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September 27, 2021 Readers Write No Comments

Achieving Health Equity through Improving Diversity in Nursing
By Karen E. Innocent, DNP, RN, CRNP

Karen E. Innocent, DNP, RN, CRNP is executive director of CE-CME for Wolters Kluwer, Health.


In meetings among nurse leaders, one of them expressed pride in only hiring nurses who have played contact sports, because nurses who were involved in sports were good “team players.” As the group praised that nurse executive’s selection criteria, I thought back to when I was growing up and remembered that my sisters and I didn’t play team sports. It was not by choice, but that my parents emphasized academic study and college preparation.

I jumped into the discussion and said that only hiring athletes could result in lack of diversity because everyone is not able to participate in contact sports. Some families value academic achievement, some may have financial limitations, and others may discourage sports because of gender norms in their cultures. We should all consider that teamwork and leadership skills can be acquired from non-athletic activities including having a part-time job, community service, or scouts.

Diversity is often associated with race, ethnicity, religion, gender, sexual identification, or disability. In addition, diversity could be viewed more broadly as political views, interests, hobbies, or lifestyle. Nurse leaders and other hiring managers in healthcare have the human tendency to hire employees who have similar characteristics as themselves. When there is homogeneity among workers, the employees have similar perspectives, beliefs, and behaviors. While this is not inherently bad, it does present a serious concern in healthcare. Creating a diverse healthcare workforce is an essential strategy for improving the quality of patient care.

Unconscious bias and structural racism have been linked to healthcare disparities. Variability in patient care can result from a lack of representation between those patients and the healthcare organizations serving them. Overwhelming evidence points to the benefits of hiring healthcare workers in proportion to the diversity represented in the communities they serve. 

Since the Institute of Medicine report “Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care” was published in 2003, healthcare leaders have recommended increasing the diversity among healthcare professionals. The landmark report synthesized decades of research and concluded that racism, discrimination, and lack of awareness of cultural needs of the patient population resulted in poor health outcomes among various underrepresented ethnicities and sexual orientations. Research in the same report demonstrated that physicians of similar ethnic groups as the population had better patient outcomes.

More recently, a United States study from 1992 to 2015 that controlled for socioeconomic status, age, education, and comorbidities found significantly higher mortality in black infants regardless of maternal risk factors (Greenwood,  Hardeman,  Huang, Sojourner, 2020). The authors recommend increasing diversity among nurses and physicians to reduce health disparities.  Patients experience better outcomes with healthcare professionals of the same race, and experience other benefits such as improved communication, empathy with the needs of the community, and development of appropriate interventions and care plans.

Achieving diversity is a process. In order to effect significant change, healthcare leaders must commit to addressing root causes that result in a lack of diversity, including outdated hiring practices and barriers to admission into schools of nursing.  Diversity experts recommend that employers target their recruitment efforts at networks including Black, Hispanic, and Asian & Pacific Islander nursing organizations, community organizations, and online social networks. They recommend improvements in the hiring process to avoid unconscious bias in the hiring decisions. 

Regarding nursing school admissions, many qualified nursing school applicants – including those of underrepresented groups – are turned away because of inadequate nursing faculty. Other barriers include inability to afford tuition and uninformed high school guidance counselors. According to the American Association of Colleges of Nursing, there are more than 80,000 qualified nursing school applicants turned away annually because of faculty shortages (AACN, 2021). As baby boomers are retiring, there are insufficient faculty to fill open positions. Low faculty salaries, lack of awareness of teaching opportunities, and lack of preparation in nursing education need to be resolved to fill this growing void.

Many students who meet academic requirements come from low-income households. They require scholarships and grants to attend nursing school. However, there is difficulty connecting these disadvantaged students with financial aid. Several research studies indicate that high school counselors are unaware of the demand for nurses, the academic requirements, and financial aid available to students. Lack of awareness and misinformation results in qualified students lacking guidance to pursue nursing as a career (Williams & Dickstein-Fischer, 2019).  More should be done to ensure that there is information and access in underrepresented communities to create a pipeline of diverse high school students to enter the healthcare profession. 

Perhaps the presence of healthcare workers who reflect the diversity of the community will not be enough. Therefore, all employees with patient interaction should have continuing professional development on diversity, equity, and inclusion principles and social determinants of health to facilitate delivery of equitable treatment. To build patient trust, there should be hotlines established to enable reporting of observed or suspected discrimination or inequitable care. Because we can’t fix what we don’t measure, health systems should track quality improvement metrics related to equitable delivery of care and implement action plans to help achieve their goals.

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