“The worst form of inequality is to try to make unequal things equal.”
Every fall semester, I look forward to greeting the new freshman class. Over the decades, regardless of my academic institution, I have been struck by the lack of visible diversity in the incoming class—that is, the far too few brown or black faces who look like me. Gazing at the sea of faces, it was clear why there was not more visible diversity in the RN workforce. The lack of diversity in nursing education programs was and remains the major reason for the lack of diversity in the RN workforce. African Americans and Hispanic/Latinos continue to be underrepresented in the RN workforce (National Academies of Sciences, Engineering, and Medicine, 2016). The 2017 National Nursing Workforce Survey revealed that only 19.2% of the survey respondents were from minority backgrounds yet minorities constitute nearly 42% of the U.S. population (National Council of State Boards of Nursing, 2019; U.S. Census Bureau, 2018). While some progress has been made, 32.2% of the 2018 new entry-level graduates were from racially and ethnically diverse backgrounds, increased from 24.4% a decade ago, there is still much work to be done if the RN workforce is to mirror the general population (American Association of Colleges of Nursing, 2019). The most effective way to increase the numbers of racial and ethnic minorities in the RN workforce is to admit and graduate more students from those backgrounds (National Academies of Sciences, Engineering, and Medicine, 2016).
One reason for the lack of diversity could be that students, who are from racially and ethnically diverse backgrounds, have often been plagued with long-standing and persistent social, economic, and environmental circumstances that impede their ability to be strong competitive applicants when seeking admission into a nursing education program. These circumstances, often referred to as social determinants, can have a profound impact on the student's chances for educational progression. Consider income or the income inequality between dominant and nondominant racial groups. In 2018, the gap between the haves and have-nots grew to its highest level in more than 50 years of tracking income inequality, most notably with Black and Hispanic individuals at the lower rungs (U.S. Census Bureau, 2019). Income inequality tends to be a precursor to disparities in educational advancement and attainment. Income is a determinant of the residential location or neighborhood. Higher resourced school districts, most often located in higher income neighborhoods, have greater wealth to invest in educational resources (e.g., better school facilities, teacher quality, better teacher-to-student ratios, advanced curricula and courses, and enrichment opportunities) that contribute to the student's academic success (Owens, 2018). Whereas, lesser resourced schools are typically located in disadvantaged areas with dwindling tax bases, fewer resources to invest in schools, and stark differences in educational quality, educational opportunities, and precollege entry preparation (Owens, 2018).
Another reason for the lack of diversity in nursing education programs could be the admission process. The admissions policies, often based on meritocracy, ostensibly are fair, equitable, and designed to admit students with the highest probability of success. The students who achieve the requisite grade point average and standardized test score will more than likely gain admission into the program. If there are capacity challenges, admission decisions can be based on descending order rank of the grade point average and standardized test score. Students with the highest grade point averages and standardized test scores are granted admission until the maximum enrollment number is reached, often followed by a wait list. This process, which is the standard operating procedure for most nursing education programs, can serve as a structural barrier for students who are from racially and ethnically diverse backgrounds. This approach provides equality of opportunity but can have outcomes that disadvantage certain groups. The process disregards the inequality in the student's previous academic environment and the academic support available in terms of comparative resources for the precollegiate education.
Am I asking that schools change their admission requirements? No, but using a social justice lens, I am advocating for academic administrators and faculty to expand admission opportunities in the upcoming admission cycle to students who are from racially and ethnically diverse backgrounds, being mindful of the historical and structural inequities that have disadvantaged certain groups. Progressing to a more diverse student body will require changing admission practices to create opportunity. One evidence-based way to expand admissions to students from diverse backgrounds could be through the holistic admissions review process (American Association of Colleges of Nursing, 2016). However, be mindful that after students are admitted, there should be an array of academic support services, mentoring programs, and an inclusive climate where all students can feel free to learn and thrive. What are some action steps that can be taken to increase diversity in nursing education programs?
- Consider the influence your approach to admissions can have on students from diverse backgrounds.
- Develop programs aimed at the successful recruitment of students who are from racially and ethnically diverse and disadvantaged backgrounds.
- Ensure there is a critical mass of incoming students who are from racially and ethnically diverse and disadvantaged backgrounds and not just an isolated few.
- Understand that students may not conform to the default Eurocentric perspective.
- Provide academic and student support services to support retention.
- Create safe spaces for students to share their feelings and perceptions.
- Provide role models and mentors to guide students along the way.
Although this editorial specifically calls for visible diversity, all forms of diversity and difference should be considered during the admissions process. Interactions and exchanges among individuals of diverse backgrounds offer a unique richness and expose students to a variety of perspectives and intersectionality. Why is this important? A commitment to diversity, equity (fair-mindedness), and inclusion ensures academic excellence (Josiah Macy Jr. Foundation, 2018). Exemplary learning environments are committed to the full range of human diversity, and the institution's commitment is reflected in its mission, culture, policies, and practices (Josiah Macy Jr. Foundation, 2018). Learning environments that embrace the full range of diversity are essential if we are to have a health care workforce that is reflective of society. Graduates from diverse backgrounds are more likely to return to their environments, be better able to address challenges unique to specific communities, and provide care rooted in an understanding of the environmental and cultural contexts that influence health and health outcomes (Schmidt, George, & Busy-Jones, 2016). A cadre of diverse health care providers is a necessary step in achieving health equity.
Teri Murray, PhD, PHNA-BC, RN, FAAN
- American Association of Colleges of Nursing. (2016). Holistic review: A quick primer. Retrieved from http://urbanuniversitiesforhealth.org/media/documents/Holistic_Review_Primer.pdf
- American Association of Colleges of Nursing. (2019). Table 11b. Race/ethnicity of graduates from generic (entry-level) baccalaureate, master's, and doctoral (research-focused) programs in nursing, 2009–2018. Retrieved from https://www.aacnnursing.org/Portals/42/News/Surveys-Data/Race-and-Ethnicity-of-Students-Nursing-Programs.pdf
- Josiah Macy Jr. Foundation. (2018). Improving environments for learning in the health professions. Proceedings of a conference chaired by David M. Irby. New York, NY: Author. Retrieved from https://macyfoundation.org/assets/reports/publications/macy_monograph_2018_webfile.pdf
- National Academies of Sciences, Engineering, and Medicine. (2016). Assessing progress on the Institute of Medicine report, The Future of Nursing. Washington, DC: The National Academies Press.
- National Council of State Boards of Nursing. (2019). 2017 National Council of State Boards of Nursing workforce study. Retrieved from https://www.ncsbn.org/workforce.htm
- Owens, A. (2018). Income segregation between school districts and inequality in students' achievement. Sociology of Education, 91, 1–27. doi:10.1177/0038040717741180 [CrossRef]
- Schmidt, S., George, M. & Busy-Jones, J. (2016). Welcome to the neighborhoods: Service learning to understand of social determinants of health and promote local advocacy. Diversity and Equality in Health Care, 13, 389–390. doi:10.21767/2049-5471.100081 [CrossRef]
- U.S. Census Bureau. (2018). U.S. Census Bureau quick facts. Retrieved from https://www.census.gov/quickfacts/fact/table/US/RHI725218
- U.S. Census Bureau. (2019). Income and poverty in the United States: 2018. Retrieved from https://www.census.gov/library/publications/2019/demo/p60-266.html