AS THE UNITED STATES continues to move toward the projected 43% majority— minority demographic balance—the health care system will serve a more diverse patient population.1 A more diverse workforce will better meet health care needs and provide more culturally relevant care, although the Institute of Medicine's Future of Nursing reports that a lack of diversity is a challenge for the nursing profession.2 Since the release of this report, the profession of nursing has made significant strides toward a more diverse workforce. The American Association of Colleges of Nursing reports significant increases in degrees granted to underrepresented minority (URM) nurses between 2013 and 2018. Overall, URM groups represent 34.2% of entry—level baccalaureate, 34.7% of master's, 33.0% of PhD, and 34.6% of Doctor of Nursing Practice enrollment.3 In 2017, the National Council of State Boards of Nursing reported that minorities make up approximately 19.5% of the nursing workforce.4 Despite this progress, the American Organization of Nurse Leaders reports that ethnically diverse nurses account for only 4% of nursing leadership. Additionally, 2016 estimates from the American Hospital Association report that racial or ethnic minorities represent only 14% of hospital board members, 11% of executive leadership positions, and 19% of management positions.5 This demographic shift, already being seen across the nation, requires increased inclusivity and diversity efforts within organizations.6
Diversity in health care significantly benefits health care organizations as well as surrounding communities. Increasing diversity in health care leadership will result in better patient outcomes and a deeper connection between the organization and the community. Minority nurses in influential leadership roles are poised to influence resource allocation to vulnerable groups and shape organizational policies aimed at eliminating health disparities in the community at large.6 Inclusive care, achieved by equipping health care professionals with diversity and cultural competency training along with a diverse workforce, is essential to meet the needs, expectations, and outcomes of health care consumers. Ethnically diverse leaders are more likely to have experience in diversity and inclusion policies and practices that inform practice. Additionally, they are more likely to support diversity initiatives such as preferential hiring and targeted advancement opportunities.7 Patients are more likely to trust providers who are “like themselves” and favor diverse organizations who deliver culturally competent care.3 A diverse leadership team is an asset that drives organizational innovation, improves patient satisfaction, and leads to improved health outcomes. Organizations with leadership teams that do not demographically reflect the communities they serve are not equipped to fully address social determinants and decrease racial and ethnic health disparities.6
CALL TO ACTION
Numerous health care organizations have made a strong call for diversity at all levels. The American College of Healthcare Executives proposes that “all stakeholders should renew and strengthen their commitment to redressing any imbalance in representation of racially/ethnically diverse individuals in leadership and governance to enhance our profession now and in the future.”8 The American Organization of Nursing Leadership takes the position “that diversity is one of the essential building blocks of a healthful practice/work environment.” Acting on these calls for a commitment to diversity can lead to a broadened pool of qualified leaders and ensure gaps in these important areas are filled, particularly in nursing.5
Despite the known benefits of having diverse leaders in health care, consistent barriers that impact the mobility of minorities into leadership positions continue to exist. Minorities are less likely to be offered central positions, receive less mentorship, and are subject to bias, stereotypes, and discrimination.7 Fewer publications and grants, lack of mentorship and sponsorship, and lack of leadership opportunities are also known to be frequent barriers to advancement and accomplishment for underrepresented minorities.9 African American women in leadership positions report feeling a pressure to prove ability more than their white counterparts in addition to feeling they are the lone voice in a group. These barriers may result in underrepresented minorities feeling more anxiety than their white counterparts and decrease the likelihood they will pursue leadership opportunities.10 Assessing for existence of these types of barriers is an important first step for organizations desiring to create a climate of inclusivity. Awareness of these barriers also prepares URM nurses to effectively address them, as they pursue leadership opportunities. To effectively recruit and retain ethnically diverse nurse leaders, both organizations and aspiring nurse leaders must be proactive.
ORGANIZATIONAL ACTION TOWARD DIVERSITY AND INCLUSION
An organizational commitment to diversity and inclusion does not mean hiring or promoting unqualified nurses for leadership positions. It is the development and integration of a strategic plan to discover and support qualified URM nurses. Organizations will reap the many benefits of having a diverse workforce through thoughtful actions that encourage and support diversity and inclusion.
Increasing the diversity of an organization's workforce and fostering a climate of inclusion and diversity must be a priority. In order to effect change and create diverse and inclusive environments for URM nurses to advance, all levels of the organization must be involved in a structured diversity management plan.11 Diversity management is an intentional and formal process designed to create and maintain a positive work environment through greater inclusion of employees from various backgrounds into organizational structures.12,13 The first step of this plan should be a thorough assessment and analysis of diversity at all levels of the organization. If after this occurs, a deficit is uncovered that focus should shift to developing a comprehensive plan that begins with the inclusion of diversity principles in the mission statement, philosophy, and day-to-day practices.14 Incorporating diversity principles into core elements of the organization can catalyze the change needed for a program to be successful. However, clear definitions and explanations of how the principles will guide the organization are important for creating a culture of inclusion. Setting clear goals and objectives helps move the plan into action. After appropriate strategies to meet the goals and objectives have been developed, adequate resources to support them should be identified and allocated. Evaluation should begin at the earliest stages of the program and continue throughout. It can be difficult to measure and evaluate the impact of a multilayered diversity management program; therefore, selecting appropriate indicators for evaluation is a crucial step of the process. Potential indicators could include grievances and complaints, diverse hiring, job satisfaction, and retention.15
Robert Wood Johnson University Hospital (RWJU) serves as an example of an organization with a strategically designed diversity management plan. The commitment is clearly expressed in the following excerpt from the mission statement: “Diversity, inclusion, and cultural competency at Robert Wood Johnson University Hospital (RWJU) are imperative to our mission of being a leading, nationally distinguished academic medical center. In our quest to ensure health equity and close health disparities, they are core values that are woven into the fabric of everything we do ... Inclusion begins with acknowledging the behaviors linked to creating a culture of dignity, innovation, and cultural effectiveness.”16 RWJU developed a 3–year plan to develop a leadership team that reflects the diverse patients the hospital serves. Mentorship programs and succession planning were among key components of the program that resulted in an increase in leadership diversity from 4% in 2012 to 32% in 2015, as well as an increase in board members from 17% to 22%.15
Leadership development begins early and is a continuous process. Mechanisms that attract and retain diverse candidates for leadership positions should be developed and integrated at multiple levels. The promotion of nursing and other health care careers through connections with school programs and community organizations creates a pipeline for future nurses and nurse leaders. While this is not an immediate solution to the problem, pipeline programs have been shown to improve academic performance in URM students, as well as increase the likelihood that they pursue a career in the health professions.17 Increased recruitment efforts at graduate nursing programs in colleges and universities with predominantly racially/ethnically diverse students can increase access to potential candidates. URM nurses are more likely than their white counterparts to pursue higher degrees in nursing, providing a rich pool from which to draw upon. However, the disparity between those with advanced degrees and those in leadership roles exists.4 Partnerships with academic centers to provide internships, residencies, and fellowships for diverse students can also serve as a pipeline for future leaders in health care. Organizations must find innovative ways to connect with the communities they serve perhaps tapping into youth organizations such as Girl Scouts or local Boys and Girls clubs.
Nurse leaders have a responsibility to advocate for representation of diverse nurses at entry, mid, and senior levels in health care management. This includes creating clear pathways for advancement into leadership positions. Specific criteria for advancement can be a useful guide for URM nurses who wish to pursue leadership roles. This information should be transparent and available for all nurses to use as a tool for career planning. Policies that foster an environment that prevents discrimination in the recruitment, hiring, and promotion processes should be adapted. Nurse leaders should ensure that policies are understood, as well as measure and reward resulting changes throughout the organization. Along with these recruitment strategies, there should also be a well-designed and documented retention plan. These plans can help increase the current overall turnover rate of 26.8% among nurses in the United States.18
Collaboration with external partners can tap into a shared goal of achieving equity and create momentum toward enhancing diversity among leadership in health care. Engaging with external partners also broadens an organization's reach to a broader audience and creates a “new” funnel of potential leaders. Health care organizations can collaborate with professional organizations representing URM nurses to create sources for scholarships and professional development funds. For example, the National Hispanic Nurses Association (NAHN), a professional society for Latino nurses, has 47 chapters around the United States. This organization is committed to creating a cadre of Latino nurses by advancing educational, professional, and leadership opportunities for its members. The NAHN provides academic scholarships as well as financial support to attend the national conference (www.nahnnet.org).19
Emerging nurse leaders should be encouraged and supported to join and become active members of professional organizations such as the National Black Nurses Association. The National Black Nurses Association (NBNA), with over 115 chapters in the Eastern Caribbean, Africa, and the United States, has a long history of collaborative partnerships with organizations. The NBNA collaborative mentorship program offers mentoring for new nurses, nurses transitioning into new roles, and those advancing into leadership roles.20 Supporting URM to join these organizations provides opportunities that may not be offered within the organization. Health care organizations could also offer support and/or cohost events such as executive breakfasts, chapter networking events, and educational programs.
Leadership development programs such as the National Center for Cultural Competence's Leadership Institute offer opportunities for leadership development. This particular program focuses on development of those from underrepresented racial/ethnic groups and individuals with disabilities interested in leadership positions in the intellectual/developmental disabilities specialty. Supporting emerging nurse leaders within a health care organization to participate in external leadership development programs such as this can reduce the strain on organizational resources.21
In addition to support for external fellowship and leadership programs, organizations might consider investing in developing internal leadership programs.
There are a myriad of prototypes of mentoring and sponsorship programs that connect emerging leaders and senior leaders in the nursing literature.
UNDERREPRESENTED MINORITY NURSES' ACTIONS FOR DIVERSITY AND INCLUSION
Undoubtedly, organizations must provide an environment for URM nurses to thrive. However, URM nurses desiring leadership roles must take action to prepare themselves for success when opportunities present. These requires a commitment to connecting and collaborating those within the organization as well as in the community at large.
Barriers to leadership for URM nurses include structural barriers, institutional and individual mindsets, and lifestyle choices. These barriers can derail or demoralize emerging URM nurse leaders. However, nurses can utilize self-awareness to be proactive and equip themselves with tools to overcome these barriers. Self-awareness provides an understanding of emotions, strengths, weaknesses, needs, and drives. It is a skill, which must be developed and practiced. Self-awareness is developed over time through practices designed to learn more about one's self. This can happen informally through meditation or through a more formal and detailed self-assessment. Based on a self-assessment, short- and long-term development goals, areas and actions that will enhance leadership skills should be considered. These goals can help determine how and where to invest in one's own leadership development. Possible development areas for leadership include communication skills, financial acumen, and negotiation. Goals should be specific, measurable, realistic, and time sensitive.
While an advanced degree is often helpful in obtaining leadership roles, URM nurses may benefit from involvement in leadership activities outside the professional role. Additional leadership opportunities may lead to permanent positions and can form a foundation for building a career. National nursing organizations such as the American Nurses Association and SIGMA (International Honor Society of Nursing) offer several leadership development opportunities. The American Nurses Association offers members an opportunity to participate in an 8-month program that focuses on mentoring partnerships. Mentees are matched to a more experienced nurse for real-world career and advice.22 SIGMA offers a 12-month program, the New Leadership Academy for Practice, designed for emerging leaders interested in developing skills needed to thrive in a health care environment. This hybrid program provides opportunities for nurses to develop skills and knowledge needed to lead teams to improve health outcomes.23 Pursuing leadership roles in nursing can be a complex and cumbersome process that can become frustrating. URM nurses are particularly vulnerable to this due to the numerous barriers faced. Success of nurse leaders requires behaviors that nurture, sustain, and reinforce resiliency.24 Emerging leaders should include self-care activities that allow for balance early in their leadership development. This valuable skill is one that can be developed in a formal leadership program such as SIGMA.
Connecting with nurses who are in leadership positions or those who also aspire to become nurse leaders is an important part of the development process. This can occur in activities as simple as engaging in professional social media platforms such as Linked In or attending seminars on health care topics at different health care organizations and academic settings. However, the connections are made, there should be an intentional focus on obtaining mentors and/or sponsors. It is important to understand the difference between these roles, as both may be needed.
A mentor is someone who gives advice and guidance whereas a sponsor actively helps achieve a goal by being an advocate.25 Mentors come in many forms, but minority nurse leaders should consider focusing on 2 specific types. The first is one who shares a cultural background and can provide guidance based on that unique perspective and personal journey. The second being someone who is experienced in a leadership position and understands the complexities of the role. A sponsor is typically a senior-level administrator within one's organization who uses their influence and network to drive the aspiring nurse leader's career vision.25
Collaboration that occurs outside the typical roles and responsibilities of a nurse is a critical step in leadership development. Formal and informal interactions with colleagues through workgroups, taskforces, and committees can lead to opportunities that would not otherwise present themselves. Such opportunities can lead to improved communication and enhanced professional presentation skills.
Participation gives insight into decision-making processes as well as operational procedures. Both critical skills are needed for leadership development among nurses.
While there are many avenues for collaboration within health care organizations, URM nurses may find a need to seek opportunities outside the work environment. For example, professional organizations offer opportunities to participate and contribute at many levels. Committee positions or working on an organization's event or fundraiser provides the chance to practice leadership and communication skills. Presenting work at a conference or event offers practice in networking with others. Simply handing out programs or introducing other speakers can build confidence and increase exposure.
Minority nurses should consider pursuing leadership opportunities outside of the workplace. Interaction with leaders through involvement in community boards, taskforces, and planning groups can create opportunities to showcase one's knowledge and abilities. Serving in leadership roles in nonprofit, religious, social, and professional organizations provides opportunities to sharpen leadership skills. Community involvement develops interpersonal skills, clarifies core values, and builds communication capabilities: all skills that are transferable to and highly valued in the workplace.26
As leadership opportunities in nursing become available, the URM nurse should consider each opportunity carefully. Although it may be tempting to accept the first opportunity, it is wise to choose a position that offers new experiences and expands existing skillsets and management abilities. Organizations with a clear diversity management plan are optimal, as they are more likely to have positive diversity and inclusion initiatives.
The lack of URM nurse leaders is clear. It is time to move beyond a discussion and into action. All stakeholders must commit to actions that actively address the lack of representation for racially/ethnically diverse nurses in leadership and governance. Failing to do so will have negative implications for the profession of nursing, as well as those we care for. Improving racial and ethnic diversity in nursing leadership requires significant planning. A wide variety of approaches are necessary to accomplish this. Achieving diversity will require organizations to commit to a clear and transparent diversity management plan that begins with awareness and acceptance of diversity and inclusion issues. Nurses from URM groups must make a commitment to engage in reflection and goal setting that is centered on developing connections and collaboration.
1. US Census Bureau. New Census Bureau Report Analyzes U.S. Population Projections. https://www.census.gov/topics/population.html
. Published March 3, 2015. Accessed September 29, 2019.
2. Committee for Assessing Progress on Implementing the Recommendations of the Institute of Medicine Report The Future of Nursing: Leading Change, Advancing Health. Assessing Progress on the Institute of Medicine Report The Future of Nursing. Washington, DC: National Academies Press (US); 2016. https://www.ncbi.nlm.nih.gov/books/NBK350167/
. Accessed October 4, 2019.
3. Enhancing Diversity
in the Workforce. American Association of Colleges of Nursing: The Voice of Academic Nursing. https://www.aacnnursing.org/News-Information/Fact-Sheets/Enhancing-Diversity
. Published April 2019. Accessed October 5, 2019.
4. Smiley RA, Lauer P, Bienemy C, et al. The 2017 National Nursing Workforce Survey. J Nurs Regulation. 2018;9(3):S1–S88. doi:10.1016/s2155-8256(18)30131-5.
5. Institute for Diversity
. The State of Health Care Diversity
and Disparities: A Benchmarking Study of U.S. Hospitals. http://www.diversityconnection.org/diversityconnection/leadership-conferences/Benchmarking-Survey.jsp?fll=S2
. Published 2015. Accessed October 5, 2019.
6. Phillips J, Malone B. Increasing racial/ethnic diversity
in nursing to reduce health disparities and achieve health equity. Public Health Rep. 2014;129(suppl 2):45–50.
7. Cook A, Glass C. The power of one or power in numbers? Analyzing the effect of minority
leaders on diversity
policy and practice. Work Occupations. 2015;42(2).
8. Increasing and Sustaining Racial Diversity
in Healthcare Management. Increasing and Sustaining Racial Diversity
in Healthcare Management. https://www.ache.org/about-ache/our-story/our-commitments/policy-statements/increasing-and-sustaining-racial-diversity-in-healthcare-management
. Published 2011. Accessed September 29, 2019.
9. Kaplan SE, Gunn CM, Kulukulualani AK, Raj A, Freund KM, Carr PL. Challenges in recruiting, retaining and promoting racially and ethnically diverse faculty. J Natl Med Assoc. 2018;110:58–64. doi:10.1016/j.jnma.2017.02.001.
10. Flores KL, Matkin GS. “Take your own path”: minority
leaders encountering and overcoming barriers in cultural community centers. J Cult Diversity
11. Cottingham MD, Erickson RJ, Diefendorff JM, Bromley G. The effect of manager exclusion on nurse turnover intention and care quality. Western J Nurs Res. 2013;35(8):970–985. doi:10.1177/0193945913483880.
12. Miller SK, Tucker JJ. Diversity
trends, practices, and challenges in the financial services industry. J Financial Ser Prof. 2013;67(6):46–57.
13. Mor Barak ME. Managing Diversity
. Los Angeles, CA: Sage; 2014.
14. Pitts D. Diversity
management, job satisfaction, and performance: evidence from U.S. Federal Agencies. Public Administration Rev. 2009:69(2):328–338.
15. Brenman M. Diversity
Metrics, Measurement, and Evaluation. Diversity
in the Workplace—Leading Association for Diversity
Conferences and Collaboration. https://workforcediversitynetwork.com/res_articles_DiversityMetricsMeasurementEvaluation.aspx
. Published January 9, 2013. Accessed October 8, 2019.
17. Bouye KE, McCleary KJ, Williams KB. Increasing diversity
in the health professions: reflections on student pipeline programs. J Healthc Sci Humanit. 2016;6(1):67–79.
18. Hughes V. Leadership
Strategies to Promote Nurse Retention. Sci J Nurs Pract. 2017;1(1):001–005.
19. National Hispanic Nurses Association. About NAHN. www.nahnnet.org
. Accessed September 8, 2019.
20. National Black Nurses Association home page. https://www.nbna.org/who
. Accessed September 8, 2019.
21. Georgetown University Center for Child & Human Development. Leadership
. Accessed September 8, 2019.
23. Nurse Leadership
Academy for Practice. SIGMA Nursing. https://www.sigmanursing.org/learn-grow/sigma-academies/nurse-leadership-academy-for-practice
. Updated 2019. Accessed October 4, 2019.
24. Dyess S, Prestia AS, Marquit DE, Newman D. Self-care for nurse leaders in acute care environment reduces perceived stress: a mixed-methods pilot study merits further investigation. J Holist Nurs. 2018;36(1):79–90. doi:10.1177/0898010116685655.
25. Baumgarten MA. The Key Role of Sponsorship—Diversity
at SLAC. The Key Role of Sponsorship Mentors vs Sponsors. https://inclusion.slac.stanford.edu/sites/inclusion.slac.stanford.edu/files/The_Key_Role_of_a_Sponsorship_for_Diverse_Talent.pdf
. Accessed October 13, 2019
26. Hewlett SA, West C, Luce C. Leadership
in Your Midst: Tapping the Hidden Strengths of Minority
Executives. Harvard Business Review. https://hbr.org/2005/11/leadership-in-your-midst-tapping-the-hidden-strengths-;of-minority-executives
. Published August 22, 2014. Accessed October 14, 2019.