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Increasing Racial and Ethnic Diversity in the Nursing Workforce

One Pediatric Hospital's Strategic Approach

Hinson, Tyonne D. DrPH, MSN, RN, NE-BC; Brostoff, Marcie MS, RN, NE-BC; Grossman, Amanda Beit BA, SHRM-CP; Ward, Valerie L. MD, MPH; Lind, Kathleen BS; Wood, Laura J. DNP, RN, NEA-BC, FAAN

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MCN, The American Journal of Maternal/Child Nursing: May 30, 2022 - Volume - Issue - 10.1097/NMC.0000000000000840
doi: 10.1097/NMC.0000000000000840
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Despite registered nurses (RNs) representing the largest segment of the health care workforce, there is a critical need for organizations to deliberately implement strategies to increase the diversity of their nursing workforce for our nation's health (Budden et al., 2016; Kovner et al., 2018; National Academies of Sciences, Engineering, and Medicine [NASEM] et al., 2021; Woods-Giscombe et al., 2020). The Institute of Medicine's (IOM, 2003) report, “Unequal Treatment” provided a wide range of recommendations to address racial and ethnic disparities in health care, including a call to expand the proportion of underrepresented minorities in the health care workforce. A year later in 2004, the Sullivan Commission on Diversity in the Health Professions further illuminated the imbalance in diversity of the nation's physicians, dentists, and nurses (IOM, 2003; Sullivan, 2004). Today, as the population of the United States becomes increasingly diverse, a cultural mismatch “chasm” between those seeking and providing health care has been widened, further accentuating the importance to expand the diversity among health professionals within health care delivery settings. As the largest and most widely distributed health care workforce attending to the health and whole person well-being of others, nurses are increasingly positioned to lead and reshape the future of health care (NASEM et al., 2021). Increasing racial and ethnic diversity in the nursing workforce is a serious near-term imperative to achieve health equity as a foundation to improve health and health care (Banister et al., 2020; Carter et al., 2015; NASEM et al., 2021; National League for Nursing, 2016).

We describe an intentional, multipronged approach initially framed as part of a tertiary acute care, pediatric hospital workforce diversity initiative in 2008. This work grew from prior organizational efforts to accelerate recruitment, retention, and professional development (Sporing et al., 2012). This foundation, in turn, shaped a more racially, ethnically diverse, RN workforce strategy over a 3-year period (2018-2021). The aims of this second-wave effort sought to 1) increase the number of racially and ethnically diverse nurses hired to reflect the diversity of patients and families receiving care, and 2) create a pipeline of diverse nurses for sustained increases in diversity hiring and retention over the next decade and beyond. Specific strategies to strengthen the retention and professional development of diverse nurses hired were also implemented during this same 3-year period.


Critical elements, such as general mistrust of providers, miscommunication, prior negative experiences and interactions within the health care system, lack of access for diverse populations, and entrenched structural and systemic barriers, have long been noted to be significant contributors to racial and ethnic disparities in care (Dawkins, 2021; IOM, 2011; Phillips & Malone, 2014; Sullivan, 2004). Despite the tremendous emphasis being placed on the provision of culturally appropriate education programs to increase cultural and limited language proficiency by providers, eliminate bias and stereotypes, and improve patient–family experience during health care encounters, efforts to diversify the nursing workforce through minority pipeline programs, specific recruitment, retention, and professional development strategies exist, but many have yet to be widely disseminated, nor scaled for replication. Health care delivery organizations and national systems must take strategic action to attend to diversity within nursing and medical education and must not miss the opportunity to influence diverse communities to address Social Determinants of Health through funding and direct operational support of nursing workforce diversity initiatives (Banister et al., 2020; Budden et al., 2016; NASEM et al., 2021; Phillips & Malone, 2014; Woods-Giscombe et al., 2020). By strategically focusing on increasing diversity in the nursing workforce, as well as the provision of culturally relevant, respectful humble care and education, health systems will improve patient–clinician communication and experience, access, and health outcomes for diverse populations in a more comprehensive way (NASEM et al., 2021; Spencer, 2020).

In 2014, the U.S. Census Bureau reported that racial and ethnic minority groups represented approximately 38% of the nation's population (Colby & Ortman, 2015). By July 2019, reports of racial and ethnic minority groups representation are reported to have increased to 42.1% (including two or more races; U.S. Census Bureau, 2019). Nurses from minority backgrounds, specifically Asian, Black/African American, and Hispanic, represent approximately 28.5% of the current RN workforce (NASEM et al., 2021). Concerns about this population–workforce disparity arise from the significant underrepresentation of minority nurses in health care “relative to their numbers in the general population” for specific races/ethnicities; and from the hypothesized impact of improved access to culturally relevant care, quality, health care outcomes, and trust among minority and socioeconomically disadvantaged populations via a diverse health care workforce (Association of American Medical Colleges, 2004; Banister et al., 2020; Philips & Malone, 2014; Scott & Zerwic, 2015; Snyder et al., 2018; Woods-Giscombe et al., 2020; Zangaro et al., 2018). Nurses influence both medical and social factors that drive health outcomes and equity of health and health care (NASEM et al., 2021). The future of nursing requires organizations and leaders to prioritize the need for racial and ethnic diversification and to increase inclusion and equity in the delivery of health care services (NASEM et al., 2021; Philips & Malone, 2014).

The racial and ethnic demographic disparity between the nursing workforce and general population calls for a focused effort to increase the presence of diverse RNs in care delivery systems across the nation. The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity (NASEM et al., 2021) plays a critical role in reemphasizing the importance of nursing in the lives and health outcomes of individuals, families, and communities. The report sheds light on the trends and relevance of the nursing workforce, its size, distribution, educational preparation, and its diversity. The report notes that White nurses comprise most of the RN workforce, representing 69% of the profession in 2018 versus 79.1% in 2000. Although the RN workforce has become more diverse over the past 2 decades, the composition of the workforce considered necessary to address current-day population health challenges remains unmet. Despite representation of Asian and Black/African American RNs equaling or exceeding the overall U.S. population, respectively, the racial and ethnic demographic composition varies widely by geography (NASEM et al., 2021). The Latino/Hispanic nursing workforce–population mismatch adds an additional layer of complexity, with Latino/Hispanic RNs representing only 7.4% of the nursing workforce despite a national population of 18.3% (NASEM, 2021; U.S. Census Bureau, 2019).

Strategies to Diversify the Nursing Profession Reported in the Literature

To address the firmly entrenched, historical underrepresentation of ethnic minorities in nursing, numerous U.S. councils and regulating bodies proposed a number of strategies and programs. Subsequent implementation of a subset of these recommendations has occurred by various academic institutions and health care delivery organizations (Department of Health and Human Services, 2017; IOM, 2011; IOM, 2003; Murray et al., 2016; Sullivan, 2004). Most of the attention has been focused on education at the undergraduate level to create pathways and pipeline programs to encourage and support diverse students pursuing health professions and nursing (Carter et al., 2015; IOM, 2011; Snyder et al., 2018). Far less consideration has been given to focused strategies for recruitment and retention at the organizational and practice level in the literature, such as internship pipeline and academic-institutional transition partnership strategies. However, researchers have identified that successful strategies are most often multifaceted and comprehensive in approach, providing a combination of many interventions for diverse students and new professionals entering the profession (Snyder et al., 2018).

Strategies to increase diversity among the nursing workforce through recruitment and hiring within practice settings exist, though most of the literature and focus has historically concentrated on pipelining within nursing education programs. In addition to our pediatric workforce professional advancement program, the literature highlights a few approaches among institutions around the United States (Sporing et al., 2012). Aurilio et al. (2019) highlighted success in diversifying the nursing workforce through internship pipeline strategies. Intentional focus on the selection of diverse nurse technicians, cultivation of relationships, mentorship, and community involvement were identified as key interventions to further diversify the nursing workforce into the future (Aurilio et al., 2019). A workforce pipeline collaborative strategy launched by an integrated, academic health care system focused on the melding of mentorship, leadership development, and clinical resource support for the successful transition of third year, racially and ethnically diverse nursing students into independent practice as graduate nurses within the health system's nursing workforce (Banister et al., 2020). The ultimate aim of this strategy was to support the transition of diverse nursing students to successful employment in the partnering health care institution through the attainment of baccalaureate degrees. Sunago (2020) identified several strategies for building a diverse nursing team from a practice perspective through six specific strategies including: 1) expanding the view of diversity; 2) identifying candidates who overcame cultural stigmas to enter nursing; 3) diversifying the interviewing team; 4) seeking candidates to complement the team; 5) fostering belonging; and 6) respecting religion and customs. These focused efforts and other methods were reported to improve an organization's culture of inclusivity, which influences improvement in outcomes of patient care, health equity, and overall employee well-being (Sunago, 2020). Phillips and Malone (2014) focused on the appropriation of funding, creation of policies, and support of practice to enhance the diversification of the nursing workforce. Their varied recommendations called for the high prioritization of practices that would ensure workforce diversity and leadership development opportunities for racial and ethnic minority nurses entering the workforce. Flores and Combs (2013) focused on the topic of strategic recruitment to increase professional minority applicants in health care. Though not solely nursing-related, Flores and Combs (2013) focused on key topics of disparities, organizational culture, barriers to recruitment, job analysis and compliance, targeted recruitment, websites and employment advertising, and training of recruiters as factors influencing diverse workforce representation.

Though many gaps remain in the literature related to evidence-based, strategic actions to diversify the nursing workforce in health care delivery organizations, results reported to date were most often achieved when nursing recruitment, transition to practice, and ongoing professional development was purposeful and intentional with a direct link to the larger organizational mission and community served.

Strategic Initiatives to Diversify the Pediatric Nursing Workforce at Boston Children's Hospital

For our tertiary care, 415-bed pediatric academic medical center in Massachusetts, workforce diversity has been a strategic priority of nursing and hospital leaders for more than a decade. Recognized as pioneers in pediatric health care delivery and family-centered practices, senior nurse leaders with accountability for the discipline of nursing today with over 3,000 RNs and Advanced Practice Registered Nurses have long recognized the importance of racial and cultural workforce composition as foundational to care quality and health outcomes. As innovators in the creation of several novel programs over the past two decades, nursing leaders launched a summer career internship for diverse high school and college students to cultivate interest in nursing as a profession, as well as a nursing student professional advancement program providing mentorship and structural support for racially and ethnically diverse employees aspiring to become bachelors-prepared nurses. These actions have cultivated a more representative and inclusive nursing workforce (Magrath, 2012; Sporing et al., 2012). Despite both efforts yielding success in addressing their initial aims over the past decade, including advancement of more than 30 underrepresented employees of Black/African American and Hispanic/Latino racial and ethnic backgrounds growing from “aspiring” nurses to RN employment within the hospital, the composition of diverse nurses within the organization's aggregate workforce in 2018 remained unchanged at ~10% following a decade of focused efforts.

The need to affect hiring practices and expand outreach to pipeline and source future candidates was framed by both the system chief nursing officer and other key organizational initiatives. Key priorities included: 1) creating a more culturally competent and multilingual nursing workforce that better reflects the racial and ethnic patient–family populations served; 2) advancing organizational commitment to the principles of equity, diversity, and inclusive excellence in support of patients, families, and team members throughout the system of care in service to local and extended communities; and 3) supporting a growing number of medically complex patients seeking highly specialized care from a national and international patient-referral base, adding increased cultural and ethnic considerations to the provision of care (Boston Children's Hospital, 2019; IOM, 2003).

As the Massachusetts state census data revealed an expansion of diverse populations particularly among Black/African Americans and Latino/Hispanic populations, this growing population of racially and ethnically diverse patient–families were also increasingly seeking care within the organization (U.S. Census Bureau, 2019). Boston is an increasingly diverse urban community. In the last several years, the population has increased by 8% overall. Twenty-three percent of Boston residents identify as Black, 19.4% identify as Latino, and 9.4% identify as Asian (Boston Children's Hospital, 2019). Given the disproportionally smaller numbers of Hispanic/Latino RNs within the state's most populated cities compared with the population (i.e., Hispanic/Latinos representing 18.4% of population vs. 2.2% of practicing RNs within Boston), executive nursing and nurse recruitment leaders deepened their partnership to develop a multipronged strategy to increase diversity recruitment and hiring (MA Department of Public Health, 2016). A focused emphasis to recruit new graduate nurses was launched in 2018 to address the significant gap between the population served and the organization's nursing workforce.

The focus of the enhanced collaboration between senior nursing and recruitment leaders was to design, implement, and measure the impact of newly conceptualized pipeline strategies, recruitment outreach, academic partnerships, relationship building, and mentoring of diverse new graduate nurses from academic programs in the greater Boston and Northeastern region of the United States. With the expansion of two roles to execute this diversity recruitment strategy, a director of nursing diversity initiatives and a talent acquisition ambassador, a unified team was formed to increase diversity recruitment initiatives.

In 2013, the hospital's newly appointed chief nursing officer and chief operating officer engaged an increasingly diverse group of organizational leaders spanning the Office of Faculty Development, Human Resources Department, and nursing executive leaders to advance the continued evolution of this work. Over the next 4 years spanning 2013 to 2017, additional steps were prioritized, including funding allocation and governance design, to operationalize an inaugural Office of Health Equity and Inclusion (Ward et al., 2022). The following year, the first doctorally prepared nurse executive with a direct reporting relationship to the chief nursing officer was hired to lead nursing diversity initiatives (2018), including professional workforce advancement programming and the cultivation of academic partnerships. Other key organizational initiatives followed through 2021 to advance the organizational values and principles for equity, diversity, and inclusion, with the development of a formal published statement of the goals and commitments that will guide our work to becoming a leader in equity for all (Figure 1; Boston Children's Hospital, 2020; Ward et al., 2022). Starting in 2018, the organization's nursing and recruitment team collaborated directly with senior nursing leaders with hiring authority to increase the number of qualified, minority new graduate and experienced nursing applicants expressing interest in and ultimately being hired within this pediatric health care delivery organization. Nursing and recruitment leaders jointly committed to the following collective strategies to reshape the composition of the nursing workforce.

Figure 1.:
Organizational Equity, Diversity, and Inclusion Timeline

Diversity Recruitment Hiring Strategies

In 2018, the blended nursing-recruitment leadership team began to initiate their multipronged strategy to increase diversity hiring among their 2019 RN hires. Strategic aims of this partnership included: (1) increasing the number of qualified, diverse new graduate and experienced BSN-prepared nurses for residency and open nursing positions; (2) building a robust nursing pipeline of diverse RN applicants with a continuation of relationship-building with those not hired as new graduate RNs for potential future experienced nursing hire opportunities; (3) identifying approaches to increase the recruitment and hiring of qualified diverse nursing candidates from the greater Boston and Northeastern region; and (4) implementation of practices that influence retention and engagement of a newly onboarded racially and ethnically diverse nursing workforce.

Starting in 2018, the team convened monthly to develop, implement, and evaluate each of the strategic actions described to increase diversity recruitment of their nursing workforce. The team believed each strategy represented an important component to increase diversity recruitment and hiring for the organization. These key strategies were first initiated in the greater Boston region in early 2019, with expansion reaching several other academic institutions throughout the Northeast region in years 2020-2021.

Outcomes of Diversity Nursing Recruitment Strategies at Boston Children's Hospital

The multipronged, diversity nursing recruitment strategy yielded significant results during its inaugural year of implementation, resulting in a 6% overall increase in 2019 for total RN diversity hires from the prior year. Significant increases in both diverse experienced and new graduate RN hires were first achieved in 2019—with continued success over the next 2 years (Figure 2). In year one (2019), 20 racially and ethnically diverse new graduates were hired to join the organization's nursing workforce. Of importance, this represented an 18% increase in new graduate diversity hiring over the prior year (2018). Thirty-four diverse experienced nurses were also on-boarded through 2019. As a result of the multipronged diversity strategic approach applied, 16.2% (or 54 nurses) of total hires for 2019 were racially and ethnically diverse. The 2019 hiring metrics surpassed both (1) the percent of diverse nurses previously hired within a single year for the organization and (2) the total number of diverse nurses ever hired in a single year when compared with each of the past 4 years (2015-2018).

Figure 2.:
Diversity Recruitment Outcomes

Subsequent years yielded continued success, although the organization's efforts were affected dramatically by challenges presented by the onset of the COVID-19 pandemic in early 2020. In year two (2020), 9 diverse new graduates were hired and 22 diverse experienced nurses were on-boarded to the workforce. Despite experiencing challenges related to recruitment, travel, and in-person relationship-building during COVID, strategic efforts still yielded a result of 12.6% diverse nursing hires for 2020 (31 of 246 nurses hired).

Nursing and recruitment leaders were committed to matching and exceeding the outcomes experienced in 2019. From October 2020 to September 2021, 76 racially and ethnically diverse nurses were recruited and hired (out of 356 RNs hired). Among the 76 diverse nurses hired, 36 were new graduates and 40 were experienced nurses. The total hires for 2021 represented 21.3% of diverse nurses, reflecting the most significant recruitment of diverse new nurses over the 3-year implementation horizon of these focused initiatives and surpassing 2019 outcomes.

Specific retention strategies have focused on building community and mentorship. Efforts included: expanded engagement of a nursing-led affinity group with a focus on mentorship and professional advancement initiatives; expansion of organization-wide cultural Employee Resource Groups (ERGs) with Nursing/Patient Care Department leaders engaging in Executive Sponsor and Chair roles; and first-year 1:1 quarterly mentorship meetings with the Director of Nursing Diversity Initiatives. Total retention of diverse new graduate nurses in 2022 following this 3-year hiring and retention strategic implementation period was 80%.

Several years before the roll-out of this comprehensive recruitment and hiring strategy in 2019, recruitment outreach to local and regional nursing college and university programs was established. However, with this expanded diversity outreach strategy, nine universities within the greater Boston and Northeastern region were visited by the director of nursing diversity initiatives and talent acquisition leaders to engage and recruit diverse new graduate nursing candidates. Over 700 students were reached during these visits spanning multiple colleges and universities. Dedicated time was provided to meet with diverse students of racial, ethnic, or socioeconomically disadvantaged affinity groups, in addition to other members of the enrolled nursing student body.

Clinical Implications

Recruitment efforts must be coupled with other key supports for diverse nurses, such as: mentorship, professional development and advancement coaching, access to nursing-affinity and ERGs, and diversity and inclusion infrastructure/leadership. A nursing-affinity group within the organization, The Nursing Cultural Sensitivity and Diversity Forum, has worked to create many of the supports through focusing on care of the racially and ethnically diverse patient–family while building a sense of community and support for diverse nurses. Organizations must also make a commitment to the professional development of diverse nurses in the workforce for advancement opportunities to managerial and leadership positions (Banister et al., 2020; Flores and Combs, 2013). Creating additional opportunities for development of diverse nurses in leadership roles will influence the organizational culture, as representation in leadership is critical to ensuring inclusive perspectives in clinical care, quality patient outcomes, and diverse nurse engagement. Organizations must establish a healthy organizational culture that values uniqueness and inclusion within the clinical and organizational environment. Without the presence of all of these elements, diverse nurses will be unable to thrive professionally, and long-term retention will be an ongoing challenge.

Although the Boston Children's Hospital approach provides a great opportunity for replication within other health care disciplines including pharmacy, social work, nutrition, physical and occupational therapy, and well beyond throughout the health care workforce, continued investments in diverse talent and programmatic support are required to sustain progress for nursing and all disciplines in future years. With the projected growth of racially and ethnically diverse populations, as well as the increasingly clear imperative to advance health equity and access to care, nursing and senior executive health care leaders must prioritize the development of strategic diversity recruitment and retention actions to address the critical imperative to advance health equity through the creation of a culturally diverse nursing workforce.


The authors express special appreciation to the following organizational executive leaders and nurse executives for their outstanding commitment and expertise in advancing nursing diversity initiatives and workplace inclusion strategies over the last three decades: Members of the Nursing Patient Care Executive Committee; Eileen Sporing, MSN, RN, NEA-BC, FAAN, senior vice president, patient care operations and chief nursing officer emerita; Susan Shaw, MS, RN, NEA-BC, vice president and associate chief nurse, nursing and patient care clinical operations (retired); Richard D. Parker, BS, lead & senior talent acquisition ambassador, Nursing/Human Resources; Earlene Avalon, PhD, inaugural director of the Nursing Career Lattice Program and director of nursing diversity initiatives; and Melissa Rodriquez, BS, MHA(c), program administration manager of the Nursing Career Lattice Program. The authors are grateful for their impactful contributions to the nursing workforce aimed to improve equity in care for children and families.

Clinical Implications for Increasing Racial and Ethnic Diversity in Nursing

  • Nursing and senior executive health care leaders must prioritize the development of strategic diversity recruitment and retention actions to address the critical imperative to advance health equity through the creation of a culturally diverse nursing workforce.
  • Strategic multipronged recruitment efforts should be coupled with diverse nursing workforce supports, as well as strong organizational diversity and inclusion leadership and infrastructure.
  • Nursing and organizational leaders must acknowledge the critical importance of mentorship, professional development, and presence of affinity-based employee-resource groups in retaining and nurturing a diverse nursing workforce.
  • Commitment to the professional advancement of diverse nurses in leadership roles will influence future recruitment and retention of diverse nurses, while strengthening organizational culture and quality patient outcomes.
  • There is a unique opportunity for implementation of multipronged diversity strategies across all health care disciplines to diversify the professional health care workforce, improve the patient–family experience, and advance health equity.


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Cultural diversity; Ethnic and racial minorities; Health equity; Hospitals; Nurses; Recruitment; Workforce

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