“Diversity is defined as individual attributes that extend beyond race, age, and gender, and also include, but are not limited to, characteristics such as national origin, immigrant status, language, color, disability, ethnicity, religion, sexual orientation, gender identity, socioeconomic status, veteran status, and family structures" [American Association of Colleges of Nursing (AACN), 2021]. Diversity highlights the vast differences among people while accentuating the similarities and intersectionality. How we are different; although we appear to be different, how are we alike, and what parts of diversity are hidden? “Inclusion is defined as a culture that encourages collaboration, flexibility, and fairness and leverages diversity so that all individuals can participate and contribute to their full potential" (AACN, 2021). How can we attain diversity of thoughts and actions? “Achieving health equity is when every person has the opportunity to reach their fullest health potential" [Centers for Disease Control (CDC), 2020]. How can we ensure all patients have access to the highest quality healthcare services? Diversity and inclusion must be present to attain health equity.
Health equity requires the delivery of culturally competent care that leads to ameliorating health disparities and inequities and improving outcomes. Culturally competent care is best delivered by healthcare providers who understand the significance of care individualization; are sensitive to the diverse cultural backgrounds of patients and their preferences; and assess and apply the social determinants of health, “conditions in the places where people live, learn, work, and play that affect a wide range of health and quality-of life-risks and outcomes" (CDC, 2021). Historical and current medical negligence and injustices experienced by underrepresented groups such as Black people have implications for the deterrence of seeking healthcare services. Thus, in some cases, patients tend to trust those who look like them. Access also serves as an impingement on the quality healthcare needs of those living in rural and underserved areas compounded by the inability to afford healthcare services.
Importance of diversity in the NP workforce
In the midst of the recommendations provided by the Institute of Medicine (IOM) Report, The Future of Nursing: Leading Change, Advancing Health, lay the critical need to increase diversity in the nursing workforce to improve access to quality, culturally competent, healthcare services, essentially leading to health equity. “NPs are recognized as expert healthcare providers who provide the highest quality of care" [American Association of Nurse Practitioners (AANP), 2021]. Maximizing the diversity of NPs while providing an inclusive environment to support the delivery of equitable care to all patients should be at the core of NP practice. “With more than 1.06 billion visits made to NPs each year" (AANP, 2021) and an increasingly diverse NP workforce, NPs have the ability to make a difference in diverse, rural, and underserved populations.
Strategies to increase diversity of NPs
The NP profession must continue to diversify until representation is adequate for the care of underrepresented groups (e.g., racial and ethnic minorities, socioeconomic disadvantaged backgrounds, men, etc.). Strategies for increasing the diversity of NPs begin with higher education institutions offering NP programs. “With projections pointing to minority populations becoming the majority, higher education institutions and prospective NPs must be educated to demonstrate a sensitivity to and understanding of a variety of cultures to provide high-quality care across settings" (AACN, 2020). The Health Resources and Services Administration (HRSA) Nursing Workforce Diversity (NWD) Grant provides an ideal model for increasing opportunities for individuals from disadvantaged backgrounds including racial and ethnic minorities using six evidence-based strategies for diversifying NPs in the workforce. These strategies are aimed at efforts to recruit, retain, and graduate students from underrepresented groups living in rural and underserved communities. Below are the HRSA (2021) strategies along with some examples:
- Holistic Review
- Creating institutional support for diversifying the admissions process and metrics to ensure the admittance of diverse, underrepresented students (e.g., racial and ethnic minority students) into institutions of higher education.
- Student Support Services
- Academic support (e.g., tutoring and writing support)
- Peer support
- Affinity groups
- Effective mentoring programs to support students' programmatic and professional goals
- Student Financial Support for the Social Determinants of Education
- Support for scholarly activities
- Recruitment and Retention of Faculty from Underrepresented Groups
- “Increasing racial and ethnic diversity among faculty in NP programs will enrich and strengthen education, practice, service, scholarship, and research" [National Organization of Nurse Practitioner Faculties (NONPF), 2018].
- Collaborative Partnerships
- Marketing and Public Relations (representing diversity, equity, and inclusion [DEI])
- Professional Organizations (diverse organizations that support underrepresented groups such as the National Black Nurses Association, National Association of Hispanic Nurses, and National Alaska Native American Indian Nurses Association)
- Creating pipeline programs with racial and ethnic minority universities such as historically black colleges and universities (HBCUs)
Other strategies include:
- Institutional Support
- Acknowledgement (Mission, Vision, Values, Strategic Goals)
- Policy and Practice Changes (e.g., mitigating bias)
- Accountability (e.g., employee evaluations)
- Providing community-wide education on DEI and racism
- Integrating the concepts of DEI and racism throughout the curriculum with a focus on health equity
Developing, implementing, and evaluating the outcomes of these evidenced-based strategies have proven effective in increasing the diversity of NPs in the workforce.
Decreasing racism within the healthcare system
Since the Civil Rights Movement of the 1960s, changes have occurred to improve the treatment of Black people; however, the underpinnings of systemic and structural racism are alive and well in the U.S. The year, 2020, bestowed upon us an undeniable reality check on the national impact of systemic and structural racism in the healthcare delivery system through the inequitable outcomes of the COVID-19 pandemic. As of March 17, 2021, the CDC reports “533,057 deaths in the U.S., 289,119 of which were reported by race. Of those 289,119 deaths in which the race was known, 14% of the victims were identified as Black, non-Hispanic." Although underrepresented in the U.S., Black people disproportionately lead the death toll rates as they suffer from existing socioeconomic hardships and the adversities brought on by the pandemic.
According to the U.S. Census Data (2018) and National Council of State Boards of Nursing (NCSBN) (2013) as cited in National League of Nursing (NLN) (2016) approximately 80% of registered nurses, NPs, and nurse-midwives in the U.S. are white, adequately addressing the race-related cultural competency of delivering healthcare services for White individuals, while people of color (e.g., Black and Native populations) are without adequate representation and access to quality healthcare. The health of people of color continues to deteriorate under the sheer auspices of care provided by a predominately white healthcare profession as seen with the COVID-19 pandemic, pregnancy outcomes, and the host of chronic illnesses and associated complications impacting their health and wellbeing. “Predictions reveal that by 2045, over half of the U.S. population will consist of minority populations" (U.S. Census Bureau, 2018). Increasing the diversity of the NP workforce is of utmost importance to reduce health disparities and inequities and improve outcomes to save lives in diverse, rural, and underserved communities. Ensuring all patients receive equitable healthcare should be at the core of nursing practice.
Geraldine Q.Young, DNP, APRN, FNPBC, CDE, FAANP is a National Organization of Nurse Practitioner Faculties (NONPF) Leadership Fellow, a Board Member at Large at NONPF, Chief Diversity and Inclusion Officer at Frontier Nursing University, Versailles, Ky., and Diverse Magazine Leading Woman in Higher Education.
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