The importance of diversity in nursing
Workforce diversity is a hot topic in nearly every industry and nursing is no different. Due to the hands-on, sensitive nature of working in the healthcare industry, enhancing diversity in nursing is especially critical for establishing quality healthcare for all patient populations among the 333 million United States residents estimated by the census bureau.1
Nurses who understand the varying needs of this population whether through education or personal experience, are likely to be able to provide better . National nursing organizations including the National Academy of Medicine (NAM), the American Association of Colleges of Nursing, the federal Bureau of Health Workforce hospital associations and other leading healthcare organizations agree that recruitment of underrepresented groups into nursing is a priority for the profession.2,3
Understanding the role of diversity in healthcare through social determinants of health
For the sake of this article, diversity refers to a wide range of characteristics including age, race, gender identity, sexual orientation, family structure, geographic location, national origin, immigrant or refugee status, education status, veteran status, language of preference, physical, functional, and cognitive abilities, socioeconomic status, religious beliefs, and more.
In the world of healthcare, the aforementioned conditions and identifiers are known as the social determinants of health. At a macro level, these can be grouped into five segments: economic stability, education access and quality, healthcare access and quality, neighborhood and built environment, and social and community context.4 All of these identifiers can have an effect on how patients seek out, receive and overall experience the healthcare system. All of these identifiers can have an effect on how patients seek out, receive and overall experience the healthcare system.
For example, many underserved neighborhoods lack access to well-stocked grocery stores and pharmacies and may have more people relying on public transportation to get around rather than cars. A nurse who doesn't take these factors into mind when providing the patient with care instructions could be setting them up for failure if their recommendations include frequent medication pickups from a faraway pharmacy. On a more personal level, a patient's culture might have restrictions on the level of interaction between sexes. A nurse might pull in a colleague to treat the patient instead to make the patient feel more comfortable and more likely to disclose information about their health.
While lack of grocery stores or public transportation is a structural issue out of the direct control of healthcare providers, being conscious of barriers such as those is critical to achieving health equity for all patient populations.
The current state of diversity in the nursing workforce
Every two years the National Council of State Boards of Nursing (NCSBN) and National Forum of State Nursing Workforce Centers conducts the National Nursing Workforce Survey, the only survey of its kind, that's focused on gathering information about the entire U.S. nursing workforce. The most recent survey results, from a survey conducted in 2020 and published in early 2021, provide a detailed look at many aspects of the nursing field including levels of education, race and ethnicity, gender, age and more.5 While the survey includes responses by registered nurses (RNs), licensed practical nurses (LPNs) and licensed vocational nurses (LVNs), for this article we will focus solely on the RN results.
Nursing diversity by the numbers
According to the NCSBN survey responses, nearly 81% of RNs reported being white/Caucasian leaving 19% of the workforce made up of minority nurses. Responses to the survey indicate that 7.2% of the group identifies as Asian, 6.7% identify as Black or African American, 5.6% reporting as Hispanic or Latinx, 2.1% identifying as biracial and less than 1% as either Native Hawaiian/Pacific Islander or American Indian/Alaskan Native.5
While both white and Asian races are overrepresented in nursing compared to the general population, there are fewer than half as many Black or African American nurses as there are in the population, and 13.3% fewer Hispanic or Latinx nurses compared to the general population.1
Further underrepresentation in nursing can be found in the ratio of those who identify as male nurses compared to female nurses. In the U.S. population, men and women are nearly equally represented at 50%,1 but within the nursing profession, only about 10% of nurses are male.5
One aspect of diversity in nursing that's underreported on is the number of Lesbian, Gay, Bisexual, Transgender, Queer and Intersex and other (LGBTQI+) identifying nurses within the profession. This gap is important to acknowledge because of the persistently common health disparities encountered by the group. According to the Center for American Progress, more than 1 in 5 LGBTQI+ adults reported postponing or avoiding medical care in 2021 due to disrespect or discrimination by providers, including 1 in 3 transgender or nonbinary individuals.6
As the healthcare workforce works to address health inequities and build a culturally diverse workforce, it's imperative that all of these statistics are taken into account to better understand how they can improve patient outcomes across the board.
The benefits of a diverse nursing workforce
Created by the National Academy of Medicine (NAM) with sponsorship from the Robert Wood Johnson Foundation, The Future of Nursing 2020-2030 presents a set of recommendations to strengthen the capacity, education, and critical role of the nursing workforce.5 This third edition of the Future of Nursing report (the other two published in 2011 and 2016) focuses heavily on the relationship between the social determinants of health and health outcomes as well as an emphasis on nursing education, wellness and , with a vision to achieve health equity in the United States. As the report states, "Health equity benefits everyone through, for example, economic growth, a healthier environment, and national security."5
More concretely illustrated by research published in the Journal of the National Medical Association in 2019, a more diverse healthcare workforce is linked to improved patient care quality and cost savings. While more research should be done as efforts persist, studies have found that greater diversity in health organizations can improve the accuracy of clinical decision-making which in turn has a positive effect on patient satisfaction and health outcomes. Interestingly, there has yet to be research that points to direct improvement from concordance between patients and primary providers, and instead, showed that patients fare better as the result of more diverse teams.7
One study, published in 2022 in the American Journal of Obstetrics and Gynecology Maternal-Fetal Medicine, found that a more diversity in nursing staff may improve maternal health outcomes. The study found that mothers giving birth in states with the highest level of diversity in nursing workforce was associated with a 20% reduced risk of severe outcomes for Black mothers, a 31% lower risk for Hispanic mothers, and a 50% reduction for Asian and Pacific Islander mothers. Further, diverse workforces also demonstrated a 32% reduction in risk for white mothers.8
The importance of healthcare professionals who spoke the same language as their patient populations was illustrated by another study. The results of this research, conducted in Ontario, Canada in 2022, found that patients who received language-concordant physician care were less likely to have adverse events, more likely to have shorter hospital stays and less likely to die in hospital when compared with their counterparts who received language-discordant care.9 While the study was specifically looking at physician language, it can likely be inferred that all healthcare providers with diverse language skills can contribute to improved outcomes.
Overcoming barriers to enhance diversity in nursing
One of the primary challenges identified in the Future of Nursing 2020-2030 report is ensuring a diverse nursing workforce that's prepared to address social determinants of health and improve patient outcomes. The methods to achieve these goals come from two different approaches: recruiting more minority nurses to the field and preparing nurses with the cultural competency needed to properly care for increasingly diverse patient populations.
Changes in nursing education
The American Association of Colleges of Nursing (AACN) has issued a position statement with recommendations on how to improve nursing education to increase diversity in nursing and prepare nursing students to appropriately care for diverse patient populations:10
1. Improve the quality of education by enhancing the capacity of academic nursing to maximize learning opportunities and experiences for students and faculty, alike, which depend in significant ways on learning from individuals with diverse life experiences, perspectives, and backgrounds.
2. Address pervasive inequities in healthcare by ensuring the preparation of nurses and other healthcare professionals able to meet the needs of all individuals in an increasingly diverse American society.
3. Enhance the civic readiness and engagement potential of nursing students who will be in positions of leadership in healthcare, as well as in society, more broadly.
Another push happening within nursing education is to increase the number of nurses with higher-level nursing degrees including Bachelor of Science in Nursing (BSN) degrees and Master of Science in Nursing (MSN) degrees. 11 and it's likely that returning to school and learning contemporary updates to nursing practices would help increase the cultural competency of nurses in the field.
Become an advocate for diversity and health equity in the nursing profession
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Sources
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