Diversifying the nation's health workforce is a key component of strategies to increase access to quality health care for all populations, reduce health disparities, and achieve health equity. Diversity among health professionals improves patient-clinician interactions and communication, patient satisfaction, and access to care. In a 2004 report, the Institute of Medicine recommended increasing the number of minority health professionals by changing the culture of health professions schools (Sullivan, 2004).
Recent data from the 2018 National Sample Survey of Registered Nurses (U.S. Department of Health and Human Services, 2019) show that White, non-Hispanic RNs accounted for the largest proportion of respondents (73.3%), followed by Hispanic RNs (10.2%), Black non-Hispanic RNs (7.8%), Asian non-Hispanic RNs (5.2%), and multiple races (1.7%). Racial and ethnic minority groups accounted for 26.7% of the RN respondents this study. In particular, for RNs who graduated after 2013, the number of individuals reporting they were not of non-Hispanic White descent was higher at 31.2% than the number of those licensed prior to 1977 at 14% (U.S. Department of Health and Human Services, 2019). Although nursing has made strides in recruiting and graduating students from minority and disadvantaged backgrounds, the United States remains far from achieving the goal of a nursing workforce that mirrors the nation's diverse population.
The Health Resources and Services Administration (HRSA), an agency of the U.S. Department of Health and Human Services, is committed to reducing disparities and improving health equity. Within HRSA, the Bureau of Health Workforce (BHW), Division of Nursing (now the Division of Nursing and Public Health) oversees several nurse training programs. In 2012, BHW developed the Transformation From Health Disparities to Health Equity Model that incorporates the concept of social determinants in a framework to facilitate a nursing workforce that more closely reflects the nation's populace. The BHW began implementing this framework into the Nursing Workforce Diversity (NWD) program, which provides grants to schools of nursing and other private and nonprofit organizations to promote the recruitment, retention, and graduation of nursing students from disadvantaged backgrounds, including racial and ethnic minorities underrepresented among RNs. In alignment with the Sullivan Report (2004) recommendation, the goal of this program is to increase the diversity of the student population within schools of nursing.
A social determinants framework is based on the evidence that multilevel social, environmental, and structural factors influence an individual student's growth and development, as well as an institution's ability to recruit, retain, and graduate underrepresented students (Williams et al., 2014). This framework identifies barriers to encourage institutions to evaluate and change current practices. Institutions can use evidence-based strategies to create a culturally responsive learning environment that is adaptable to the complex needs of a diverse student population.
The NWD program began embedding the social determinants framework into its funding opportunities in Fiscal Year (FY) 2013. Since then, the program has supported more than 92 awards to schools of nursing that use the social determinants to address and increase diversity in their student populations. In Academic Year (AY) 2014–2015, the NWD program trained more than 4,444 students, with nearly 100% of the trainees funded through NWD coming from underrepresented minorities or disadvantaged backgrounds, including nearly 28% who reported Hispanic ethnicity.
In FY 2015, NWD provided an administrative supplement to the National Institute on Minority Health and Health Disparities (NIMHD), a part of the National Institutes of Health, to help fund the Urban Universities for HEALTH (UU-HEALTH) study. UU-HEALTH was intended to identify best practices and novel approaches to health workforce diversity, with specific relevance to the nursing workforce. This study found that a holistic admissions process was a key strategy to increasing diversity among nursing students.
Holistic admissions is a specific diversity recruitment and retention strategy derived from the concept of social determinants. When implemented in schools of nursing, the holistic admissions approach assesses an applicant's unique experiences, qualities, and attributes alongside traditional measures of academic achievement (Glazer et al., 2016). The purpose of holistic admissions is not to lower the standard of nursing education, but rather to broaden the concepts of the characteristics of a successful student who can contribute to the school of nursing's mission and goals. Holistic admissions is a strategic process that matches the goals and mission of the nursing institution, and promotes diversity and educational excellence. UU-HEALTH (2014) found that among health professions schools that changed to holistic admissions in the previous decade, 72% reported an increase in diversity, while measures of students' academic success were unchanged, and in some cases had even improved.
The FY 2017 revised NWD Notice of Funding Opportunity, informed by the UU-HEALTH work, required applicants to implement a comprehensive systems approach to the recruitment, enrollment, retention, and graduation of students from disadvantaged backgrounds in nursing schools. The comprehensive systems approach included the use of the social determinants framework and implementation of holistic admissions. This investment represented $18 million in funds provided to 34 schools of nursing.
In AY 2018–2019, a year after the implementation of holistic admissions, the NWD program supported the training of more than 11,000 students, with 51% of trainees from underrepresented minorities, 61% from disadvantaged backgrounds, and approximately 13% from a rural residential background. NWD awardees collaborated with 789 clinical sites to provide more than 7,000 training experiences to NWD trainees. Implementing holistic admissions and social determinants has had a significant impact on the number of students from disadvantaged backgrounds, including under-represented racial and ethnic minorities, trained in schools of nursing who will ultimately enter the nursing workforce.
The BHW is engaged in multi-pronged strategies to increase diversity and achieve health equity. The NWD program is one major tool in pursuit of the health equity strategic goal. Each evidence-based strategy, standing alone, is not sufficient to achieve diversity of students from disadvantaged backgrounds (World Health Organization, 2008). The emphasis cannot focus on one strategy. Multiple strategies have to be built and work together to create a system that benefits the student as a whole. The systems approach is one that is detailed, intentional, and ongoing, and is built to increase the diversity in the students recruited and then enrolled into schools of nursing. To make the system fully comprehensive, institutions also must assess the structural and systemic forces that impede the success of students from disadvantaged backgrounds. This system takes dedication and is a deliberate initiative to implement necessary changes to foster a sense of support and success at all levels, including the individual student, the school of nursing, nurse faculty, and the health care system as a whole.
Increasing workforce diversity promises to broaden access to high-quality care and reduce the incidence, prevalence, and burden of disease among patient populations. These are important steps toward attaining health equity at the highest level of wellness for all people. Nursing pipeline programs such as NWD are changing the culture of nursing education to promote diversity among students, and ultimately the nursing profession.
Tara D. Spencer, MS, RN
Chief, Nursing Education
and Practice Branch
Division of Nursing and Public Health
Bureau of Health Workforce
Health Resources and
- Glazer, G., Clark, A., Bankston, K., Danek, J., Fair, M. & Michaels, J. (2016). Holistic admissions in nursing: We can do this. Journal of Professional Nursing, 32(4), 306–313.
- Sullivan, L.W. (2004). Missing persons: Minorities in the health professions, a Report of the Sullivan Commission on Diversity in the Healthcare Workforce. https://www.aacnnursing.org/Portals/42/News/Sullivan-Report.pdf
- Urban Universities for HEALTH. (2014). Holistic admissions in the health professions: Findings from a national survey. http://urbanuniversitiesforhealth.org/media/documents/Holistic_Admissions_in_the_Health_Professions.pdf
- U.S. Department of Health and Human Services, Health Resources and Services Administration, National Center for Health Workforce Analysis. (2019). 2018 National Sample Survey of Registered Nurses brief summary of results. U.S. Department of Health and Human Services.
- Williams, S.D., Hansen, K., Smithey, M., Burnley, J., Koplitz, M., Koyama, K., Young, J. & Bakos, A. (2014). Using social determinants of health to link health workforce diversity, care quality and access, and health disparities to achieve health equity in nursing. Public Health Reports, 129(1, Suppl 2), 32–36 doi:10.1177/00333549141291S207 [CrossRef]
- World Health Organization. (2008). Closing the gap in a generation: Health equity through action on the social determinants of health. Final report of the Commission on Social Determinants of Health. World Health Organization.