The events of 2020 have brought a new global awareness for the need to focus on diversity, equity, and inclusion (DE&I). Independent Sector, a national membership organization that focuses on providing programs to strengthen civil society and ensure all people in the United States thrive, provides definitions (Table 1) that appeal to a wide variety of professions. For nurses, the American Nurses Association's (ANA) Nursing's Social Policy Statement (2010) brings awareness to nursing's commitment to address the needs of a diverse patient population. As early as 1995, the policy stated that as a profession, nursing practice is based on values that are “culturally defined” and that the relationship between patient and nurse occurs “within the context of the values and beliefs of the patients and the nurse” that then extends to the family and the community (p. 67).
Diversity, Equity, and Inclusion
DE&I is moving to the forefront of the ANA agenda. In a personal communication, Dr. Ernest Grant, President of the ANA, stated “I am a firm believer that nursing should be reflective of the people that we serve. It is imperative that the nursing profession is inclusive of language and policies that address and embrace DE&I. We must recognize that such policies and standards have an impact on the patients, families, our communities, the health care system, and most importantly our colleagues. We must not only come up with new policies that address DE&I, but we must also address the circumstances that created a system that was not inclusive” (E. Grant, personal communication, December 22, 2020).
In our roles as nursing professional development (NPD) leaders, we need to ensure DE&I is threaded throughout practice environments and easily visible in educational and professional development offerings.
Building an Environment of DE&I
Professional organizations are being called on to speak to DE&I. The Association of Nursing Professional Development threads these concepts throughout their Scope and Standards (Harper & Maloney, 2016) as they speak to:
- diversity awareness (p. 24)
- increasing diversity in the nursing workforce (p. 26)
- supporting a practice environment that includes patient populations with more complex clinical needs associated with the impact of chronic illnesses, aging, and greater cultural diversity (p. 26), and
- “respects diversity by considering cultural, ethnic, generational, and other differences in planning to meet learner needs” (p. 34).
Awareness starts with conversations and self-reflection. Here are some questions for self-reflection that also may help to start a conversation with others:
- What are your personal views of DE&I at your organization? In your department?
- Is it hard for you to work with other health care professionals, patients, and families who have different values than you?
- After reviewing the definitions of DE&I, is your department on target for supporting a positive DE&I environment?
- Can you see an opportunity for change?
- When you look at your current department, are there employees from different ethnicities?
- Does your department reflect your nursing workforce? Your patient population?
- Does your department currently have policies that support DE&I?
- Does your organization and/or department value and respect people from all cultures and backgrounds? If so, how do they do this?
- Does the professional development you provide reflect and explore the social and cultural diversity of the population?
- Does organizational leadership demonstrate a commitment to DE&I?
- Does your organization and your department encourage any qualified person to apply for a higher position?
- In a perfect DE&I world, what would your department look like?
These reflections and conversations help in creating a baseline awareness of where you are at regarding DE&I in your work environment and planning a future vision. Use the final question—“in a perfect world”—to create that vision.
Increasing Diversity in the Nursing Workforce
The National Council of State Boards of Nursing and The Forum of State Nursing Workforce Centers (Smiley et al., 2018) report the RN population is composed of 80.8% White/Caucasian; 6.2% African American; 7.5% Asian; 5.3% Hispanic; 0.4% American Indian/Alaskan Native; 0.5% Native Hawaiian/Pacific Islander; 1.7% two or more races; and 2.9% other—hardly a representation of the community population served.
Recognizing the need to increase DE&I in a health care workforce that includes all team members, from administration to support staff is important, but more needs to be done than just hiring diverse colleagues. For the NPD administrator, ensuring the diversity of the health care workforce starts with building an education department that represents the organization and the patient population. In all practice settings—whether a centralized education department in a large health care system, community hospitals, rural or unit-based educators—the first step to awareness is one of assessment and self-reflection as noted above. The purpose is to explore biases and prejudice while identifying a common goal—creating a work environment that supports colleagues and patients. From there, the NPD administrator should purposefully build a department that supports DE&I in both its workforce and the educational offerings they provide.
Supporting a DE&I Practice Environment
Strategies to support DE&I exist in the practice environment. Bob Hess, PhD, RN, FAAN, the Founder and Chief Executive Officer of the Forum for Shared Governance, described shared governance as a “managerial innovation invented by nurses 40 years ago that gives bedside providers and managers equal say in the decisions affecting care and the resources that support it” (B. Hess, personal communication, December 20, 2020). Dr. Hess asks, “What better way to promote interprofessional cooperation that cuts across gender, profession, roles, and underrepresented groups by bringing them to the same table with a common purpose—to provide better professional, organizational, and patient outcomes.”
Well-written, inclusive organizational policies also provide expectations relating to behaviors, practice, and decision making while supporting positive outcomes. Policy advocacy for DE&I inclusion starts with appropriate race and ethnicity representation on policy committees. This group then reviews current policies making sure all stakeholders are represented while looking for unintentional stereotypes. The result should be a statement of intent that mirrors the values of the organization and/or department. When done well, the result is the creation of an equitable practice environment.
Nursing Professional Development
For NPD, DE&I is part of a process, not a single educational experience. Like all quality professional development, the educational design process begins with the identification of a practice gap. In determining the practice gap, the organization with the nurse planner can draw from past or current situations or may perform a self-assessment such as identifying areas of concern while providing opportunities for reflection and improvement. Areas for performance improvement may lie within a single profession, may be interprofessional in nature, and may be related to patient/family or support person needs or the organization. Additionally, the nurse planner identifies where the underlying educational need exists—whether that be knowledge, skill, and/or practice.
Once the gap has been identified, the nurse planner ensures that there is representation of all stakeholders on the planning committee and that the attitude, judgements, beliefs, and values within the planning committee are recognized. If the educational activity includes information for the population the organization serves, there should be representation from that population. For example, if the gap includes providing care to a specific community population, the nurse planner ensures representation from that population is included in all aspects of activity planning. Inclusion makes sure the information is presented in a language understood by both the planning committee and the learner. Learning outcomes are then developed based on collaborative discussions and feedback from the planning group, as are the content and strategies used to deliver the educational offering. The use of case studies, reflection, and role-playing that reflect the population are examples of strategies to engage the learner. It is critical that these perspectives are considered during program development to allow for a diversity of thought to appropriately guide both practice and learning.
Organizational core competencies that address professional behaviors, as well as performance criteria from practice competencies, are also written to reflect the value, philosophy, and goals of the organization. For example, Quality and Safety Education for Nurses (n.d.) speaks to how principles of patient-centered care include “diverse cultural, ethnic, and social backgrounds [that] function as sources of patient, family, and community values” (“Knowledge” section). These declarations need to be part of the organization's competencies that guide professional behavior and patient interactions.
NPD outreach to create partnerships is a critical component to ensure inclusion. Using a “pipeline-model-approach,” colleges of nursing are making efforts to admit students from underrepresented populations with outreach to high school students, offering financial, social, and ongoing academic support (Murray et al., 2016). Health care organizations—and NPD practitioners specifically—should out-reach to become part of these programs working together to connect multicultural students and practice.
Reaching out to community leaders and being part of community-based discussions may also provide additional appreciation and understanding for the diversity of the community. Health care is considered an extension of the community, so meeting DE&I goals is critical.
Social media has taken a leading role in the development of opinions, expressing views, and sharing experiences. Mindful use of social media to positively express the goals of DE&I in the community and from the health care organization perspective could be a game changer for the organization trying to connect with the community. Working with the organization's media/communication department to message DE&I would be of benefit to all.
Finally, the impact role modeling can have on influencing the behaviors of colleagues is most important. No matter the level of authority, demonstrating behaviors and comments that support DE&I influences by example. It is up to every practitioner to commit to the demands for a more equitable and inclusive work environment by mirroring positive actions.
The events of 2020 have resulted in a call to action—not just discussion. There is a need to make changes in how we address and prioritize DE&I, with the goal of systemic change that results in a more equitable environment for health care practice and patient healing. As a professional group, we need to identify and embed strategies that promote a continuation of DE&I from academia and throughout lifelong learning and professional development. As nurse educators, we have the potential to expand the capacity for improving the presence, participation, and achievement of all practitioners. The challenge is to purposely mobilize this potential.
- American Nurses Association. (2010). Nursing's social policy statement: The essence of the profession. Nursesbooks.org.
- Harper, M. G. & Maloney, P (Eds.). (2016). Nursing professional development: Scope and standards of practice. Association for Nursing Professional Development. doi:10.1097/NND.0000000000000255 [CrossRef]
- Kapila, M., Hines, E. & Searby, M. (2016). Why diversity, equity, and inclusion matter. https://independentsector.org/resource/why-diversity-equity-and-inclusion-matter/
- Murray, T. A., Pole, D. C., Ciarlo, E. M. & Holmes, S. (2016). A nursing workforce diversity project: Strategies for recruitment, retention, graduation, and NCLEX-RN success. Nursing Education Perspectives, 37(3), 138–143 PMID:27405194
- Quality and Safety for Nurses. (n.d.) QSEN competencies. https://qsen.org/competencies/prelicensure-ksas/
- Smiley, R. A., Lauer, P., Bienemy, C., Berg, J. G., Shireman, E., Reneau, K. A. & Alexander, M. (2018). The 2017 national nursing workforce survey. Journal of Nursing Regulation, 9(3), S1–S88 doi:10.1016/S2155-8256(18)30131-5 [CrossRef]
Diversity, Equity, and Inclusion
|Diversity||“Includes all the ways in which people differ, encompassing the different characteristics that make one individual or group different from another. While diversity is often used in reference to race, ethnicity, and gender, we embrace a broader definition of diversity that also includes age, national origin, religion, disability, sexual orientation, socioeconomic status, education, marital status, language, and physical appearance. Our definition also includes diversity of thought: ideas, perspectives, and values. We also recognize that individuals affiliate with multiple identities.” (para. 3)|
|Equity||“The fair treatment, access, opportunity, and advancement for all people, while at the same time striving to identify and eliminate barriers that have prevented the full participation of some groups. Improving equity involves increasing justice and fairness within the procedures and processes of institutions or systems, as well as in their distribution of resources. Tackling equity issues requires an understanding of the root causes of outcome disparities within our society.” (para. 4)|
|Inclusion||“The act of creating environments in which any individual or group can be and feel welcomed, respected, supported, and valued to fully participate. An inclusive and welcoming climate embraces differences and offers respect in words and actions for all people. It's important to note that while an inclusive group is by definition diverse, a diverse group isn't always inclusive. Increasingly, recognition of unconscious or ‘implicit bias’ helps organizations to be deliberate about addressing issues of inclusivity.” (para. 5)|