Increasing Racial Workforce Diversity in Nursing to Minimize Health Care Disparities

Health care organizations face challenges with the initiative to increase racial diversity within the nursing workforce. Despite efforts to diversify, the 2018 Bureau of Labor and Statistics showed that amongst 3.2 million registered nurses in the United States (U.S.), 75.5% are whites, 13.1 % are Black or African- American, 9% Asian and only 7.2% are Hispanic or Latino. In contrary, more than half of all Americans are projected to belong to a minority group by 2044 and foreign-born population depicts an estimated increase from 2.5 million in 2014 to around 3.3 million in 2060 (Colby & Ortman, 2015). The Hispanic population is expected to grow over the next years and the number is projected to exceed the numbers of Whites in the country. The current shift in the nation’s demographic calls for the need to recruit and retain a racially diverse workforce that reflects the country’s population change.

Disparities in healthcare are well documented between majority, and racial minority and underserved populations (HRSA, 2017; Phillips & Malone, 2014; Snyder, Stover, Skillman & Frogner, 2015). Findings from the 2017 Health Equity Report by the U.S. Department of Health and Human Services (DHHS), and Health Resources and Services Administration (HRSA) described that ethnic-minority groups are more likely to live in disadvantaged and low-income neighborhoods than their non-Hispanic white counterparts. As a result, minority groups have increased likelihood to be uninsured.

Racial and ethnic diversity among healthcare professionals has been reported to somewhat improve underserved and minorities population healthcare outcomes, and increase their access to care (HRSA, 2017; Phillips & Malone, 2014; Snyder, Stover, Skillman & Frogner, 2015). There are numerous nursing studies that elucidated on strategies and outcomes of improving health partiality. While healthcare access and outcomes are slowly improving with the inception of the 2010 Institute of Medicine Future of Nursing recommendation to increase diversity in nursing workforce, minority nurses remain underrepresented (Phillips & Malone, 2014). There is a heightened need to diversify nursing workforce at all levels – education, all healthcare practice, and nursing research. Thus far, improving racial healthcare outcome disparity by increasing nursing workforce diversity remains a significant healthcare issue.  The purpose of this paper is to examine nursing workforce diversity and its impact in the nation’s healthcare disparity.

Racial Minority Healthcare Disparity

U.S. federal guidelines defined racial minority as Black not of Hispanic origin, Hispanic, Asian or Pacific Islander, and American Indian or Alaskan Native (Federal Guidelines for Definition as a Minority, 2013). Data suggest that albeit the attempt to improve healthcare outcomes and reduce health care disparities, racial health inequality persist (Mathews, MacDorman, & Thoma, 2015).

One of the widely used indicator of the country’s health is the rate of infant mortality and the priority is to achieve better pregnancy outcomes for women and children’s health. In 2013, the U.S. infant mortality rate (IMR) was 11.11 in infants born to non- Hispanic black mothers which is twice the rate of offspring from non- Hispanic white at 5.06. Similarly, data from HRSA demonstrated that 20.7% of American Indians/Alaska Natives, 19.5% of Hispanics, 11.0% of blacks, 9.9% of Native Hawaiians and other Pacific Islanders, and 7.8% of Asians lacked medical insurance (2017).

Disparities in health care is an endless saga in the nation. Quality of care, population health and health care cost are impacted with the presence of disparities (Artiga, Foutz, Cornachione, & Garfield, 2018). There are various initiatives to address healthcare disparity which includes the passage of Affordable Care Act (ACA). ACA was implemented in 2013, the aim is to include provisions that advance efforts to reduce disparities and in 2014 number of uninsured people was reduced by over 10 million (Artiga et. Al, 2018). Inspite, coverage gains under the ACA, non-elderly Hispanics, Blacks, American Indians and Alaska Natives remain significantly more likely uninsured than Whites. In effect, disease burden associated with the disadvantaged groups and growth of minority to become the majority requires an increase demand of more than 776,400 nurses reported by HRSA (2017). However, Phillips and Malone in 2014 elaborated that decreasing healthcare disparities among racial minorities by increasing nursing workforce diversity was an unspoken assumption (p.48). An exploration is warranted whether a racially diverse nursing workforce will reduce healthcare disparities among minorities.

Impact of Increasing Nursing Workforce Diversity

Nursing Workforce Diversity Ethical Concept

The Future of Nursing Report emphasized the importance to develop strategies in increasing the diversity of the nursing workforce in terms of race/ethnicity, gender, and geographic distribution. Influence of a nursing workforce reflects the population demographics will lead to improve treatment and provides a better understanding of a person’s emotional health and well-being (Future of Nursing Campaign for Action, 2016). Increasing nursing workforce diversity is in alignment with the nurse’s code of ethics.  

Provision nine of the Nurse’s Code of Ethics pertains to social justice and was defined as reaching out to a world in need of nursing. Nurses must take action to influence non-governmental organizations, international bodies, leaders, legislators and governmental agencies in matters of healthcare by addressing the social determinants of health and reaching the increasing number of minorities and disadvantaged patient population (Fowler, 2015). The need for racially diverse nursing workforce encompasses the ethical principle of Justice which refers to an equal and fair distribution of resources, based on analysis of benefits and decision burden (American Nurses Association, 2016).

Increasing diversity in nursing workforce exemplifies a concept in the ANA Nursing Code of Ethics that a professional nurse should have broad social vision. Socially envisioned nurse will have a sympathetic understanding of different creeds, nationalities and races, and will not permit personal attitude towards various groups to interfere with her function as a nurse. The code accounts for respect for persons and exclusion of unjust discrimination beyond patients to include colleagues, students, and all with whom the nurse comes in contact (Fowler, 2015).

Legislation in Increasing Nursing Workforce Diversity

Affordable Care Act included many provisions that reauthorized the health professions education and training programs under the Title VIII of the Public Health Service Act (PHS). The PHS Act provides the largest source of federal funding grants for nursing education, by offering financial support for organizations to advance their educational programs, promote diversity in the field, and repay loans for nursing students who work in facilities with critical shortages (Congress, 2015). Essentially, the act offers opportunities for individuals who are from disadvantaged backgrounds, students from economically disadvantaged families and racial and ethnic minorities who are underrepresented in the nursing profession (American Nurses Association, 2016).

Funding plays a critical role in recruiting the next generation of nurses and addressing the faculty shortages facing the profession (Fowler, 2015). The PHS act funding will expire by 2020. In response, representative David Joyce introduced House of Representative (H.R.) 728 bill – Nursing workforce Reauthorization Act of 2019. The bill amends title VIII of the PHS act and extend funding towards advanced education nursing grants in support to clinical nurse specialist programs, and for other purposes including section four provision which is to increase nursing workforce diversity (Congress, 2019). H.R. 728 legislation needed collective action of healthcare workers with the nurses in the forefront to lobby and promote advancement of the bill to enact into law.

Implementing diversity action plans and other programs aimed to increase racial and ethnic diversity within the nursing workforce is important (Mason, Gardner, Outlaw, & O’Grady, 2016). Diversifying the nursing workforce entails a quantifiable strategic plan. For instance, increasing programs and resources for minority nurses and students suggested by Phillips & Malone (2018) should incorporate creating and disseminating evaluation metrics and measures that assess the contributions of a diverse workforce towards eliminating health disparities (p.49). 

Racial Nursing Workforce Diversity in Nursing Education

The objectives were to increase the number of Hispanic students, recruit the project for the autumn semester Hispanic pre-nursing students, increase the number of Hispanic students to complete the nursing program, and improve cultural competency to increase awareness and understanding of cultural diversity.  A few of the activities involved tasks such as tutoring in all subjects, nursing exam review sessions, summer externships, recruitment sessions at high schools, one-to-one nursing student mentoring and coaching by the project coordinator, financial help, and regular discussions concerning challenges (Georges, 2012).

Prior to the implementation of the project, there were only four Hispanic students admitted to the nursing program. After three years when the project completed, the outcomes resulted with 31 students enrolled and all successfully completed the BSN program. In addition, ten 10 students haved completed an MSN program. The results demonstrated that the activities and tools were effective in achieving the objectives. The ethnicity of the co-coordinator and the project director were crucial to the accomplishments of the project because students could communicate with them in Spanish. However, the lack of funding to sustain the project were depleted. Despite the challenges, the department of nursing remains committed to increasing the number of Hispanic student enrollment (Georges, 2012). Federal funding could help continue the project and increase racial and ethnic diversity in the nursing workforce. A diverse group of nurses or teachers have a competitive advantage with a unique set of skills, experiences, and perspectives.

Racial Nursing Workforce Diversity in all Health Care Practice

The nursing profession exists to serve all patients, regardless of their cultural, racial, or ethnic background which leads to the value of creating a more diverse workforce. Research has suggested that patients prefer care from a member of the same race or ethnicity (Flores & Combs, 2013). The unique, positive interpersonal relationship acquired from a diverse nursing workforce increases both patient and employee satisfaction.

 Research studies have demonstrated positive outcomes from having a racial and ethnic diverse nursing workforce. One research study wanted to investigated which types of diversity were associated with which outcomes within the context of nursing. The purpose of the study was to examine the influence of age, gender, education, race/ethnicity, and perceived value diversity on nurse job satisfaction, nurse intent to stay, and patient satisfaction. The sample included 2,900 patients and 6,500 RNs from acute care hospitals. The data were collected from survey questionnaires over a six-month period. The results of the study confirmed a positive relationship between race/ethnicity diversity and nurse job satisfaction as well as age diversity and intent to stay. The findings of the research study supported and suggested that policy initiatives focusing on nursing’s racial diversity should continue (Gates & Mark, 2012). The study is an example illustrating how important racial and ethnic diversity action plans are worth funding. Financial resources could help nurses change their environment, recruit an RN workforce from minority backgrounds and improve quality of care. The nursing workforce must reflect the diversity of the population it serves.

Furthermore, goals to increase minority representation in the APRN and nurse leadership population is important. Nurses seeking funds for a higher level of education should be able to prove how their organizational outcomes resulted in exc

ellence, due to the compassionate and hardworking front line bedside nurses providing care. These nurses should be awarded funding for education for their successes and contribution to improved patient outcomes.

Racial Nursing Workforce Diversity in Nursing Research

Nursing Workforce Diversity Caveat

The initiative to increase racial and ethnic diversity is one aspect for addressing the nursing shortage. Although, the Affordable Care Act emphasized on maintaining health status and preventing acute health crisis, it is too early to determine whether new care delivery models such as nurses taking on new roles in prevention, would even contribute to a new growth in demand for nurses (U.S. Department of Health and Human Services, 2014).

Conclusion

Initiatives to increase racial and ethnic diversity in the nursing workforce is an ongoing challenge. The assessment and evaluation of the initiatives must go beyond monitoring and reporting participation as performance measure; evaluations should focus on the mission and goals of the program in enhancing the diversity of the health workforce at all levels and to reduce health care disparities. It is important to note that programs need to be tailored to specific populations and context (Snyder, Stover, Skillman, & Frogner, (2015).

The goal of eliminating health care disparities, will not be achieved without the engagement of racial minority nurses as reflected in the passage of ACA. It is critically important to secure diversification of nursing workforce, funding should be provided, and policies to attain such goal should be created and supported. What remained valuable is a strategic plan to attract, retain and mentor minority nurses. The entire health care institution from education to all health care practice areas and research should collaboratively work together to achieve a common goal. With a collective voice, nurses could ask representatives to cosponsor the Nursing Workforce Reauthorization Act (H.R. 728) and urge Congress to have fundings remains available for nurses. Greater diversity in the health workforce is critical to improve health care delivery for an increasingly diverse population. Investments in health professions training programs that promote inclusion of students from all racial and ethnic backgrounds are critical for diversifying the workforce, and these investments need to continue. Funding resources is important in recruiting the next generation of nurses, however there are other critical health care investments in other areas that need to be considered.

The U.S. population diversification is apparent, and the nursing workforce is expected to reflect those changes in order to meet the needs of the patient and improve quality care (Mason et al., 2016). Empowering and mentoring minority nurses to assume leadership position could facilitate attracting a more diverse workforce. Initiatives to increase nursing workforce diversity should remain a high priority in an effort to curb healthcare disparities. Overall, nurses could work collectively through political action groups and reshape areas of healthcare policy and legislation.

References 

• American Nurses Association. (2016). Funding for nursing workforce development. Retrieved from http://nursingworld.org/DocumentVault/GOVA/Federal/Federal-Issues/NursingWorkforceDevelopment.html
• Artiga, S., Foutz, J., Cornachione, E., & Garfield, R. (2018, June 14). Key Facts on Health and Health Care by Race and Ethnicity. Retrieved April 30, 2019, from https://www.kff.org/disparities-policy/report/key-facts-on-health-and-health-care-by-race-and-ethnicity/

• Association of American Colleges. (2016). Title VII and title VIII reauthorization. Retrieved  from https://www.aamc.org/advocacy/budget/healthprof/150298/t7reauthorization.html
• Colby, S. L., & Ortman, J. M. (2015, March). Projections of the size and composition of the U.S. population: 2014 to 2060. Retrieved from https://www.census.gov/content/dam/Census/library/publications/2015/demo/p25-1143.pdf
• Congress. (2015, June). Title VII of the public service act. Retrieved from https://www.congress.gov/114/bills/hr2713/BILLS-114hr2713ih.pdf
• Bureau of Labor and Statistics (2019). Employed persons by detailed occupation, sex, race, and Hispanic or Latino ethnicity in 2018. Retrieved April 29, 2019, from https://www.bls.gov/cps/cpsaat11.htm
• Federal Guidelines for Definition as a Minority. (2013). Retrieved April 29, 2019, from http://grfx.cstv.com/photos/schools/nacda/sports/moaa/auto_pdf/2013-14/misc_non_event/FederalDefinitionofMinority.pdf
• Flores, K., & Combs, G. (2013). Minority representation in healthcare: Increasing the number of professionals through focused recruitment. Hospital Topics, 91(2), 25-36. doi:10.1080/00185868.2013.793556
• Fowler, M. D. (2015). Guide to the code of ethics for nurses with interpretive statements: Development, interpretation, and application (2nd ed.). Silver Spring, MD: Nursebooks.org.
• Future of Nursing Campaign for Action. (2016). Institute of medicine the future of nursing: Leading change, advancing health recommendations related to diversity. Retrieved from http://campaignforaction.org/wp-content/uploads/2016/04/IOM-Diversity-Recommendations3.pdf
• Gates, M. G., & Mark, B. A. (2012). Demographic diversity, value congruence, and workplace outcomes in acute care. Research In Nursing & Health, 35(3), 265-276. doi:10.1002/nur.21467
• Georges, C. (2012). Project to expand diversity in the nursing workforce. Nursing Management – UK, 19(2), 22-26.
• Health Resources and Services Administration. (2017). The future of the nursing workforce: National and state level projections, 2014-2030. Retrieved from https://bhw.hrsa.gov/sites/default/files/bhw/nchwa/projections/NCHWA_HRSA_Nursing_Report.pdf
• Health Resources and Services Administration. (2017). Health Equity Report 2017. Retrieved from https://www.hrsa.gov/sites/default/files/hrsa/health-equity/2017-HRSA-health-equity-report.pdf
• Mason, D. J., Gardner, D. B., Outlaw, F. H., & O’Grady, E. T. (2016). Policy & politics in nursing and health care.(7^th edition) St. Louis, MO: Elsevier.
• Mathews, T. J., MacDorman, M. F., & Thoma, M. E. (2015). Infant Mortality Statistics From the 2013 Period Linked Birth/Infant Death Data Set. Retrieved April 29, 2019, from https://www.cdc.gov/nchs/nvss/linked-birth.htm
• Morbidity and Mortality Weekly Report (MMWR). (2019, April 29). Retrieved from https://www.cdc.gov/mmwr/index.html
• Phillips, J. M., & Malone, B. (2014). Increasing Racial/Ethnic Diversity in Nursing to Reduce Health Disparities and Achieve Health Equity. Public Health Reports,129(1_suppl2), 45-50. doi:10.1177/00333549141291s209
• Snyder, C. R., Stover, B., Skillman, S. M., & Frogner, B. K. (2015, July). Facilitating Racial and Ethnic Diversity in the Health Workforce. Retrieved April 29, 2019, from http://depts.washington.edu/uwrhrc/uploads/FINALREPORT_Facilitating Diversity in the Health Workforce_7.8.2015.pdf