Diversity: A continuing challenge
by Susan Trossman, RN
The face of the nation's workforce continues to evolve into one of increasing diversity. Projections show white men comprising only 45 percent of the workforce by the year 2000, while women, people of color and immigrants will account for 80 percent of labor force growth, according to a 1996 report by the Center for Women Policy Studies.
Yet, hold a mirror up to the face of nursing, and you will see a different profile -- one that continues to be more monolithic than diverse. And as American society becomes ever-more varied, this lack of workforce diversity is potentially harmful to the profession and the population it serves.
Consider the results of the March 1996 National Sample Survey of Registered Nurses just released by the U.S. Department of Health and Human Services Division of Nursing. The survey shows that nearly 90 percent of the total RN population is white, compared to roughly 72 percent of the total U.S. population. (See graphic, "Distribution by Racial/Ethnic Group, March 1996" and "Survey of RNs shows strong opportunities in nursing".)
The need for nurses to deliver culturally competent and effective health care cannot be denied. When RNs don't fully understand cultural practices, the result can be longer patient stays, non-compliance with treatment and a loss of meaningful communication between patient and nurse. (See "Mental disorders and culture-bound syndromes," "Nurses need to strengthen cultural competence for next century," and "Working with the aging patient.")
Ensuring appropriate care to a changing population, as well as encouraging a workplace environment that allows a free exchange of ideas among co-workers of differing racial and ethnic backgrounds, can be achieved mainly in two ways, according to registered nurses concerned with this workforce issue. However, neither is quick or easy.
One solution is to increase the ranks of historically under-represented racial/ethnic groups; the other is to promote cultural understanding in the profession.
According to the RN sample survey, the RN minority population has nearly doubled from 1980 to 1996, but it still has not kept pace with the overall growth of the U.S. minority population.
"We as Hispanic nurses have grown by 10,000 in the last several years, but we represent only 1.6 percent of the RN population. That's nowhere near the growth of the Hispanic population," said Antonia Villarruel, PhD, RN, FAAN, president of the National Association of Hispanic Nurses (NAHN) and a Michigan Nurses Association member.
Barriers to diversity
Villarruel, who also is an assistant professor of nursing at the University of Pennsylvania, believes there are several barriers to increasing the ranks of Hispanic nurses. Hispanic teen-agers are the least likely of all racial/ethnic minorities to complete high school, she said. There also is a lack of successful role models who can talk about the many contributions Hispanic nurses have made to the community, which would help attract more people to the profession.
Nursing also fails to break down significant barriers. For example, "What kind of outreach do institutions have in place to recruit people of color?" Villarruel said. She also questioned admissions standards and the reputation some institutions have for making Hispanic students feel unwelcome.
Beatriz Miranda, MA, RNC, FAAN, echoed Villarruel's concerns about nursing truly embracing a culturally diverse workforce. "Statistically, you have your answer. Ninety percent of health care givers are Caucasian. I think that's a critical problem, especially when considering the browning' of America," said Miranda, past president of the Philippine Nurses Association of America and a New Jersey State Nurses Association (NJSNA) member.
She traced part of the difficulty of attracting culturally diverse students to faculty make-up. "You need to make an effort to recruit culturally diverse faculty, and nursing hasn't made that effort," Miranda said. Currently enrolled in an advanced practice registered nurse program, Miranda said she has not met a non-white faculty member.
This leads to a vicious cycle: Diverse faculty members are needed to recruit a varied student body. Diverse students need to get into the higher education system to assure a diverse faculty in the future.
Mary Koithan, PhD, CS, RN, is an assistant professor of nursing at the University of Nevada at Las Vegas. She said her university and others struggle to recruit more diverse faculty members. Of the 24 nursing faculty on board at UNLV, only one has minority status.
Koithan also acknowledged ongoing problems with graduate programs. "We are way too inflexible. We set up major roadblocks in front of potential minority students," she said. The barriers range from financial costs to teaching styles.
National Black Nurses Association President Betty Smith Williams, DrPH, RN, FAAN, also sees barriers to increasing African-American representation within nursing, but particularly at the advanced education levels.
The small number of master's- and doctoral-prepared nurses is indicative of a self-fulfilling prophecy, stated Williams, the first African-American nurse hired to teach at a California university and currently professor emeritus at California State University Long Beach. If people cannot see themselves in certain roles, they will not seek those roles, she said.
Williams described several ways to increase African-American representation in registered nursing. One is to improve access to quality secondary schools that have strong basic science programs vital to success in nursing. Another is to look at the current nursing community.
"There is a large pool of African-Americans who are in nursing. However, many are practicing as licensed vocational nurses (LVNs)," she said. The nursing profession should work to steer people from LVN and associate degree of nursing (ADN) programs and initially guide them instead to RN baccalaureate and advanced nursing programs, according to Williams. "We need to channel the best and the brightest into these programs so they can be assured of having solid career opportunities that will lead to further educational and career advancement."
She also stated that some African-American students who are heading for four-year colleges might view nursing as a more attractive profession if the minimum preparation for RNs was at the baccalaureate level.
Nursing leaders also expressed the need for continued encouragement, support and mentoring of young people within their community. Many minority nurses associations, which generally were founded because of a lack of support within the overall nursing community, are particularly adamant about employing these strategies.
Villarruel said each of the 32 NAHN chapters has some type of formal or informal mentoring activities. "Each of us feels a strong commitment to bringing up our youth," she said.
Most nurses probably would agree that the ideal approach to providing health care to a culturally diverse population is to have the same diversity within the RN workforce.
"I would like to see more emphasis placed on increasing the number of nurses who work with their specific (racial-ethnic) population," said Kem Louie, PhD, CS, FAAN, president of the Asian American Pacific Islanders Nurses Association.
As a second-generation Chinese-American, Louie believes she can better serve the health care needs of the Chinese-American population because she can relate to their health care beliefs and practices. However, just because she is Asian-American does not mean she can easily meet the needs of all who fall under the government's minority classification of "Asian American Pacific Islander." Within this category are 27 subgroups -- including Native Hawaiian, Chinese and East Indian -- and 75 to 100 languages, said Louie, a NJSNA member, as well as a professor and chair of the graduate nursing program at College of Mount St. Vincent in New York City.
Diane Downing, MSN, RN, also sees many advantages to having a culturally diverse workforce, including the important benefit of having workers who can speak a client's language. She and her staff deliver care to an incredibly diverse client population, which includes large numbers of Hispanics and Asian-American Pacific Islanders.
"Over and over again, the literature shows that, in terms of health care, people respond better to health care providers who share their cultural background," said Downing, a Virginia Nurses Association member and immediate past president of the Public Health Nursing Section of the American Public Health Association. And, she added, "it is important that schools of nursing attract a diverse student body, because if you study and work with folks from different backgrounds, then you begin to understand cultural patterns without having to practice on patients first."
Working within the workforce
Nurses interviewed also agreed that the next best alternative to increasing diversity in nursing is to increase cultural competency and sensitivity within the present workforce.
"Minority nurses have prejudices. Majority nurses have prejudices. These prejudices follow you to the patient's room, to the classroom and to your team work," said Carla Serlin, PhD, RN, director of ANA's Ethnic/Racial Minority Fellowship Programs. Unfortunately, the profession of nursing hasn't traditionally valued cultural competence within the body of knowledge nurses need to know, she said. And frequently, the information learned in nursing programs is not carried over to practice.
Louie sees taking the time to learn about the population a nurse serves as an ethical obligation. "If you don't know who your clients are, how can you build the nurse-patient relationship that is so vital to effective health care?" she said.
In terms of employee-targeted cultural diversity programs, Serlin described a common pitfall. "When employers do approach the topic, they often hold lunch-time presentations where people feel uncomfortable for a couple of hours and then go home and shake it off," she said. "Why assume people can learn and understand all about cultural differences in one lunch-time session, when people have a lifetime of ingrained values and beliefs?"
Serlin said she favors cultural diversity programs that provide for open dialogue over time -- an approach that she describes as "repeated inoculation." "We need to talk about cultural diversity, what it means to be different," said Louie, who also favors programs that promote ongoing dialogue. "But we should have venues to talk without fear of criticism. If I'm ignorant, I want to be told in a way that will teach me."
Susan Trossman, RN, is senior reporter for The American Nurse.