lll, Issues Related to Diversity in Nursing
Education and Practice

Education
Increasing recruitment, retention and graduation

‘The underrepresentation of minorities in nursing education perpetu-
ates the underrepresentation of minorities in the nursing workforce. Thus,
the nursing education system is the starting point for addressing the issue
of increasing diversity in the nursing workforce. Lack of significant in-
creases in the number of racial/ethnic minority nurses suggests that there
is a chronic lack of access to educational opportunities. Minorities have
historically been under represented in schools of nursing as they have
been in most health professions schools. The production of racial/ethnic
minority nurses increased somewhat from the early to mid 1990s, The
number of racial/ethnic minority graduates from basic nursing education
programs increased from 9,548 to 13,394 for the period from 1990-91 through
1995-96 but their representation among all graduates only increased one
percentage point-from 13.2 percent to 14.2 percent (National League for
Nursing, 1997). More recent data indicate that only 16 percent of newly
licensed RNs in 1998 were racial/ethnic minorities (National Council of
State Boards of Nursing, 1999).

Short term recruitment and retention programs funded by the Federal
government and other organizations, while necessary and usctul, have not
been sufficient to fundamentally alter the historical pattern of minority
underrepresentation in nursing education. Nursing programs currently gradu-
ate only about one-half of the number of minonty students needed to reflect
the diversity of the general population. Clearly, continuation of this trend will
‘not result in the growth in the number of minority RNs necessary to achieve
the desired diversity of the nursing workforce. Substantial improvements in
admissions and graduations are necessary 10 bring about the necessary in-
creases. This is especially true since the growing diversity of the U.S. popu-
lation is projected to continve well into the 21st century. Moreover, current
levels of underrepresentution have implications for the ability to “catch up.”
It has been estimated that an increase of more than 20,000 in the number of
minority nurses is needed in order to increase the proportion of minority
nurses by just | percent (Stanley, 1995).

There are few studies in the literature and little data documenting and
describing the barriers and factors that have impeded substantial growth in
the numbers of minority enrollments and graduations from nursing programs
for specific raciaVethnic minority groups. In addition, there are no system-
atic and comprehensive data on the source and composition of the minority
applicant pool for nursing programs or on the rates at which minority stu-
dents complete or drop out of their nursing education programs. The multiple
routes of entry into nursing education contribute to the difficulty of collect-
ing and assessing such data in a comprehensive manner, Nonetheless, such

NATIONAL ADVISORY COUNCIL ON NURSE EDUCATION AND PRACTICE


Kass BL, Weinick RM, Monheit AC. Racial and ethnic differences in
health, 1996. Rockville (MD): Agency for Health Care Policy and Re-
search; 1999. MEPS Chartbook No. 2. AHCPR Pub. No, 99-0001.

Mayberry, LJ, Affonso, DD, Shibuya, J, Clemmens, D, “Integrating Cul-
tural Values, Beliefs, and Customs into Pregnancy and Postpartum Care:
Lessons Learned from a Hawaiian Public Health Nursing Project,” J
Perinat Neonat Nurs 1999; 13(1): 15-26.

Meadows, M., “Moving Toward Consensus on Cultural Competency in
Health Care” in Closing the Gap. U.S, Department of Health and Human
Services, Office of Minority Health. January 2000.

Minnick, A., Roberts, MJ, Young, WB, Marcantonio, R., and Klcinpell,
RM, “Ethnic Diversity and Staff Nurse Employment in Hospitals,” Nurs-
ing Outlook 1997, 4535-40.

National Advisory Council on Nurse Education and Practice, Report to
the Secretary af the Department of Health and Human Services on the
Basic Registered Nurse Workforce. 1996,

National Association of Hispanic Nurses, “Bridges and Barriers: Educa-
tional Mobility of Hispanic Nurses,” prepared under contract for the
Division of Nursing, Bureau of Health Professions, Health Resources
and Services Administration, Mar. 1998.

National Council of State Boards of Nursing. “Demographic Data” Newly
Licensed Registered and Licensed Practical/Vocational Nurses, 1996,
1997.

National League for Nursing, Nursing Datasource, 1997,Volume 1,
Trends in Contemporary Nursing Education, Division of Research, New
York, NY, 1997,

Ross-Lee, B. “Social, Cultural, and Economic Barriers to Becoming Fac-
ulty" in Minority Faculty in the Health Professions for the 21" Century-
Selected Proceeding, Sept., 1995.

Schmieding, NJ, “A Novel Approach to Recruitment, Retention, and Ad-
vancement of Minority Nurses in a Health Care Organization,” Nursing
Administration Quarterly, 1991, (15) 4, 69-76.

Stanley, J, “Analysis of Subtteties in the Health Professions Environ-
ment—Progression Academia (Nursing), Minority Faculty in the Health
Professions for the 21° Century Selected Proceedings, Sept, 1995

U.S, Department of Commerce, Bureau of Census, “Population Projec-
tions of the United States by Age, Sex, Race, and Hispanic Origin, 1995-
2050, Current Population Reports. Series P25~1130,

U.S. Department of Health and Human Services, Health Resources Ad-
ministration. Recruitment and Training of Minority Populations for Nurs-
ing: A Retrospective Study of a Federal Program, Developed by JWK
International under Contract No. 232-78-0172, 1979,

28

NATIONAL ADVISORY COUNCIL ON NURSE EDUCATION AND PRACTICE


Policy Goal: To create and maintain workplace environments and em-

ployee support programs that promote and document recruitment, reten-
tion, and advancement of minority nurses,

Action Items:

* — Identify, gather, analyze, and disseminate information on successful
workplace interventions to recruit, retain, and advance minor-
ity nurses,

* — Identify and disseminate information on successful workplace
interventions to manage diversity issues in the practice environ:
ment,

* Conduct pilot projects to identify successful strategies and dis-
seminate results.

* Mobilize national organizations, accrediting bodies, and legisla
tures to enact policies on diversity in the workplace.

* Develop academic partnerships with hospitals and community-
based organizations to support career development.

Issue: There is limited research documenting the benefits of a diverse
nursing workforce on access to care, outcomes of care, and cost,

Diversity in the workforce is an essential element to improving access to
care, patient care outcome, and reducing health care coxts. In order to
expand the body of knowledge and empirical evidence on the benefits
improving diversity in the workforce there is a need for more research
that explores and documents the relationships between increasing nurs:
ing workforce diversity and improving access to and outcomes of care.

Policy Goal: To document the effects and benefits of a culturally diverse
nursing workforce in regards to access to care, outcomes of care, and
cost.

Action Items:

* Collect and analyze data regarding the relationship between the
provision of care by minority nurses and outcomes of health care
for minority patients,

* Conduct pilot projects that demonstrate partnerships between
the community and minority nurses for addressing minority health.

Issue: Nurses are unprepared to serve the growing culturally diverse
population.

‘The increasingly culturally diverse population poses new challenges for
the nursing profession. These challenges range from the preparation of a
sensitively prepared and culturally diverse workforce, to reduction and
eventual elimination of disparities in adverse patient outcomes. The inte-
gration of culture as a core component in the development of nurses and
in the delivery of patient care has not been systematically implemented.
Schools of nursing are at varying levels of understanding and know!l-
edge on how to develop and implement culturally focused and sensitive
courses! programs. There needs to be an evaluation and presentation of
successful and unsuccessful approaches to these challenges.

24

NATIONAL ADVISORY COUNCIL ON NURSE EDUCATION AND PRACTICE


APPENDIX B

Expert Workgroup on Diversity

Eula H. Aiken, PhD, RN

(representing Regional Nurse Compacts)
Nursing Programs Director

Southern Regional Education Board

592 Tenth Street, NW

Atlanta,GA 30318

Geraldine Bednash, PhD, RN

(representing American Association of Colleges of Nursing)
Executive Director

American Association of Colleges of Nursing

1 Dupont Circle

Suite 530

Washington, D.C. 20036

Hattie Bessent, EdD, RN, FAAN
5622 Sophist Circle South
Jacksonville, FL 32219

Maxine Bleich

President

‘Ventures in Education

245 Fifth Avenve, Suite $02
New York,NY 10016

‘Stephanie Ferguson, PhD, RN
Associate Professor

Division of Nursing

Howard University

NW Annex 1,Room 131

501 Bryant Street

Washington, D.C. 20059

C. Alicia Georges, MA, RN, FAAN
(former member National Advisory Council on Nurse Education and
Practice )
Lecturer and Coordinator
of the RN Program
Lehman College, CUNY
Department of Nursing
Bedford Park Blvd. West
Bronx, NY 10468

NATIONAL ADVISORY COUNCIL ON NURSE EDUCATION AND PRACTICE

3a


|. Introduction

Renewed and reinforced efforts are required to effectively address
the underrepresentation of racial/ethnic minority populations in the regis-
tered nurse workforce. This underrepresentation continues despite the
Jong history of efforts to address it, As we enter the 21st century, the
development of a nursing workforce that reflects the racial/ethnic/cultural
diversity of the Nation's population remains a challenge to the mission of
assuring an adequate supply and distribution of qualified nursing person-
‘nel to meet the health needs of the Nation. In 1996 there were an estimated
246,000 RNs of racial/ethnic minority backgrounds. Although this number
reflects a doubling of the number of minority nurses since 1980, the growth
has been insufficient to produce the numbers necessary to reflect the
percentages of minorities in the Nation's population. Minority nurses
comprised 9.7 percent of the RN population in 1996. By way of compari-
son, racial/ethnic minority groups comprise 28 percent of the U.S. popu-
lation. Examination of the underrepresentation among specific groups
reveals even greater cause for concern. For example, Hispanics who com-
prise approximately 11 percent of the U.S. population, comprise less than
2 percent of the registered nurse population. Similarly, African Americans
comprise 12 percent of the U.S. population but only 4 percent of the
registered nurse population (See Chart A). Moreover, minority popula-
tions are projected to increase substantially during the coming decades.
It is projected that by the year 2020 minority populations will comprise
nearly 40 percent of the Nation's population. By the middle of the 21st
century, those population groups that are currently in the minority will,
collectively, nearly equal the majority population in size (U.S. Dept. of
Commerce, 1996),

Efforts to produce a nursing workforce that reflects the diversity of the
population are primarily justified by the rationale that a diverse workforce is
essential to meeting the health care needs of the Nation's population. Minor-
ity populations have higher rates of certain diseases, lower rates of success-
ful treatment, and in some cases shorter life expectancies than the majority
population, In addition, minority populations are more likely to reside in
areas with chronic shortages of health care providers, Although a number of
factors contribute to racial and ethnic disparities in health, inadequate ac-
cess to quality and appropriate care is onc of the more significant. Therefore,
as the Nation's population becomes more ethnically and racially diverse, the
underrepresentation of people from racial/ethnic minority groups in the over-
all basic registered nurse workforce exacerbates the challenge of delivering
culturally appropriate and sensitive nursing services (National Advisory
Council on Nurse Education and Practice, 1996). Current trends in the num-
bers of minority students in the nursing education pipeline suggest that
without significant interventions to improve the numbers their representa-
ton among the total nurse population will continue to fall short in relation to
minorities in the population.

NATIONAL ADVISORY COUNCIL ON NURSE EDUCATION AND PRACTICE


For a substantial number of nurses. basic nursing education at the
associate degree level is a stepping stone for advancing their careers
through further education. According to data from the 1996 Sample Sur-
voy of Registered Nurses the percent of minority graduates from associ-
ate degree programs who subsequently obtained a baccalaureate degree
or higher ranged from 14 percent of Asian/Pacific Istander RNs to 23
percent of African American/Black RNs,

The pattern of minority student entry into nursing suggests
that strategies are needed to increase the numbers who enroll in ge-
neric baccalaureate programs and to facilitate and accelerate the aca-
demic mobility of those who obtain their basic education in associate
degree programs if larger percentages are 1 acquire the baccalaureate
degree by the targeted date. To effect this increase in baccalaureate
preparation: and promote educational mobility there needs to be a
better understanding of the factors that motivate, facilitate and hinder
the pursuit of the baccalaureate degree. Asian/Pacific Islander stu-
dents are more likely to pursue the baccalaureate as their basic nurs~
ing education. Study of the factors that influence their patterns of
entry into basic nursing education may provide insight into strategies
that may work for other groups.

Barriers and facilitators to successful pursuit of baccalaure-
ate preparation, There is a perception in minority communities, as
well as in the population at large, that a “nurse is a nurse.” Conse-
quently many do not see the need to go further than an associate
degree and are not aware of the advantages of receiving a baccalaure-
ate or higher degree. For many minority students, the associate de-
gree is more accessible and affordable than the baccalaureate degree.
For some, the preference for obtaining the associate degree at a com-
munity college is related to close family ties as well as finances (CDM

Group, 1998).

A study conducted by the National Association of Hispanic
Nurses (NAHI) cites the need to develop and sustain educational
programs that facilitate articulation between programs at different odu-
cational levels and hence, educational advancement. That study found
that barriers to educational mobility identified by participants (His-
panic ADN nurses who had completed their BSN and BSN nurses who
had completed their MSN) included institutional policies, limited fi-
nancial aid, perceived discrimination by faculty and peers, and His-
panic cultural values such as the importance of the family and pre-
scribed gender roles. Conversely, the support of fumily, peers, and
faculty were seen as facilitators to completing degree requirements
(NAHN, 1998).

Significant numbers of those enrolled in associate degree programs
do so after working in other fields. However, additional study is needed
to determine factors influencing the educational mobility patterns of these
“second career” individuals, Additional studies of the factors that influ-
ence the choice of entry path to nursing chosen by specific racial/ethnic
minority groups us well as factors affecting educational mobility are
needed in order to implement effective mechanisms for increasing the
numbers of baccalaureate prepared minority graduates.

NATIONAL ADVISORY COUNCIL ON NURSE EDUCATION AND PRACTICE


U.S, Department of Health and Human Services, Health Resources and
Services Administration. Assuring Access to Essential Health Care, 1998.

‘Washington Consulting Group. Survey of Beneficiaries of Nursing Edu-
cation Projects. Prepared Under Contract No. HRSA 240-91-0016, for the
Division of Nursing, Bureau of Health Professions, Health Resources

and Services Administration, 1993,

NATIONAL ADVISORY COUNCIL ON NURSE EDUCATION AND PRACTICE

29


MEMBERS OF THE NATIONAL
ADVISORY COUNCIL ON

NURSE EDUCATION AND PRACTICE
(As of April 2000)

CHAIR Denise H. Geolot, PhD, RN, FAAN
Director
Division of Nursing
Bureau of Health Professions
Health Resources and Services Administration

CO-CHAIR Susan Johnson Warner, EdD, RN
Director of Nursing Programs
St. Cloud State University
St. Cloud, Minnesota

MEMBERS Eula Aiken, PAD, RN
Nursing Program Director and Executive Director
Council on Collegiate Education for Nursing
Southern Regional Education Board

Atlanta, Georgia

Dyanne Affonso, PhD, RN, FAAN

Professor and Olson Endowed Chair in Women’s
Health

College of Nursing

University of Nebraska Medical Center

Omaha, Nebraska

Polly Ann Bennett, BSN, RN
Student, Nurse-Midwifery Program
School of Nursing

University of Michigan

Ann Arbor, Michigan

Maxine Bleich, BA
President

Ventures in Education. Inc.
New York, New York

Eileen T. Breslin, PhD, RN
Dean and Professor

School of Nursing
University of Massachusetts
Amherst, Massachusetts

Carol Bush, MS, RN

Assistunt Vice President for Clinical Support Services
Intermountain Health Care, Ine.

Salt Lake City, Utah

NATIONAL ADVISORY COUNCIL ON NURSE EDUCATION AND PRACTICE


* Work with the Natrona! Education Association (NEA), other
professional groups, and high school academic counselors
to provide accurate information about various types of nurs-
ing education programs and the academic preparation required
to enter and complete these programs.

* Encourage nursing education programs to “adopt a high school”
so that minority students and their advisors at the high school
level can be educated regarding the nursing career opportuni-
ties and the academic preparation required to enter the nursing
profession.

* Link nursing education programs with other programs (c.g. after
school, rites of passages) to help focus and prepare students for
nursing careers.

Issue: The majority of the minority registered nurse workforce hay less
than a baccalaureate education, Moreover, most minority students in
baxic nursing education programs are enrolled in associate degree
programs.

The current and emerging health care system requires a nurse workforce
whose education prepares them to function across health care sectors
and systems in providing and managing nursing services to individuals,
families, groups, and populations, As is true for the nursing workforce
in general, most minority nurses and students are not prepared for this
scope of practice.

Policy Goal: To increase the overall number and percentage of bacca-
Jaureate-prepared minority nurses in the basic nurse workforce. At
Jeast two-thirds should hold baccalaureate or higher degrees by the
year 2010.

Action Items:

* ‘Target resources at increasing the numbers of minority bacca-
laureate students through both recruitment and student support
activities.

* Fund demonstrations to establish collaborative arrangements
between community colleges and baccalaureate programs.

* Enhance the educational mobility for minority Licensed Practical
Nurses, and graduates of diploma and associate degree programs.

Leadership

Promote minority nurse leadership development

Issue: There is a need for minority nurses in leadership positions at all
tevels in the health care arena.

There are few minorities at the policy making level in service, institu
tions of higher education and in research. Successful strategies that
have been used to develop minority nurse leaders need to be documented
and more widely implemented.

22

NATIONAL ADVISORY COUNCIL ON NURSE EDUCATION AND PRACTICE


information 1s critical to understanding the factors that affect the recruitment.
retention, and graduation of these students and to the development of effec-
tive strategies for ackressing their underrepresentation in nursing education
programs. It has been observed that until there are more data to identify and
describe the barriers and forces that negatively influence minorities to choose
nursing as a career, it will be difficult to design und implement new ways to
attract and retain minorities (Buerhaus, et. al., 1999), The Institute of Medi-
cine (LOM) committee report on ensuring racial and ethnic diversity in the
health professions suggested that many obstacles can be eliminated by
expanding or replicating existing successful intervention models, However,
the committee found that only a few programs have been rigorously as-
sessed and evaluated, They found that nationwide there are successful
programs but many are overlooked as a result of lack of documentation and
publication, They concluded that there needs to be increasing emphasis on
timely dissemination of evaluation findings in a format that can be used by all
of the constituencies involved in these efforts (IOM, 1994),

The Expert Workgroup on Diversity came to similar conclusions in
their deliberations concerning actions required to increase diversity in
nursing. Based on the experiences and knowledge provided by the
Workgroup a number of barriers to increasing the numbers and percent-
ages of minorities in nursing education were identified and have been
considered in the NACNEP development of policy goals and actions items
related to nursing education, These include:

The image of nursing. Minority populations, as well as the popula-
tion at large, are poorly informed about careers in nursing. They have
inaccurate perceptions about the contributions and roles of nurses in
health care delivery and little is known about the differences in the scope
of practice for the various categories of nurses.

Inadequate guidance and pre-nursing academic preparation. A
national effort to increase the numbers of minorities in the professional
nursing workforce cannot ignore the issue of primary and secondary educa-
tion as the base and frame upon which success in post secondary educa-
tion is built (CDM Group, 1998), The educational systems from which
many aspiring minority nursing students come have not prepared them
appropriately for the rigors of the nursing curriculum, Consequently,
many who aspire to become nurses are not eligible for admission to the
programs and there is a significant attrition rate among those students
who ure admitted. Some experts feel that there is a tack of realistic expec-
tations among minority students and the minority population at large
about the academic requirements necessary to become a nurse. It has
been suggested that these requirements should be communicated to stu-
dents at levels from K-12, in order to ensure adequate preparation by the
time they are ready to apply for admission to nursing programs. Informa-
ton about academic requirements for nursing should also be provided to
principals, faculty, and counselors in high schools.

Financial constraints, The cost of a nursing education, particularly at the
baccalaureate level, creates a barrier to the enrollment of minosity students, many
of whom are from financially disadvantaged backgrounds. The availability of
adequate financial assistance is critical component for initiatives aimed atrecruit-
ing and retaining minonty students in nursing programs.

NATIONAL ADVISORY COUNCIL ON NURSE EDUCATION AND PRACTICE


panents, For some groups, encounters with nurses of their racial/ethnic
background are likely to be very limited because the number of nurses is
so small in relation to the population.

‘Table 2. Employed nurses in specified racial/ethnic groups
per 100,000 U.S. population in specified racial/ethnic groups

Afncan American

American Indiarv Alaska Native
Asian/Pacific Islander
Hispanic

White(non-Hispanic)

SRERR

Source: Computed from data reported in the Nasional Sample Survey of
Registered Nurses, March 1996 and population data from the U.S. Bureau of
the Census.

Minority nurse contributions to care delivery, Their relatively small
numbers notwithstanding, minority nurses are significant contributors to
the provision of health care services in this country and leaders in the
development of models of care that address the unique needs of racial!
ethnic minority populations, The literature provides information on pro-
gram initiatives in which minority nurses have lead in the development
and implementation of successful community-based partnerships und
models of care delivery to vulnerable minority populations (Affonso, et,
al, 1993; Bolton et. al, 1998). These projects demonstrate the role of minor-
ity nurses as advocates for minority health care improvement and leaders
in the development of partnerships within minority communities to ad-
dress criticul health problems. More data and research are needed to
further document the unique contributions of the minority nurse workforce
to health care delivery and to the health outcomes of specific populations.
There is also need for wider dissemination and publication of such data,

Diversity in the work setting. Recruitment and retention of minority
hurses are important to meeting health care goals. especially for minority
patients, in all health care settings. Ethnic diversity in the workplace is
also important because it is widely thought to stimulate improvements in
quality, efficiency, and customer satisfaction (Minnick, et. al., 1997}, Asis
true for nurses in general, the principal employment setting of minority
nurses is the hospital. Data from the 1996 Sample Survey of Registered
‘Nurses indicate that the proportion of minority nurses employed in hospi-
tals varied from 73 percent of Asian/Pacific Islander nurses to (0) percent
of African American/Black nurses and American Indian/Alaska Native
nurses. Because the hospital is also the most common clinical setting for
nursing student practicums and jobs obtained by new nurses, the hospi-
tal environment is influential in determining whether students and new
nurses come to value diversity among their workplace colleagues, men-
tors, and supervisors (Minnick, et. al, 1997).

As Chart B indicates, most nurses employed in hospitals are staff
nurses, Little is published wbout the extent to which work environments in
which minority nurses are employed provide support and encouragement
for career progression that would allow them to contribute their expertise
ata variety of levels in the organization.

4

NATIONAL ADVISORY COUNCIL ON NURSE EDUCATION AND PRACTICE


to minority faculty alone. ‘The pool of minority faculty ts too small
to enable them to address the needs of all minority students.
Moreover, changing the cultural milieu requires that more
nonminority faculty become mentors of minority students (Ross-
Loe, 1995; Griffiths. 1999),

Increasing the numbers with baccalaureate and higher degrees

In addition to the challenge of increasing the numbers of minorities
in nursing education programs is the need to increase the numbers who
ure prepared at the baccalaureate and higher degree levels. Baccalaure-
ite prepared nurses form the educational base from which advanced
Practice nurses, nurse educators, and researchers for the future are de-
veloped. Moreover, baccalaureate programs are more likely than associ-
ate degree or diploma programs to contain curriculum that prepares nurses
for the increased complexity in the scope of practice that is required
(NACNEP, 1996). NACNEP has encouraged direct entry into generic
baccalaureate programs. However, the associate degree is generally the
more likely means of entry to a nursing career for minority and nonminority
students. ‘As Tuble | indicates, with the exception of Asian/Pacific Is-
landers, GO percent or more of minority graduates from basic nursing
education programs in 1996 graduated with an associate degree. Less
than 40 percent were graduates of baccalaureate programs. ‘The NACNEP
has made a recommendation that Federal resources should be targeted at
increasing the overall number and percentage of baccalaureate-prepared
nurses in the basic nursing workforce. The Council has further recom-
mended that a policy target should be adopted to achieve a basic nurse
workforce in which at least two-thirds hold baccalaureate or higher de-
grees in nursing by the year 2010, Continuation of the trends noted in
this table will not result in a minority nurse workforce with the educa-
tional mix recommended by NACNEP.

‘Table 1, 1996 Racial/Ethnic Minority Graduates From Basic Nursing Education

Programs by Degree Level
Total Baccalaureate Associate Degree Diploma
Total [Number | Number Percent | Number Percent | Number Percent

133994 4972 371 7s 585 588 44
African
American 08 zm uO wR a7 = 44
Hispanic 97 Has 353 1927 @3 12 44
Asian/Pac.
Islander Hn 1396 456 1516 ws 148 43
American
Indian 629 m6 280 a Os 4 22

Sovree: National League for Nursing. Nurriny DaraSource 1997.

NATIONAL ADVISORY COUNCIL ON NURSE EDUCATION AND PRACTICE



Policy Goal; To increase the number of minority nurses in policy/
leadership positions in health care administration, academia, and
research,

Action Items:

* Collect and analyze data on minority nurses in leadership
positions.

* Develop leadership models that are based on unique leadership
styles of nurses from diverse backgrounds.

* — Increase the representation of minorities in national and State
professional organizations and private and public institutions.

* Create systems to provide mentor ship to minority nurses
throughout their careers.

* Disseminate information about leadership opportunities and
leadership training opportunities to minority nurses.

Issue: Minority nurse leaders often experience social isolation, re-
duced networking and minimal support systems,

More effective sapport systems for minority nurse leaders need to be
developed. The development of these systems can be facilitated by docu-
menting the career pathways of those minority nurses who have become
leaders and identifying the factors that enabled them to obtain and
remain in leadership positions.

Policy Goal: To reduce social isolation of minority nurse leaders by
increasing opportunities for professional development activities that fo-
cus on creating support systems,

Action Items:

* Assess funded minority nurse leadership and career develop
ment programs to determine their success and potential for repli-
cation of promising models,

* Create and expand support systems for minority nurse leaders,

* Encourage and promote mentoring of minority nurses in aca-
demic and service settings.

Practice/Workforce and Cultural Competency

Develop practice environments that improve diversity
Promote the preparation of all nurses to provide cultur-
ally competent care

Issue: The work environments in which many minority nurses are
employed provide insufficient support and encouragement for ca-
reer progression and for assisting staff to respect and build on their
diversity.

A supportive work environment is conducive to the reeruigment and
retention of minority nurses who, in turn, can facilitate access of
minorities to health care, Examples of successful environments need
fo be identified and replicated.

NATIONAL ADVISORY COUNCIL ON NURSE EDUCATION AND PRACTICE


coalitions. The action plans developed reflected the commitment of the
individuals and the groups to correcting the problems identified,

‘The third congress, “Caring for the Emerging Majority: A Blue-
print in Action, ~ was held in 1997. This congress built on the first two and
teams of minority leaders and community-based projects rather
than individual leaders. The 31 teams attending the congress (a total of
155 indivicuals) were selected from 59 teams who submitted proposals in
response to a notice in the Federal Register. The focus areas addressed
by the teams were recruitment, retention, and graduation of minority stu-
dents; increasing the numbers of minority nurse leaders; and preparing all
nurses to provide culturally competent care. In 1998 the Division of Nurs-
ing awarded grants to 18 of the 31 teams, providing seed money for further
development and implementation of their proposals. Proposals from other
teams have been cither partially or fully funded through grant programs in
the Division or elsewhere.

The Ad Hoc Workgroup on Diversity of the NACNEP was formed in
December 1996, primarily to consider ways to increase the effectiveness
of and maximize the impact of funds appropriated for the Nursing Educa-
tion Opportunities for Individuals from Disadvantaged Backgrounds (NEO)
program, the principal program within the Division of Nursing targeted to
improve diversity in the nursing workforce, The workgroup was also
charged to consider the larger scope of nursing workforce diversity is-
sues and to develop a strategic plan for addressing diversity in education
and practice. For this portion of its charge the NACNEP workgroup ex-
pressed the need for additional expert input which resulted in the conven-
ing of the Expert Workgroup on Diversity. (See Appendix A).

The Expert Workgroup on Diversity was convened by the Division
of Nursing in September 1998 at the request of the NACNEP Ad Hoc
Workgroup on Diversity. Through a process described later in this report,
the Expert Workgroup developed recommendations that covered policy
goals and actions for stakeholders in the issues related to nursing
workforce diversity, The Expert Workgroup embraced the recurring rec-
‘ommendation of the Minority Nurse Leadership Congresses that the nurs-
ing profession needs to specif'y and implement an action-oriented agenda
that addresses diversity issues if improved workforce diversity and health
care outcomes are to be realized on a broad-scale basis. This Workgroup
reviewed the three Minority Congresses’ recommendations, grouped under
four broad themes of education, practice, leadership, and cultural compe-
tency, The members of the workgroup discussed issues and identified
national policy goals and actions for cach theme. A concern that cut
across all policy goals set forth by the group was the need for ensuring
sustainability of efforts in the absence of external funding and account-
ability of those receiving funds to increase diversity, The Workgroup
developed and submitted a report to NACNEP that outlined recommended
goals and actions for addressing the identified issues related to diversity
in nursing education and practice.

NATIONAL ADVISORY COUNCIL ON NURSE EDUCATION AND PRACTICE


Diversity to advise NACNEP in the development of a national agenda for
increasing nursing workforce diversity. The 18 members of the Workgroup,
recognized for their expertise in nursing and in workforce diversity is-
sues, represented a variety of organizations including the NACNEP,
national minority nurse organizations, schools of nursing, national nurs-
ing assoctations, national healthcare associations, national medical school
associations, and private organizations.

This Workgroup developed recommendations that covered four
broad themes~education, practice, leadership, and cultural competency.
The recommended goals and actions were accepted by NACNEP as it
developed the goals and action items in this report. The following goals
are recommended by NACNEP-

Enhance efforts to increase the recruitment, retention, and
graduation of minority students

* Identify educational environments and programs that success
fully support recruitment, admission, retention, and graduation
of minorities and more widely implement successful models

* Increase the number of minority faculty in nursing programs
over the number reported by the American Association of Col-
leges of Nurses for 1997-98

* Improve the evaluation of and accountability for the outcomes
of programs that are funded to increase diversity in nursing

* Establish collaborative partnerships among health professions
education groups to participate in the identification of indicators
for the academic and practice success of minority students

© Educate minority communities regarding nursing as a career

* Increase minority students’ and their advisors/counselors’ un-
derstanding of the academic requirements necessary to facilitate
access 10 a professional nursing program

* Increase the overall number and percentage of baccalaureate-
prepared minority nurses in the basic nurse workforce. At least
two-thirds should hold baccalaureates or higher degrees by the
year 2010

Promote minority nurse leadership development

* Increase the number of minority nurses in policy/leadership po-
sitions in health care administration, academia, and research

© Reduce social isolation of minority nurse leaders by increasing
opportunities for professional development activities that focus
on the development of support systems

vill

NATIONAL ADVISORY COUNCIL ON NURSE EDUCATION AND PRACTICE


minority nursing faculty ix lacking. Such data is essential to design-
ing successful models of minority faculty development.

Policy Goal: ‘To increase the number of minority faculty over the number
for 1997-98 as reported by the American Association of Colleges of
Nurses.

Action Items:
* Gather, analyze, and disseminate data on models that have been
successful in the development of minority nurse faculty,
* Increase funding for graduate degree and faculty development
programs that focus on minority nurses.
© Evaluate data to develop a profile of successful minority nurse

faculty that can be used to guide the programmatic efforts for
minority faculty development.

Issue: Long-term data documenting the successes and failures of previ-
ousty funded approaches to increasing diversity in the nursing workforce
are scarce and little is known about the sustainability of such programs
in the absence of external funding.

Financial support for programs that enhance the production of minority
nursing gradvates is crucial to increasing the mumber of minoritis enter-
ing the nursing workforce. Moreover, it is important to target scarce
financial resources to the mast effective methodologies and sustainable
programs. The development and use of long-term tracking and reporting
methods will provide data on the sustainability of programs and facili-
tate evaluation of their success over time.

Policy Goal: To improve the evaluation of and accountability for the out-
comes of programs that are funded to increase diversity in nursing.

Action Items:

* Track, monitor, and evaluate programs funded for increas~
ing minority enrollment in nursing.

* Provide technical assistance that helps funded institutions with
the development and implementation of tracking and reporting
methods.

* Promote efforts to sustain programs beyond external funding.

Issue: Admission criteria often rely heavily on standardized test scores
and fail to include other indicators of future success of minorities as
nursing students and health care providers.

The underdeveloped test taking skills of many minority students are
often reflected in poorer performance on standardized tests than majority
students. Limiting the qualifying criteria for admission to health profes-
sions education programs to standardized text scores serves asa barrier
fo substantially increasing the number of minorities in thoxe programs,

Policy Goal: To establish collaborative partnerships among health pro-
fessions education groups to participate in the identification of indicators
for the academic and practice success of minority students.

20

NATIONAL ADVISORY COUNCIL ON NURSE EDUCATION AND PRACTICE


tive RNs are more likely than other nurses to have obtained graduate
education. Still, with the exception of Asian/Pacific Islanders, less than
‘one-half of the RN population (minority and non minority) has at least
baccalaureate preparation. While this is a concern for the nursing workforce
as a whole, it is especially important for RNs in racial/ethnic minority
groups where well over one-half have less than a baccalaureate educa-
tion. The creation and expansion of opportunities for educational mobil-
ity for minority RNs (as for all nurses) are essential for altering the educa-
tional mix of the minority nurse workforce. Such opportunities will need to
address the fact of the high percentage of full time employment among
minority nurses Which indicates the need for financial support if these
nurses are to return to school to obtain baccalaureate or graduate degrees
inatimely manner, Data from the 1996 Sample Survey of Registered Nurses
indicate that in March 1996 the percentage of employed minority RNs
working full-time ranged from 87 percent of African American/Black nurses
to 76 percent of Hispanic/Latinos.

The aging of the minority nursing workforce. In some minority
groups. notably African Americans/Blacks and American Indians/ Alaska
Natives, the relatively large proportion of older nurses could pose an
additional significant challenge to improving workforce diversity. For
example, more than one-third of all African American/Black nurses are 50
years of age or older. The average age of African American/Black and
American Indian Alaska Native RNs in 1996 was 46 and 45 years, respec-
tively, and less than 20 percent in each group were under 35 years of age.
As these older nurses leave the workforce there is the potential for de-
cline in the presence of these groups in the workforce in the coming years
unless there are sufficient increases in the numbers of new entrants to the
workforce to compensate for the losses. Hispanic/Latino and Asian/Pa-
cific Islander RNs, with an average age of about 41 years, are the youngest
of the RN population,

Cultural Competency

The increasingly diverse population of the Nation requires greater
attention to issues related to the delivery of culturally appropriate and
sensitive nursing services, Cyltural competence is tied to quality of care
and the appropriateness, acceptability, accessibility, and utilization of ser-
vices. It is also related to diversity in the nursing workforce. Developing
a culturally competent RN workforce involves educating all RNs to pro-
vide safe and effective care to diverse populations and recruiting a racial!
ethnically diverse nursing student body, A culturally competent nurse
has the ability to honor and respect the beliefs, attitudes, lifestyles, mores,
traditions, customs and behaviors of others and is able to develop inter-
ventions and services that affirm and reflect the value of different cul-
tures. Cultural competence is particularly imperative to efforts ta deliver
better preventive health care to growing minority populations, Moreover,
there is heterogeneity within all racial/ethnic groups with regards to a
number of factors that affect health practices and attitudes, Therefore,
the provision of training and cultivating cultural competency should
include all health care providers including minority and majority nurses.

Tt has been observed that the nursing profession has a struggle
promoting cultural competency because the profession is so overwhelm-

NATIONAL ADVISORY COUNCIL ON NURSE EDUCATION AND PRACTICE

7


Judy Goforth Parker, PhD, RN
Professor

Department of Nursing

East Central University

Ada, Oklahoma

Norma L. Rodgers-Hunter
Student

School of Nursing
Bloomfield College
Bloomfield, New Jersey

Sally E. Ruybal, PhD, RN:
Professor of Nursing
College of Nursing
University of New Mexico
Albuquerque, New Mexico

Carol A. Singer, EdD, RN

Director, Division of Nursing and Health
Sciences

Manatee Community College
Bradenton, Florida

Antonia Villarruel, PhD, RN, FAAN
Assistant Professor

University of Pennsylvania
Philadelphia, Pennsylvania

Rick Wolfname
Student

Sulish Kootenai College
Pablo, Montana

EXECUTIVE Elaine G. Cohen, MS, RN
SECRETARY Division of Nursing
Bureau of Health Professions
Health Resources and Services
Administration

NATIONAL ADVISORY COUNCIL ON NURSE EDUCATION AND PRACTICE


Marilyn P. Chow, DNS, RN, FAAN
Vice President, Patient Care Services
Kaiser Permanente
Oakland, California

Charlotte Jane Dey, MPA, RN
Deacon

Grace Episcopal Church
Jefferson City, Missouri

Marge Drugay, ND, RN, C
President

Drugay and Associates
Tucson, Arizona

Maryann F. Fralic, DrPH, RN, FAAN

Director of Corporate and Foundation Relations
School of Nursing

The Johns Hopkins University

Baltimore, Maryland

Doreen Frusti, MS, RN
Chair, Department of Nursing
Mayo Medical Cemer
Rochester, Minnesota

Bruce W. Goldberg, MD

Assistant Professor

Oregon Health Sciences University
Portland, Oregon

Marjorie B. Grimsley, BA

President

Colorado Chapter of the Federation

of Families for Children’s Mental Health
Denver, Colorado

Susan J. Grobe, PhD, RN, FAAN
La Quinta Professor of Nursing
The University of Texas at Austin
Austin, Texas

Barbara J. Hatcher, PhD, RN

Director of Scientific and Professional Affairs
American Public Health Association
Washington, D.C.

Gloria J. Myers, JD

Associate General Counsel
Mission St. Joseph Health System
Asheville, North Carolina

NATIONAL ADVISORY COUNCIL ON NURSE EDUCATION AND PRACTICE


NATIONAL ADVISORY COUNCH. ON NURSE EDUCATION AND PRACTICE


EXECUTIVE SUMMARY

The National Advisory Council on Nurse Education and Prac-
tice (NACNEP) is authorized under Title VIE of the Public Health Ser-
vice Act to provide advice and recommendations to the Secretary and
Congress concerning the range of issues relating to the nurse
workforce, education, and practice improvement. In its 1996 Report to
the Secretary on the Basic Nursing Workforce the council identified
increasing the racial/ethnic diversity of the RN workforce as one of
the measures necessary to ensure the availability of a workforce ap-
propriate to meet the nursing needs of the population, As the conse-
quences of a rapidly growing racial/ethnic minority population and
relatively slow growth in the number of minority RNs have become
increasingly evident, NACNEP has now determined that the Nation
should set an action agenda to rally and direct efforts to address the
longstanding issue of underrepreseatation of racial/ethnic minorities
in the nursing workforce. This report presents issues related to racial/
ethnic diversity in nursing education and practice and recommends
goals and actions that can serve as a national action agenda to be
undertaken to address those issues. The magnitude of the challenges
involved with increasing nursing workforce diversity requires a na-
tional effort involving the public and private sectors. Initiatives must
involve the educational system that produces the nurses as well as the
employment settings in which they work. In order for these efforts to
be effective and sustainable there must be consistent, visible support
from the highest levels of government and the private sector,

A culturally diverse workforce 15 essential to meeting the health
care needs of the Nation's population. Not only are minority popula-
Hons increasing substantially but they also have higher rates of cer-
tain diseases, lower rates of successful treatment, and in some cases,
shorter life expectancies than the majority population. Minority popu-
lations are also more likely to reside in areas with chronic shortages of
health care providers. Although a number of factors contribute to
racial and ethnic disparities in health, inadequate access to quality
and appropriate care is one of the more significant. Despite their rela-
tively small numbers among the nursing workforce, minority nurses
are significant contributors to the provision of health care services in
this country and leaders in the development of models of care that
address the unique needs of racial/ethnic minority populations. There-
fore increasing their numbers is.a major strategy in reducing the health
disparities that exist among the Nation's population.

‘The NACNEP recognized the need for additional expertise wo iden-
tify the issues related to nursing workforce diversity and initiatives that
would effectively address the issues. As a result, the Division of Nursing,
under the direction of the NACNEP. convened the Expert Workgroup on

NATIONAL ADVISORY COUNCIL ON NURSE EDUCATION AND PRACTICE


Leadership

The promotion of diversity in nursing education and practice is
inextricably linked to leadership in two fundamental ways. First, a commit
ment from the dean of the school of nursing or other organization leader to
diversity in nursing is essential, This commitment should be stated in the
institutions’ or the organizations’ mission statements and strategic plan.
Leadership in the work setting must focus on developing and maintaining
an environment conducive to fostering the leadership potential of all staff.
1h is a responsibility of the leadership in any arena to enable and maximize
the potential of all. Because current nurse leaders are in a position to use
their clinical expertise and managerial skill to positively influence healthcare
delivery, they should promote cultural diversity as a means of optimizing
the provision of quality health care to the Nation's population,

‘Seoondly, minonity nurse leadership in educabon and in the practice setting
iscrucial to endeavors to improvediversity in nursing. Minority nurse leaders are
advocates and role models for minonity nursing students and nurses and they are
‘ina unique position to move the diversity agenda forward. They are also pivotal
to launching research and public health initiatives targeting minonty and other
underserved populations. In addition, they serve as a resource for assisting non-
minority health professionals to reach diverse populations effectively and with
sensitivity. Minority faculty provide leadership, serve as role models, provide
Perspective on dealing with minority patients, and promoe culturally competent
approaches to enhance the effectiveness of health service delivery to minority
populations. Moreover, with the presence of Langer numbers af minority faculty
there is a heightened awareness of minonity health issues and an increased capac
ity for research and development of new initiatives that further help in improving
minority health.

Development of greater numbers of minority nurse leaders is key to
efforts to recruit and retain more minorities for nursing education programs
as well as practice settings. However, there are a number of challenges to the
development of significant numbers of minority nurse leaders. The major
challenge is the small number of minority nurses in general and the even
smaller numbers with graduate degrees. Data on minority students being
educated at the graduate level—the pool from which faculty, researchers, and
other leaders are drawn- illustrate one challenge to building a critical mass.
For example, data from the National League for Nursing, indicate that the
total number of minority students graduating from masters’ programs in 1996
was only 1,424 (National League for Nursing, 1997). This goes back to the
issue of education and the need to encourage current nursing students as
‘well as nurses in practice to pursue higher degrees.

Another challenge to the development of a critical muss of minority
nurse leaders is the need to change the perceptions of minority nurses
who have leadership potential but have not expressed a desire for or
interest in a leadership role. Untapped potential often exists among those
who do not initially express interest in career advancement. For them,
leadership training and mentoring can provide the stimulus for setting
new career goals (Griffiths, ct. al. 1999), Mentoring is especially important
in minority leadership development. Lack of access to an advisor and
mentor, minority or otherwise, can be a crucial barrier to developing minor-
ity faculty and minority academic leadership (IOM, 1994),

NATIONAL ADVISORY COUNCIL ON NURSE EDUCATION AND PRACTICE


Pouce *

Education And Practice

Report To The Secretary Of
Health And Human Services
And Congress

2000

U.S, Department of Health and Human Services

Health Resources and Services Administration

Bureau of Health Professions
Division of Nursing



Nilda Peragallo, PhD, RN

Associate Professor

College of Nursing

University of Mlinois (M/C 802), Chicago
Mental Health and Administrative Nursing
Department of Public Health

845 S. Damen Avenue

‘Chicago, Illinois 60612-7350

Carmen Portillo, PhD, RN

{representing National Association of Hispanic Nurses)
Assistant Professor of Mental Health

Community and Administrative Nursing

School of Nursing, Box 0608

University of California

San Francisco, CA 94143

‘Timothy Ready, PhD

( representing Association of American Medical Colleges)
Assistant Vice President for Community

and Minority Programs
Association of American Medical Colleges

2450N Street, NW

‘Washington, D.C. 20037

Tris Sanchez

(former student intern at the Division of Nursing and former student mem-
ber National Advisory Council on Nurse Education and Practice)
P.O, Box 244

‘San Juan, TX 78589

Carla Serlin, PhD, RN
(representing American Nurses Association)
Director

‘Teresa Varela, MSN, RN

(former student member National Advisory Council on Nurse Education
and Practice)

477 17th Street, #2

Brooklyn, NY 11215

Antonia Villarruel, PhD, RN

(current member National Advisory Council on Nurse Education and
Practice and Co-chair Diversity Workgroup)

Assistant Professor

University of Pennsylvania

420 Guardian Dive

Philadelphia, PA 19104

NATIONAL ADVISORY COUNCIL ON NURSE EDUCATION AND PRACTICE


NATIONAL ADVISORY COUNCIL ON NURSE EDUCATION AND PRACTICE


© Increase the use of mentors for students and those nurses that
are young in their careers

Develop practice environments that promote diversity

* Create and maintain workplace environments and employee sup:
Port programs that promote and document recruitment, retention
and advancement of minority nurses

Promote the preparation of all nurses to provide culturally
competent care

* Establish cultural competence standards in education and
practice

* Document the effects and benefits of a culturally diverse and

competent nursing workforce in regards to access to care, out
comes of care, and cost

NATIONAL ADVISORY COUNCIL ON NURSE EDUCATION AND PRACTICE


2 er
APPENDIX A

Convening of the Expert Workgroup on Diversity

In September 1998, the Division of Nursing, under the direction of
the NACNEP, convened the Expert Workgroup on Diversity to
develop recommendations and an action plan for a national nurs-
ing workforce diversity agenda. The plan was to be used to assist
the NACNEP in the development of an action agenda for diversity
in nursing.

The 18 members of the Workgroup are recognized for their exper-
tise in nursing and in workforce diversity issues. Members repre-
sented a variety of organizations including the NACNEP, national
minority nurse organizations, schools of nursing, national nursing
associations, national healthcare associations, national medical
school associations, and private organizations. In addition, two
minority graduate nursing students were included in the
Workgroup, To provide a national perspective on diversity is-
sues, representatives from all regions of the country were included
in the Workgroup.

The Expert Workgroup members also represented the minority popula-
tions as follows:

Minority Population
African American
American Indian
Asian/Pacific Islander

Hispanic

|

Context for the Development of the Diversity Agenda and
Action Plan

In preparing for the meeting, Division of Nursing staff conducted a
content analysis of recommendations from the three Congresses and
the Basic Nursing Workforce Report of NACNEP. Four broad themes
of education, practice, leadership. and cultural competency were iden-
tified as well as five crosscutting themes of data, mentoring, regula-
tion, resources, and technology. The Expert Workgroup was asked to
review the recommendations under each category, and using their
knowledge and expertise, develop a draft national nursing workforce
agenda and action plan with policy goals and options or actions for
each goul. Data on the current status and trends on minorities in the
RN population and in nursing education were presented to the group
prior to their discussions,

NATIONAL ADVISORY COUNCIL ON NURSE EDUCATION AND PRACTICE


IV. Issues, Policy Goals, and Actions

Education

Enhance efforts to Increase the recruitment, retention, and
graduation of minority students

Issue: There is a need for widespread identification and implementa-
tion of successful models for recruiting, admitting, retaining, and gradu-
ating minority nursing students,

There is some documentation in the literature of effective minority re-
eritment and retention models and a number have been implemented
by nursing programs across the country. However information about
the existence of such models and how they hurve been operationalized is
not readily available to many institutions that could benefit from knowl-
edge of those models.

Policy Goal: To identify educational environments and programs
that successfully support recruitment, admission, retention, and
graduation of minorities and to more widely implement successful
models.

Action Items:

* Gather and analyze information on the minority applicant pool
to nursing programs.

* Identify and document motivators, facilitators and barriers
that uffect minority student participation in basic nursing
education programs.

* Gather, analyze, and disseminate information on interventions
that have been successful in recruiting, admitting, and gradu-
ating students from basic nursing education programs, and
licensing minority graduates to practice nursing.

* Support the replication of successful models that demonstrate
success in retention and graduation of minority students.

* Increase the competence of all faculty to address the educa-
tional needs of minority nursing students.

* Establish criteria for successful educational models from the
perspective of racial/ethnic minorities.

Issue: There are insufficient numbers of minority faculty and insuf-
ficient data regarding the profile of successful minority nursing
faculty,

Faculty development programs are exsential to increasing the pool
of minority nursing faculty. Data regarding the profile of successful

NATIONAL ADVISORY COUNCIL ON NURSE EDUCATION AND PRACTICE


U.S. Department of Health and Human Services

Health Resources and Services Administration
Bureau of Health Professions
Division of Nursing



ingly homogenous, with approximately 90 percent white women. There is
a need to work with current practitioners but particular energy should be
focused on preparing a new generation of nurses. Therefore, an initial
step is convincing nursing faculty of the importance of promoting cultural
competency (Hegyvary, 1997). Again, this goes back to the issue of the
need for leadership with an appreciation of the need for und vision to
promote cultural competency training. While it is difficult to change atti-
tudes, an urgent and minimal charge ix to ensure that practitioners provide
culturally competent care to the patients they serve. Thus, determining
the elements of culturally competent cure is an important goal for nursing.

Materials relative to the teaching of cultural competence are avail-
able but it has been estimated that less than 25 percent of nursing pro-
grams today offer substantive content on culturally competent care
Gohnson, 1997). Currently, neither standards for program accreditation
nor nursing practice focus on this component of care. Up to this point. no
comprehensive standards of cultural or linguistic competence in health
care service delivery have been developed by any national body. How-
ever, the Office of Minority Health of the U.S, Department of Health and
Hurmun Services has recently released draft standards for culturally and
linguistically appropriate services (CLAS) which represents a significant
move toward the first set of national cultural and linguistic standards in
health care delivery. These standards, if adopted, will support a more
uniform and comprehensive approach to cultural competency standards
and practice (Meadows, 2000).

Learning about the values, beliefs, and customs surrounding the
health status of minority populations is essential, but integrating this
knowledge into actual health care services delivery may be difficult. This
challenge has been successfully addressed in initiatives led by minority
nurses that can serve as a model of a unique approach to the delivery of
culturally competent care (Mayberry. et, al 1999), Further research is needed
to document the benefits and effects of cultural competence in the provi-
sion of health care services. This area holds the potential for research
opportunities for all nurses but may be of particular interest for minority
nurses,

18

NATIONAL ADVISORY COUNCIL ON NUASE EDUCATION AND PRACTICE


NATIONAL ADVISORY COUNCIL ON NURSE EDUCATION AND PRACTICE


Non-supportive institutional policies and environments. In some
instances, institutional policies and conditions constitute barriers to the
recruitment, admission, retention, and graduation of minority students.
‘These include:

+ Highly restrictive admissions policies—For many health profes-
sions programs, standardized test scores are the principal criteria
determining admission. Thus, performance of minority students
‘on standardized tests continues to be a barrier to admission to
nursing as well as other health professions programs. Test scores
are only one of several factors that may be used for determining
which students are most likely to complete a program and become
successful health care providers. Moreover, there is debate as to
the cultural bias of standardized exams and their ability to predict
graduation of minority students. There is currently a national
dialogue on indicators for success in health professions schools
that go beyond standardized test scores. [tis important for direc-
tors of nursing programs to participate in this dialogue and in the
development of other indicators of student success that should
be considered when making admission decisions.

+ The lack of a systematic mentoring infrastructure-It is generally
agreed that the availability and use of mentors are important factors in
the educational advancement of minorities in nursing and other health
professions education, Yet many institutions lack a systematic means
of providing mentoring for students, Mentors support and facilitate
the students’ development and help to cultivate the self esteem and
self confidence that are critical to the successful completion of an
academic program, While mentors are often faculty members, they do
not have to be (Bessent, 1997), The Institute of Medicine committee
report on ensuring racial and ethnic diversity in the health profes-
sions suggests that in order not to place an undue burden on a few
individuals within an institution, steps might be taken to bring minor-
ity youth into open, trusting relationships with a variety of role mod-
els and supportive professionals. The IOM concludes that ongoing
commitment to mentoring requires # solid program infrastructure at
the institutional level. (IOM, 1994),

The paucity of minority faculty—Minority faculty are pivotal in
attracting and nurturing future minority nurses to practice in their
communities. However, as is true in other health professions.
minority faculty are underrepresented in nursing education. Data
from the American Association of Colleges of Nursing indicate
that only 9 percent of full time instructional faculty in baccalaure-
ate and graduate nursing programs are racial/ethnic minorities
{American Association of Colleges of Nursing, 1998). The avail-
ability of a critical mass of minority faculty in health professions
schools has come to be recognized as a major factor in the recruit-
ment and retention of minority students.

While increasing the number of minority faculty is an important
factor in increasing the numbers of minority nursing students and
graduates, the support and mentoring provided to minority stu-
dents to help them complete their nursing education cannot be left

NATIONAL ADVISORY COUNCIL ON NURSE EDUCATION AND PRACTICE


NATIONAL ADVISORY COUNCIL ON NURSE EDUCATION AND PRACTICE


SS a TE er
References

Affonso, DD, Mayberry, LJ, Graham, K, Shibuya, J, and Kunimoto, J, “Pre-
natal and Postpartum Care in Hawaii: A Community-Based Approach,”
JOGNN 1993 22(4):320-325.

Bolton, LB, Georges, AC, Hunter, V, Long, O, und Wray, R, “Community
Health Collaboration Models for the 21" Century,” Nurs Admin Q, 1998, 22
(3)6-17,

Buerhaus, PI, and Auerbach, D, “Slow Growth in the United States of the
Number of Minorities in the RN Workforce,” /mage: Journal of Nursing
Scholarship, 1999 31(2)179-183.

American Association of Colleges of Nursing, /997-/998 Salaries of In-
structional and Administrative Nursing Faculty in Baccalaureate and
Graduate Programs in Nursing, 1998_

Bessent, H, “Closing the Gap: Generating Opportunities for Minority
Nurses in American Health Care,” in H. Bessent (Ed), Strategies for
Recruitment, Retention, and Graduation of Minority Nurses in Col-
leges of Nursing, American Nurses Foundation. Washington, D.C.,
1997,

CDM Group, “Strategies for the Recruitment, Retention, and Graduation of
Hispanics into the Baccalaureate Level of Nursing,” prepared under con-
tract for the Division of Nursing. Bureau of Health Professions, Health
Resources and Services Administration, Apr. 1998.

Hegyvary, S., "Toward Culturally Appropriate Care,” Caring for the Emerg-
ing Majority: A Blueprins in Action, Nurse Leadership Invitational Con-
gress Proceedings, 1997.

Griffiths, MJ and Tagliareni, E, “Challenging Traditional Assumptions
About Minority Students in Nursing Education” Nursing and Health
Care Perspectives 20 (6):290-295. National League for Nursing. New
York 1999,

Institute of Medicine ([OM). Balancing the Scales of Opportunity:
Ensuring Racial and Ethnic Diversity in the Health Professions.
Lewin, M. and Rice, B.,ed. Washington, D.C. National Academy Press,
1994,

Johnson, R., “Mainstreaming Cultural Competency Concepts Into the
Nursing Core Curriculum at the Undergraduate Level," Caring for the
Emerging Majority: A Blueprint in Action, Nurse Leadership
Invitational Congress Proceedings, 1997,

NATIONAL ADVISORY COUNCIL ON NURSE EDUCATION AND PRACTICE


Chart B. Percent of Minority RNs Employed in Hospitals and
Percent Staff Nurses, March 1996

Aslan. African Hispanic
AmericanBlack

100

American,
Indian
[1% Employed in Hospitals I % Staff in Hospitals

Source: National Sample Survey of Registered Nurses, Division of Nursing,
BHPr

Data from the National Sample Survey of Registered Nurses indi-
cate that, while their numbers in those positions are much smaller than
their non-minority counterparts, African American/Black and American
Indian/Alaska Native nurses employed in hospitals are as likely as non-
minority purses to have the position title of administrator/assistant ad-
ministrator, Also, with the exception of Asian/Pacific Islanders, larger
percentages of minority nurses than of non-minority nurses employed in
hospitals have the title of supervisor. The percentage of African Ameri-
can/Black and Hispanic/Latino nurses with the position title of head nurse
is equal to of greater than the percentage of non minority nurses with that
title, There is a need for better understanding of factors that have influ-
enced these percentages in order create and maintain work environments
that will expand on the achievements and develop strategies to promote
career progression for all nurses.

Recognizing and highlighting the need for enhanced minority
nurse visibility and recognition of their contribution to health care
delivery in their organization are important first steps to developing
work environments that support and retain minority nurses. There is
little in the literature that provides information on approaches to re-
eruit, retain, and advance minority nurses in health care settings,
However, there is a need for deliberative action on the part of admin-
istrators to facilitate the retention and advancement of minority nurses.
Explicit action must be taken to identify diversity-related issues within
the work setting and to develop strategies to address them. A lnissez-
faire approach will not confront the unconscious practice biases that
exist (Schmieding, 1991),

NATIONAL ADVISORY COUNCIL ON NURSE EDUCATION AND PRACTICE


NATIONAL ADVISORY COUNCIL ON NURSE EDUCATION AND PRACTICE


Barbara Hatcher, PhD, RN

(current member National Advisory Council on Nurse Education and
Practice)

Director of Scientific and Professional Affairs

American Public Health Association

1OLS 15* St. NW, Suite 300

Washington, D.C, 20005

Nancy Langston, PhD, RN

(representing National League for Nursing)
Dean and Professor

School of Nursing

Medical College of Virginia

Virginia Commonwealth University
P.O. Box 980567

Richmond, VA 23298

Bettye Davis-Lewis, EdD, RN

(representing National Black Nurses Association)
Chief Executive Officer

Diversified Health Care System

5320 Jackson Street

Houston, TX 77004

Kem Louie, PhD, RN, CS, FAAN

(representing Asian American and Pacific Islander Nurses Asso-
ciation)

Professor and Chairperson

Graduate Nursing Program

College of Mount St. Vincent

6301 Riverdale Avenue

Bronx, NY 10471

Gloria Myers, JD
(current member National Advisory Council on Nurse Education
and Practice)

Associate General Council

Mission St. Joseph Legal Services

509 Biltmore Avenue

Asheville. NC 28801

Judy Goforth Parker, PhD, RN

(representing National Alaska Native American Indian Nurses As-
sociation)

Department of Nursing

East Central University

1000 East 14* Street

Ada, OK 74820

a4

NATIONAL ADVISORY COUNCIL ON NURSE EDUCATION ANDO PRACTICE


The policy goals and recommended strategies were to be developed with
consideration of the following:

* The current status of diversity in nursing education and practice

+ The opportunities and the obstacles in the internal and external
environment that affect diversity in nursing education and practice

* The financial and human resources needed for implementing the
recommended options

+ Constraints in implementing the action plan

+ Strategies that include joint efforts between public and private
institutions and approaches to implementing these relationships

+ Strategies that consider and incorporate national, State, local,
and institutional needs and plans

Method for Developing the Draft Diversity Agenda

Expert Workgroup members discussed issues and identified policy goals
for each theme. A specified time period was devoted to discussing cach of
the themes of education, practice, leadership, and cultural competency.
However, members were encouraged to return to any of the previously
discussed themes if they needed to make additions, deletions, or changes
10 the policy goals and actions, After Expert Workgroup members agreed
that the list of policy goals and options that had been identified was com-
plete, they prioritized the policy goals. A concern that cut across all policy
goals set forth by the group is the need for sustain ability of efforts in the
absence of external funding. The issues, policy goals and options pro-
duced by the group were submitted to NACNEP for deliberation. This
information was the basis for the issues, policy goals, and actions set forth
in this report.

32

NATIONAL ADVISORY COUNCIL ON NURSE EDUCATION AND PRACTICE


The magnitude of the challenges involved with increasing nursing
workforce diversity requires 4 national effort involving the public and
private sectors. Initiatives must involve the educational system that pro-
duces the nurses as well as the employment settings in which they work.
In order for these efforts to be effective and sustainable there must be
consistent, visible support from the highest levels of government and the
private sector,

‘The National Advisory Council on Nurse Education and Practice
(NACNEP), in its 1996 Report to the Secretary on the Basic Nursing
Workforce, identified actions that the Federal Government should take to
ensure the availability of an RN workforce with a composition appropriate
to meet the nursing needs of the nation’s population. Improving the racial/
ethnic diversity of the RN workforce is one of the key areas identified in
that report.

This NACNEP report presents issues related to rucial/ethnic diver-
sity in nursing education and practice and recommends goals and actions
that can serve as 4 national action agenda to be undertaken by the public
and private sectors to address those issues. The focus areas include
increasing diversity by enhancing efforts to increase the recruitment, re-
tention and graduation of minority students, especially at the baccalaure-
ate level; developing practice environments that improve diversity by
promoting recruitment, retention, and professional development of minor-
ity nurses; promoting minority nurse leadership development; and pro-
moting the preparition of all nurses to provide culturally competent care,

Chart A. Percent Minority in the U.S. Population, Schools of
Nursing, and the Registered Nurse Population,
1996

4 10 8 20 25

BB at. amersaisck ME Hisp/tatinos =|) asianiPt Bh mer. inaiaia. Nat.

Source: Based on data from the Division of Nursing 1996 Sample Survey of
Registered Nurses, the National League for Nursing and the U.S.
Bureau of the Census

NATIONAL ADVISORY COUNCIL ON NURSE FOUCATION AND PRACTICE


time NEO has been the principal program in the Division of Nursing
focused on diversity. During the 10-year period from its inception as a
separate categorical program in 1989 through 1998 the program awarded
208 grants totaling $33.4 million. Findings froma study of beneficiaries
of nursing education projects funded by the Division of Nursing indicate
that if it had not been for the nursing education opportunities projects
funded under Section 820 and Section 827, many of the efforts instituted
to increase diversity in nursing would not have been undertaken. More-
over, indicating the effect of this targeted effort in helping to build a
capacity for diversity, 85 percent of the projects surveyed continued
activities past the termination of Federal funding. (Washington Consult-
ing Group, 1993).

All of the programs administered by the Division of Nursing under
Title VILL, to some extent, address the diversity goal, The Advanced
Education Nursing program, Professional Nurse Traineeship program,
Nurse Anesthetist Traineeship program, and the Nurse Practitioner and
Nurse Midwifery program have all furthered the goal of improving
workforce diversity by giving funding priorities to programs that demon-
strate cither substantial short term progress or a longstanding track record
of enrolling and graduating trainees from those minority or low income
populations identified as at risk of poor health outcomes.

Another program within the Bureau of Health Professions, the
Scholarships for Disadvantaged Students program, provides grants to
schools of nursing to provide financial assistance to students who are
from disadvantaged backgrounds. The Indian Health Service has also
sponsored a number of programs designed to improve the access of
American Indians to careers in nursing,

The Division of Nursing has sponsored three Minority Nurse Lead-
ership Congresses-held in 1992, 1993, and 1997-each of which has pro-
vided a forum in which minority nurse leaders have explored the issues
related to diversity in nursing education, practice, and research, and pro-
duced recommendations for actions to improve diversity.

The first congress, “Caring for the Emerging Majority: Creating
a New Diversity in Nurse Leadership,” was held in 1992, Its purpose was
to develop an action agenda to enhance the recruitment and education of
minority students, to increase the number of minority nursing graduates,
and to improve the provision of health care to minority populations.
Congress participants, who included minority leaders in nursing educa-
tion, practice, research, and higher education, developed individual ac-
tion plans for improving diversity to be implemented in their spheres of
influence.

The second congress, “Caring for the Emerging Majority: Em-
powering Nurses Through Partnerships and Coalitions,” was held in
1993. More than 100 minority nurse leaders in nursing education and
practice were brought together to examine model partnerships and coali-
tions that had been developed in minority communities across the coun-
try. Workgroups were formed, focusing on a single topic chosen by the
participants. These groups proposed specific approaches t solving
health care problems of the emerging majority through partnerships and

NATIONAL ADVISORY COUNCIL ON NURSE EDUCATION AND PRACTICE


TABLE OF CONTENTS

List of members of National ele fee Council on

Nurse Education and Practice .. th
Preface ....... ae)

Section II; Background.
Past and Continuing Federal Efforts to Address
Diversity Issues in Nursing ... ‘ es

‘Section IIb Issues Related to Diversity in Nursing Education
Education
Leadership ..
Practice/Workforce ......
Cultural Competency ..

Section IV: Issues, Policy Goals, and Actions ........
Enhance Efforts to Increase the Recruitment,

Retention, and Graduation of Minority Students —

Promote Minority Nurse Leadership Development ..

Develop Practice Environments that Improve Diversity .....

Promote the Preparation of All Nurses to Provide

Culturally Competent Care .

References ....

Appendices
A. Convening of the Expert Workgroup on Diversity ........ 31
B. Expert Workgroup on Diversity Group Members ........... 3

NATIONAL ADVISORY COUNCIL ON NURSE EDUCATION AND PRACTICE


Policy Goal: To educate all nurses to provide culturally competent care.

Acthon Items:

* Provide funding for the development of content on cultural diver-
sity in the curriculum.

* Create the curriculum resources and tools necessary to teach and
measure cultural competence in nursing education and practice.

* Incorporate cultural diversity in the school/ institution's state-
ment of philosophy.

* Develop standards of pructice that incorporate a body of know-
ledge on cultural competence.

* Integrate cultural competency as a part of accreditation standards
for education and practice.

© Disseminate literature and guidelines on the subject of cultural
competency.

* Promote the use of information on cultural competency available
from the Internet

Issue: Practice performance standards and measurements for assessing
cultural competence are insufficient.

Because the emphasis placed on cultural competence in the provision of
care ts fairly recent, health care providers need more skills and knowl-
edge in this area. Data regarding cultural competence in the workforce
is lacking because assessment measures have not been developed for
educational programs or practice settings. The Office of Minority Health,
U.S. Department of Health and Human Services has recently issued new
guidance in the form of 14 draft standards for culturally and linguisti-
cally appropriate services (CLAS) that are intended to support a more
uniform and comprehensive approach to cultural competency standards
and practice.

Policy Goal: To establish cultural competence standards in education
and practice.

Action Items:

* Increase funding for research and research opportunities that
relate to establishing outcome measures and standards for
cultural competence.

* Develop a forum for providing technical assistance and peer
Teview opportunities for minority nurses seeking to develop

research proposals related to cultural competence performance
standards.

* Review and consider for adoption the recommended standards
for culturally and linguistically appropriate services proposed by
the Office of Minority Health, U.S. Department of Health and
Human Services.

NATIONAL ADVISORY COUNCIL ON NURSE EDUCATION AND PRACTICE

25


Analysis of successful minority nurse leadership programs, such as
the American Nurses’ Association Ethnic-Racial Minority Fellowship Pro-
gram holds the potential for providing a wealth of information to be used
as a basis for expanding that particular mode! or some other models for
increasing the pool of minority faculty and other nurse leaders.

There is not only the need to produce more minority nurse leaders
‘but also to sustain those who have achieved leadership positions, The
small numbers of minority administrators, educators, and researchers re-
sult in significant challenges for those who are currently in those leader-
ship positions. For example, in the case of minority faculty, the multiple
Toles of mentor, role model, and participant in minority affairs activities, in
addition to teaching, practice, and research can be an overwhelming chal-
lenge. Minority leaders, especially, need a network of supportive peers
and to date, this support system has been somewhat limited,

Resources should be used to build and strengthen a cadre of nurses
who will be leaders for meeting the healthcare needs of a culturally diverse
population, Organizations that obtain external funding for programs to
develop minority leaders must be committed to sustain such programs
when external funding is concluded, Sustainability of such projects is en-
hanced through the preparation and dissemination of technical reports
and surveillance activities that highlight success.

Practice/Workforce

The underrepresentation of minority nurses and its effect on the
nursing profession's ability to meet health care needs are the overarching
practice/workforce issues relative to the minority nurse workforce. Other
issues are the retention and advancement of minority nurses in work sct-
tings, changing the educational mix of the workforce, and implications of
the aging minority nurse workforce.

Underrepresentation and its implications. In 1996, 217,000, or about
10 percent of the 2,116,000 employed RNs in the U.S, were from racial!
ethnic minority backgrounds, These figures are in sharp contrast to the
diversity of the U.S. population at that time, More than one-fourth or
71,000,000 of the Nation's population were persons of the racial/ethnic
backgrounds. The small numbers of minority nurses in relation to minority
populations have implications for the availability of nurses to deliver
culturally appropriate, sensitive, and competent care to the Nation's grow-
ing minority populations, The likelihood of increasing acceptability of ser-
vices on the part of minority populations increases with the numbers of
minority nurses and the language and cultural compatibility that they offer,
This is not to imply that provision of nursing services to minority groups
should be solely the responsibility of minority nurses. All nurses will need
to become more aware of and better able to relate to the needs of this
growing segment of the population. There is a need for the identification of
creative mechanisms for sharing the knowledge and expertise of minority
nurses with the larger nursing community caring for diverse populations,
Nonetheless, the relatively small number of minority nurses limits their
availability to the populations who probably need them mast. The follow-
ing minority nurse to minority population ratios highlight the significant
gap in the availability of minority nurses to serve as advocates for minority

NATIONAL ADVISORY COUNCIL ON NUASE EDUCATION AND PRACTICE


The views expressed in this document are solely those of the National Advisory Council on Nurse
Education and Practice and do not necessarily represent the views of the Health Resources and
Services Administration nor the U.S. Government,


Action Items:

* Gather, analyze, and disseminate information regarding charac-
teristics of minority students involved in successful models
of recruitment and retention in basic nursing education
programs.

* Implement and evaluate collaborative partnerships to identify
predictors of success.

* Identify the predictors of successful completion of a nursing
education program.

Issue: Minority populations, like the general public, are poorty informed
about careers in nursing.

There is a general lack of understandiny of the contributions aned
roles of nurses in health care delivery.

Policy Goal: To educate minority communities regarding nursing as a

Action Items:
* Launch a national media campaign targeted to positively influ-
ence the attitudes and perceptions about nursing as a carcer for mi-
* — Mobilize the nursing community to work with the media and
motion picture industry to promote nursing as a worthwhile career
and as a profession with a diverse workforce.
* — Educate minority communities on the various roles performed by
nurses.
* — Work with minority organizations (sororities, fraternities, profes-
sional associations, churches, civil rights, and other groups) to im-
prove the public's understanding of the academic preparation re-
quired to enter a nursing career.

Issue: Many minorities with an interest in a nursing career do not
have the academic preparation that will facilitate their entry into,
retention, and graduation from nursing education programs.

In many cases students and their academic advisors do not under-
stand the types of nursing educational programs and their entry
requirements.

Policy Goal: To increase minority students’ and their advisors/counse-
lors’ understanding of the academic requirements necessary to facili-
tate access to a professional nursing program.

Action Items:

* Develop K-12 initiatives focusing on nursing a5 a career
for minorities and provide appropriate information on the
academic requirements,

* Link students in K-12 with innovative programs so that
they can understand the value of nursing within the larger
social content.

NATIONAL ADVISORY COUNCIL ON NURSE EDUCATION AND PRACTICE

21


NATIONAL ADVISORY COUNCIL ON NURSE EDUCATION AND PRACTICE


‘Table 3, Number and Percent of Minority and Non-Minority Hospital
Employed RNs by Selected Position Titles, 1996

Total Adiministratoc! | Supervisor | Head Nurse
Race/Ethnicity Hospital Asst.
Employed | Administrator
No, a No. * No. * No. *
American Indian/Alaska Native 6250| 100 240 3 568 | 9.1 Ws | 22
Asian/Pacific Islander 57351} 100 404 O7 845) 15] 2196 | 39
African American/Black $4901) 100 | 1349 25 | 2155) 39] 5497 | 100
Hispanic/Latino 22807 | 100 200 09 818) 36] 1312) 58
‘Tosal Minority 141309) 100 | 2193 16 | 4386/ 31 9140 | 6S
Total Non-Minority 1121346 | 100 | 27569 25 |30261| 27 | 68702 | 58

Source: National Sample Survey of Registered Nurses, March 1996, Division of Nursing, Bureau of

Health Professions.

The educational mix of the minority nurse workforce-The NACNEP
has concluded that the changing health care environment significantly
influences the essential knowledge and skills needed by the current basic
nurse workforce to provide appropriate care to the population and that the
educational mix of the existing registered nurse workforce needs to be
altered to include larger numbers of those who are at least baccalaureate
prepared. RNs differ according to racial/ethnic background in the percent-
ages with at least baccalaureate educational preparation(as Chart C illus-
trates). Asian/Pacific Islander and Atrican American/Black RNs are more
likely than all other RNs to have obtained at least baccalaureate prepara-
tion. Moreover, African American/Black and American Indian/Alaska Na-

Chart C. Percent Distribution of RNs in Each Racial/Ethnic Group
by Highest Educational Preparation, March 1996

Atr AmorBlack

Amer Ind/Ala Nat

& diploma El assoc Degree
©) Baccsisuente Deg {2 mastors +

Source: National Sample Survey of Reginered Nurses, Division of Nursing. Bureau of Health

Professions.

NATIONAL ADVISORY COUNCIL ON NURSE EDUCATION AND PRACTICE



PREFACE

‘The health of the Nation depends on an adequate supply of nurses
and « nursing workforce that reflects the racial and ethnic diversity of the
population. Racial und ethnic minorities currently comprise more than
one-fourth of the Nation's population and will comprise nearly 40 percent
by the year 2020, The most recent nursing workforce data available docu-
ment that less than 10 percent of all RNs are minority nurses. These facts
and the current trends in the numbers of minority students in the nursing
educational pipeline suggest that without significant interventions the
nursing workforce will continue to be out of balance with the health care
demands imposed by the changing population demographics. Renewed
and reinforced efforts are required to effectively address the
underrepresentation of raciaVvethnic minority populations in the registered
nurse workforce,

This report is a wake-up call for action. It is intended to serve us a
starting point for the many agencies and organizations that are involved in
nursing education and practice to operationalize the recommended items
in order to remedy this longstanding and growing challenge to the profes-
sion. The actions that are recommended intentionally do not suggest or
identify specific organizations to be responsible for their implementation.
However, the report is being widely disseminated to those involved with
nursing and the delivery of health care services in general, including the
Secretaries of the Department of Health and Human Services and the De-
partment of Education, members of Congress, professional organizations,
schools of nursing, foundations, policy makers, service administrators.
and to the people of this Nation whom this issue concerns and impacts.
All entities with responsibilities and concerns in this area are urged to
review and embrace the recommendations as agenda setting prioritics as
they relate to the mission of their organization.

The National Advisory Council on Nursing Education and Practice
(NACNEP) will continuously monitor and benchmark progress toward these
policy goals and action items. This monitoring and reporting on progress
will require the full participation of the entities implementing the actions
and ongoing feedback about successes and lessons learned.

NATIONAL ADVISORY COUNCIL ON NURSE EDUCATION AND PRACTICE


ee
ll. Background

Past and Continuing Federal Efforts to Address Diversity
Issues in Nursing

The issue of increasing diversity in the healthcare workforce and the
implementation of efforts to address it are longstanding. Since the 1960s
the Federal Government has provided funding for programs and initiatives
with the intent of increasing the representation of racial/ethnic minorities
inthe health professions. The Allied Health Professions Personne! Train-
ing Act of 1966 (P-L. 89-751) authorized a program of Nursing Educational
Opportunity grants (Section 861) for financially needy students and also
provided contract authority (Section 868) for “Pull Utilization of Nursing
Educational Talent” projects to foster the recruitment of such individuals.
Under the impetus of this legislation, the Division of Nursing launched a
recruitment program designed to create opportunities for youths from dis-
advantaged backgrounds to complete a nursing education program. These
recruitment efforts were further expanded, following the enactment of the
Nurse Training Act of 1971, to assist a broad spectrum of individuals,
including financially of otherwise disadvantaged persons, raciaVethnic
minorities, older women, veterans of the Armed Forces, and licensed prac-
tical nurses. Between 1968 and 1974, 25 contracts and nine grants amount-
ing to $4.8 million, were awarded under these authorities. A retrospective
contract study of the outcomes of projects funded under this legislative
authority found that the Full Utilization program was successful in attract-
ing persons from ethnic minority groups into nursing. (USDHHS, 1979).

‘The Nurse Training Act of 1975 (Title VII of the Public Health Ser-
vice Act) placed support for diversity projects under Special Project Grants
and Contracts, The Special Projects grants program was authorized under
Section 820 of the Public Health Service Act to improve nursing practice
through projects that increase the knowledge and skills of nursing person-
nel, enhance their effectiveness in primary health care delivery, and in-
crease the number of qualified professional nurses, The Act specified that
at least 10 percent of the funds appropriated under this section be used to
pay the costs of projects to increase nursing education opportunities for
individuals from disadvantaged backgrounds. Additionally, this legisla-
tion provided for payment of stipends for the project students. The
Omnibus Budget Reconciliation Act of 1981 provided increased emphasis
on diversity by requiring that at least 20 percent of funds appropriated for
special project grants be obligated for assistance to nursing education
opportunities for students from disadvantaged backgrounds projects.

The Nurse Shortage Reduction and Education Extension Act of 1988
gave new emphasis to efforts addressing the workforce diversity issue by
establishing a new provision, Section 827, Nursing Education Opportuni-
ties for Individuals from Disadvantaged Backgrounds (NEO), Since that

NATIONAL ADVISORY COUNCIL ON NURSE EDUCATION AND PRACTICE