Growing the ranks of minority nurses

Growing up, Wallena Gould, now 52, wanted to be a nurse. But by the time she was 20, she was a mother on welfare and struggling to get her college degree at Fairleigh-Dickinson University in New Jersey.

Not having money for a car to travel to clinical training sites, “I ended up majoring in accounting,” Gould recalled. She took a job at a large accounting firm, but after a year, Gould, now married, told her husband that she wanted to go back to school to pursue her dream.

It took until 2002 before she earned her degree in nursing at Gloucester County College in Sewell, N.J. Her nursing career began in the operating room of Presbyterian Medical Center in Philadelphia, where she first experienced nurse-delivered anesthesia. “No one really talked about that type of advanced role,” she said.

Gould kicked up her aspirations another notch and went back to La Salle University to get the advanced degree required to become a certified registered nurse anesthetist, or CRNA, one of the highest paid positions in nursing. Despite living in a city that was two-thirds minority, Gould, who is African-American, was one of only a few minority students in La Salle's program. And “there was no minority faculty,” she said.

The fact that Gould, today a nurse anesthetist at Main Line Endoscopy Centers in Bala Cynwyd, Pa., found few people of color in her program reflects a reality that has plagued the nursing profession for decades. Of the estimated 3 million nurses currently active in the U.S., just less than 25% are racial or ethnic minorities, despite those groups making up 38% of the general population.

The gap is even wider among advanced practice registered nurses. About 13% of APRNs are from an ethnic or racial minority, according to a 2016 report from the National Academy of Medicine.

The nation's changing demographics—population experts predict the U.S. will become a majority “minority” nation by 2050—is putting greater pressure on hospital systems and physician practices to hire a more diverse nursing workforce.

Many view such efforts as key to reducing the large disparities in health outcomes plaguing ethnic and minority communities. Patients respond better when they receive “culturally competent care”—when caregivers meet the social, cultural and linguistic needs of their patients.

“The thing we know about ethnic diversity or cultural competency is that it will affect how much healthcare people access, as well as the quality of care that they get,” said Vernita Todd, senior vice president of external affairs for Health Center Partners of Southern California. HCP is a consortium of 17 community healthcare organizations serving more than 766,000 patients, of which more than 85% are uninsured or underinsured. “If you're talking to a provider and your first language is not English, and they have no one who can speak your language, how well are you going to comply with what a provider instructs you to do?”

While the absence of a culturally competent healthcare workforce has been recognized as a problem by healthcare professionals for at least the past two decades, the next decade will present a golden opportunity to address the issue. The nation will see rising demand for nurses as the oversized baby boom generation moves into its high healthcare years, while many of that generation's nurses will be leaving the workforce.

The Bureau of Labor Statistics projects there will be more than 1 million job openings for registered nurses over the next five years. About one-third of the current nurse workforce is age 50 and older, according to the Health Resources and Services Administration, and a significant portion are expected to retire over the next decade.

“Over half of us are retiring in the next three to five years,” said Lynne Reede, senior director of professional practice for the American Association of Nurse Anesthetists. “So we have to keep pulling in more folks who have interest and come from those underrepresented groups.”

While white women make up more than three-quarters of the nursing workforce, according to the HRSA, there has been some growth in minority trainees at the nation's nursing schools. Between 2006 and 2015, the proportion of minority students enrolled in bachelor's degree nursing programs rose from 25% to 32%, according to the American Association of Colleges of Nursing. The number of minority students in doctorate nursing degree programs climbed from 19% to 31% in that time.

But many say that better minority representation still falls far short in the nursing workforce. “On some level, we are getting the recruitment and the excitement correct,” said Stephanie DeKemper, associate director of government health solutions for global management consulting firm Navigant Consulting. “What we really need to do is focus on mentoring to make sure that we're getting enough of these students to matriculate through, and then fund and create mechanisms to expand the capacity at the university level so that we're getting even more of these students into the school of nursing.”

There certainly isn't a shortage of people looking to enter the profession. “There are more minority students applying for these positions in the school of nursing,” DeKemper said. “What has happened is that … there are not enough slots to accommodate these students.”

The surge in demand in recent years has forced many nursing school programs to turn away prospective candidates. During the 2014-15 school year, more than 68,000 qualified applicants were rejected by professional nursing programs because of a lack of clinical teaching sites and qualified faculty, limited class space and budget cuts, according to a 2015 survey of nursing schools by the AACN. Only 45% of 265,000 total applicants were accepted.

Some advocates say the stepped-up demand to get into nursing schools has led some programs to give short shrift to cultural diversity when making selections. “When you have a shortage mentality and you have limited capacity, that drives a whole bunch of other selection criteria that may or may not be sensitive to cultural or ethnic diversity as a priority in student admission criteria,” said Jan Jones-Schenk, national director for nursing at Western Governors University, an online school that offers both bachelor's and master's degrees in nursing.

Jones-Schenk said many programs rely primarily on high school grade point averages to screen prospective students. Using that limited criteria can overlook minority candidates who are capable of successfully completing the programs.

The ethnic and racial disparity has raised questions over whether changes should be made to nursing programs' selection process to increase the pool of qualified candidates.

Many schools begin their selection by looking primarily at candidates with the highest GPAs. While most experts agree that high grades in courses such as biology and English can be helpful predictors, views tend to vary as to how reliable a cumulative GPA can be toward identifying a successful student.

“There is no science that supports GPA as a measure of anything,” Jones-Schenk said. “I think the trap that we've all fallen into is thinking that GPA is a screen that we can safely use that's reliable, valid and consistent.”

A growing number of programs have changed their admission process to incorporate a more holistic approach as a way to diversify their student populations and find more qualified candidates. In addition to a student's GPA and test scores, they are assessed for other criteria such as life experience.

A 2014 study funded in part by HHS' National Institute on Minority Health and Health Disparities found that 67% of health professional schools had changed their admissions process over the past 10 years toward holistic admissions, which included more than 90% of medical and dental schools and 47% of nursing programs.

“If you use the academic attributes as your first screen, it's far too granular,” Jones-Schenk said. “You miss those really important attributes like connection to the community and diversity because you're looking at the wrong thing first.”

But the challenge to increase the number of minority nurses does not end with raising acceptance rates into nursing programs. Some of the same socio-economic factors that can limit the number of minority students in nursing programs can also negatively impact their performance while in school, which can lead to higher dropout rates among minority students, especially after the first year.

“In a lot of communities of color our educational system has not been up to par,” said Freida Outlaw, executive consultant for the American Nurses Association's Minority Fellowship Program. “There's a whole lot of work that goes into creating young people who can be in the pipeline in order to be educated in the way that they need to be educated to be successful in a nursing curriculum.”

Much in the same way diversity is seen as helping achieve health equity, Outlaw and others said creating greater diversity among nursing school educators offers students mentors and role models who can encourage them to complete their studies. According to the AACN, minorities make up only 12% of full-time nursing school faculty.

“They need to see and want to see and have a desire to see faculty that look like them,” said Karen Bankston, associate dean for clinical practice, partnership and community engagement at the University of Cincinnati's College of Nursing. “Even the brightest of students who come in with having had some advantages and exposure to good, sound education are often looking for someone who understands some of the idiosyncrasies that others may not understand.”