will enhance their leadership acumen to support the quality of patient care. Their involvement in leadership activities provides evidence of the program's effectiveness in achieving its desired outcomes. In the context of this research, the authors propose the following questions to nurse leaders for thoughtful consideration and action.
- ▪ Do your AA nurses recognize that professional internal and external activities that they are engaged in demonstrate leadership?
- ▪ Does the infrastructure within your organization capture and highlight these leadership activities?
- ▪ How does implicit bias impact leadership opportunities for AA nurses for leadership opportunities within your organization?
- ▪ How do you help AA nurses recognize their leadership contributions to their organization and the nursing profession?
- ▪ Does your organizational mentoring program recognize and address the needs of the diverse nurse?
Programs such as the CLCDN that provide infrastructure for financial support, mentoring, and educational offerings will support AA nurses' leadership success. Additional research is needed to explore how programs such as the CLCDN influence AA nurses': 1) aspirations and access to leadership roles; 2) decisions influencing pursuit of advanced degrees; 3) implicit and explicit racial bias in the workplace; and 4) the impact on healthcare disparities. The better we understand these experiences and equip AA nurses with the tools needed for success, the greater their influence will be on ensuring every patient receives exemplary care and our healthcare institutions are better positioned to care for the diverse populations we serve.
1. Rhodes KV, Kenney GM, Friedman AB, et al. Primary care access for new patients on the eve of health care reform. JAMA Intern Med
2. Taylor SL, Lurie N. The role of culturally competent communication in reducing ethnic and racial healthcare disparities. Am J Manag Care
. 10 Spe. SP1–4. 2004. https://doi.org/10.13016/jysr-kkt7
. Accessed June 8, 2020.
3. National Prevention Council, Annual Status Report
, Washington, DC: U.S. Department of Health and Human Services, Office of the Surgeon General, 2014. Available at http://www.surgeongeneral.gov/initiatives/prevention/about/annual_status_reports.html
. Accessed June 8, 2020.
4. Budden J, Moulton P, Harper KJ, Brunell ML, Smiley R. The 2015 national nursing workforce survey. J Nurs Regul
5. Massachusetts Department of Public Health. Data brief: Health professions data series registered nurses 2014. In: Massachusetts Department of Public Health Bureau of Community Health and Prevention, Editor. Boston MA: Masschusetts Department of Public Health; 2016. Available at https://www.mass.gov/files/documents/2018/07/06/health-professions-data-series-registered-nurses-2014.pdf
. Accessed June 8, 2020.
6. US Department of Census. Quick facts. http://quickfacts.census.gov/qfd/states/00000.htm
. Accessed November 2, 2018.
7. Stempniak M. Healthcare needs more diverse leadership teams. In: Hospitals & Health Networks
. 2015. https://www.hhnmag.com/articles/6703-health-care-needs-more-diverse-leadership-teams
. Published November 10, 2015. Accessed June 5, 2020.
8. American Association of Nurse Executives. AONE salary and compensation study for nurse leaders. http://www.aone.org/resources/salary-study.shtm
. Accessed December 18, 2018.
9. Collins PH. The social construction of black feminist thought. Signs J Women Cult Soc
10. Banks-Wallace J. Womanist ways of knowing: theoretical considerations for research with African American women. Adv Nurs Sci
11. Rubin HJ, Rubin IS. Qualitative Interviewing; The Art of Hearing Data
. 3rd ed. Thousand Oaks, CA: Sage; 2012.
12. Lincoln YS, Guba EG. Naturlistic Inquiry
. Newbury Park, CA: Sage Publications; 1985.
13. QSR International Inc. NVivo. https://www.qsrinternational.com/nvivo/home
. Accessed February 17, 2020.
14. Payton TD, Howe LA, Timmons SM, Richardson ME. African American nursing students' perceptions about mentoring. Nurs Educ Perspect
15. Dapremont JA. Success in nursing school: black nursing students' perception of peers, family, and faculty. J Nurs Educ
16. Murray TA. Factors that promote and impede the academic success of African American students in prelicensure nursing education: an integrative review. J Nurs Educ
17. Gona C, Pusey-Reid E, Lussier-Duynstee P, Gall G. The experiences of black nursing alumni at a predominantly white institution. Nurse Educ
18. Curtis EA, Vries JD, Sheerin FK. Developing leadership in nursing: exploring core factors. Br J Nurs
19. Spence Laschinger HK, Fida R. Linking nurses' perceptions of patient care quality to job satisfaction: the role of authentic leadership and empowering professional practice environments. J Nurs Adm
20. Shirey MR. Authentic leadership, organizational culture, and healthy work environments. Crit Care Nurs Q
21. Curtis EA, Sheerin FK, Vries JD. Developing leadership in nursing: the impact of education and training. Br J Nurs
22. Brady Germain P, Cummings GG. The influence of nursing leadership on nurse performance: a systematic literature review. J Nurs Manag
23. Relf MV. Advancing diversity in academic nursing. J Prof Nurs
24. Shaffer FA, Davis CR, Dutka JT, Richardson DR. The future of nursing: domestic agenda, global implications. J Transcult Nurs
25. Barbe T, Kimble LP, Bellury LM, Rubenstein C. Predicting student attrition using social determinants: implications for a diverse nursing workforce. J Prof Nurs