Although the challenge to increase underrepresented minorities in healthcare remains elusive, it has been suggested that there's a relationship between diversity in the classroom and clinical practice and positive patient outcomes.1 Leadership expectations set the stage for cultural competence, and empirical evidence of the impact of cultural competence on diversity is hindered due to the underrepresentation of minorities in nursing.1 At the forefront of primary healthcare and positioned to provide community members with health information that can change knowledge, attitude, and behavior, the art and science of nursing needs a paradigm shift. The lack of minorities in leadership positions further hampers the progress of marginalized persons.
Addressing the issue of how numerous studies show that race/ethnicity has an impact on health outcomes, nurse leaders in practice and education have the responsibility to identify the importance of cultural diversity in leadership as it relates to nursing. Within the field of nursing, classroom diversity should also be linked to faculty diversity. There's a need for institutional commitment to diversity because it appears that faculty participation in cultural competence development is linked to institutional requirements.1 Further education is needed among minorities because the lack of a baccalaureate or higher degree will isolate them from leadership opportunities through which they can influence and shape healthcare practice and outcomes.1
Steps to facilitate change in health disparities include education of nurse leaders and a focus on social health policies.2 Turning to the notion of evidence-based practice, nursing can benefit from expert opinions on issues of diversity, disparity, and the application of cultural competence from other disciplines. For example, one review determined to what extent interventions using cultural leverage decreased health disparities in communities of color.3 Three intervention categories were reported based on a systematic review of the literature.
First, the authors discussed interventions that modified a minority's behavior; second, they identified interventions that increased access to care for minorities; and third, they highlighted interventions that changed health systems' approach to the care of minorities. Interestingly, the behavioral intervention utilized the individual's culture to leverage health promotion. The access and health system change interventions overlapped the most; both used culturally specific nurse case managers and/or community health workers to address health disparities. It was noted that none of the studies reviewed examined the impact of an intervention on health disparities. However, the authors observed that nurse-led studies provided detailed descriptions of how race influenced healthcare.3
The importance of cultural diversity in leadership
In 2010, the National Center for Healthcare Leadership (NCHL) linked health disparities to leadership competencies.4 It explained that strategic diverse leadership is important and a leader's beliefs about diversity drive the extent and nature of an agency's diversity programs. Specifically, the NCHL suggests that leaders demonstrate how patient diversity should be an important strategic driver and the agency's workforce demographics should reflect patient demographics. Described as the cornerstones of strategically diverse leadership, the NCHL suggests that a strategic plan, performance metrics, accountability, and community involvement are needed to create the right infrastructure that empowers and enables employees to build personal and organizational diversity leadership skills. (See Table 1.)
Core leadership competencies described by the NCHL include the ability to:
- identify and manage the impact of formative life experiences
- expand one's worldview that embraces key diversity dimensions
- accept and manage one's own implicit biases
- self-monitor and adjust one's communication style
- utilize cognitive reframing to change one's behavior.
Congruent with the NCHL's ideas on leadership and health disparities, one study concluded that disparity can be reduced by leaders remaining focused and dedicated to their organization excelling in diversity.5 Specific leadership actions, such as enabling, cultivating, and reinforcing cultural and linguistic competence, allow for the growth of diverse leaders who do their part to reduce disparities in processes, as well as improve outcomes of care.5 In other words, it's the responsibility of leaders to prioritize diversity in leadership as it's related to healthcare and outcomes processes.
In an effort to improve patient outcomes, nursing management has the obligation to utilize evidence generated by interdisciplinary colleagues. For example, although not conducted by nurses, the Commonwealth Fund study showed that healthcare organizations that have leaders who promote policies and procedures to embrace diversity have improved patient satisfaction scores.6 Noting how healthcare leadership alone can't eliminate health disparities, one study acknowledged the impact of the community environment and the individual's socioeconomics and/or health beliefs.5
The notion of concordance-matching where the demographics of the employees match that of the patients has drawn attention and an analysis by researchers, demonstrating how patients experienced improved access when providers mirrored their race, ethnicity, or culture.7 That is, there was an increased number of individuals from underserved populations who accessed care because practitioners of the same race were present. In addition, better patient-provider communication and relationships were reported.
Although cultural competence is promoted, it has been questioned whether culturally competent providers can perform to their full potential when diverse leadership is absent.5 Social factors may contribute to the lack of minorities in nursing leadership, as well as the healthcare system, but at an organization level leadership should counteract some of the factors that prohibit minorities in leadership positions and improve career advancement at the local level.5
“Is it because I'm Black?”
In 1969, singer/songwriter Syl Johnson sang that something was holding him back in the song “Is It Because I'm Black?” The Institute of Medicine's 2003 seminal report Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare clearly documented that disparate health outcomes for Blacks were a product of prejudice and bias on the part of the healthcare provider toward the patient.8 Highlighting numerous studies demonstrating that provider bias and prejudice result in decreased care for Blacks, the report recommended culturally targeted professional development to include: (1) race/ethnicity, (2) religion, (3) the LGBTQ population (lesbian, gay, bisexual, transgender, and queer/questioning), and (4) culturally and linguistically appropriate services.
Years later, in a sample of 65 nursing faculty from a large public northeastern college system, one study examined the relationship between nursing faculty attitudes toward culturally diverse patients and transcultural self-efficacy utilizing Bonaparte's Cultural Attitude Scale.9,10 Sadly, the findings indicated that there was a positive attitude toward White and Asian patients among older, longer licensed faculty, whereas there was a negative attitude toward Black patients among faculty whose basic nursing education was in the United States. Furthermore, the study reported that the Cultural Attitude Scale showed a more negative attitude toward culturally diverse patients compared with 20 years ago.9
Another study noted that a lack of diversity in healthcare leadership and workforce is a barrier to culturally competent care.11 Moreover, poor communication between providers and patients of different racial, ethnic, or cultural backgrounds contributes to health disparities, which are, in part, the result of a lack of healthcare providers who act in culturally and socially competent ways.1
From the classroom to the bedside, nursing faculty and nurse leaders have the responsibility to model unbiased attitudes toward all. Colleges, as well as healthcare organizations, need to set the expectation that providers have an obligation to meet the patient's needs regardless of whether the patient is of a diverse racial or cultural background with values, beliefs, and behaviors unlike that of the provider.
Opening up to diversity
In summary, it may have been an unrealistic expectation to think that racial health equity would be established once the nation voted President Obama into office. Although the stubborn stain of racial divide in healthcare outcomes remains, professional development among nursing faculty and clinical care nurse leaders should include the NCHL's list of leadership competencies. Organizational and institutional commitment to diversity rests with leadership. When the classroom or the clinical care area is poorly designed and doesn't meet the needs of diverse patient populations, organizational success is at risk. Leadership's ability to have an open mind toward diversity is essential. Starting with the education of nurse leaders, discussions regarding diversity, health disparities, and the role of cultural competence can't go unaddressed.
1. Pacquiao D. The relationship between cultural competence education and increasing diversity in nursing schools and practice settings. J Transcult Nurs
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2. Giger J, Davidhizar RE, Purnell L, Harden JT, Phillips J, Stickland O. American Academy of Nursing Expert Panel Report: developing cultural competence to eliminate health disparities in ethnic minorities and other vulnerable populations. J Transcultural Nurs
3. Fisher TL, Burnet DL, Huang ES, Chin MH, Cagney KA. Cultural leverage: interventions using culture to narrow racial disparities in health care. Med Care Res Rev
. 2007;64(5 suppl):243S–282S.
5. Dreachslin JL, Hobby F. Racial and ethnic disparities: why diversity leadership matters. J Healthc Manag
6. Beach MC, Saha S, Cooper LA. The role and relationship of cultural competence and patient-centeredness in health care quality. http://www.commonwealthfund.org/usr_doc/Beach_rolerelationshipcultcomppatient-cent_960.pdf
7. U.S. Department of Health and Human Services. The Rationale for Diversity in the Health Professions: A Review of the Evidence
. Washington, DC: Government Printing Office; 2006.
9. Bonaparte BH. Ego defensiveness, open-closed mindedness, and nurses' attitude toward culturally different patients. Nurs Res
10. Kontzamanis E. An investigation of the relationship between nursing faculty attitudes toward culturally diverse patients and transcultural self-efficacy. City University of New York, New York; 2013.
11. Carolan I, Smith T, Hall A, Swallow VM. Emerging communities of child-healthcare practice in the management of long-term conditions such as chronic kidney disease: qualitative study of parents' accounts. BMCHealth Serv Res