BY BENJAMIN J. FOSTER, MBA
Healthcare disparities in the United States healthcare system have long been an issue. The disproportionate impact the COVID-19 pandemic had on people of color forced organizations to take a closer look at what could and should be done to address disparities and inequities in our healthcare system. Trusted organizations such as the American Nurses Association, the American Hospital Association and the Centers for Disease Control and Prevention provided research and interventions that organizations can adopt to begin the work required to close the gap in health equity. In this article, we will explore nurse and patient mix demographics and discuss strategies organizations are implementing to better align the racial diversity of their nursing workforce with patient demographics.
According to the 2020 National Nursing Workforce Study conducted by NCSBN, about 80% of nurses in the U.S. are white; nurses of color (i.e., non-white nurses) account for about 20% of the nursing workforce. In contrast, patients of color make up close to 40% of the U.S. patient population (HRSA Uniform Data Systems). For the nursing workforce to reflect patient racial and ethnic demographics, the U.S. needs to prepare 600,000 more nurses of color. Aligning nurse demographics with patient demographics to address health inequities is a monumental task. Nursing schools and healthcare organizations must take a multi-pronged approach and implement programs to ensure all nurses are providing culturally competent care while also increasing the number of newly trained nurses of color.
Focusing on diversity, equity and inclusion is at the forefront of improving care received by patients in the healthcare system. Diversity in nursing is key because patients do better and are more comfortable when they are cared for by a nurse who relates to them and can effectively communicate care plans. Additionally, a diverse healthcare team provides patients with healthcare workers who are informed and sensitive to cultural nuances and issues relating to inclusion and equity. Maternal mortality is an extreme example of healthcare inequity in the U.S. when comparing favorable outcomes for Black women with other racial/ethnic groups. According to Press Ganey, the HCAHPS survey data show that Black women report less satisfaction in their experiences from admission to discharge compared to white women (Leveraging Your Survey & Analytic Strategy to Support Equity). Not only are Black women less satisfied with their care, the CDC reports that Black women are also three times more likely to die from pregnancy-related causes than their white counterparts (Maternal Mortality Rates in the United States, 2020). Systemic racism, access to prenatal care and bias are some factors contributing to the issue. To minimize opportunities for bias to go unaddressed, organizations must also investigate the demographics of their caregivers and patients.
As individual organizations, there are limitations in what can be done to address systemic racism in our healthcare system and caregiver demographics. Nonetheless, organizations are implementing creative strategies to address systemic racism and caregiver demographics. For example, a healthcare system in northern California is piloting a “work from anywhere” nurse staffing model to increase the racial diversity for one of their navigation programs. The COVID-19 pandemic forced the organization to improve operational procedural documentation and implement more virtual care models. Improved procedural documentation and new technology to support patient navigation virtually gave the organization the opportunity to explore completely new geographic talent pools for nurses. The organization implemented a goal to staff the program with racially diverse nurse navigators who align with their patient demographics. Nurses of color represent less than 15% of their full-time nursing workforce, while patients of color represent 45% of all patients. The organization expanded its nurse recruitment efforts to target nurses of color in Texas and Florida. The navigation program is on track to staff the navigation program with 40% nurses of color. To ensure the newer out-of-state nurses of color are onboarded successfully, the organization is pairing them with experienced, local nurse navigators and utilizing improved procedural documentation in day-to-day operations.
Not all healthcare organizations are able to create a “work from anywhere” program to align nurse demographics with patient demographics. A regional healthcare system in Georgia took a different approach to better align nurse demographics with patient demographics at a facility where patients of color represent 60% of all patients. Only 30% of the facility’s full-time nursing workforce are represented by nurses of color, so the organization partnered with an external staffing agency/healthcare consulting firm that specializes in hiring experienced nurses of color to work longer-term assignments as a part of the organizations broader DEI efforts. Instead of establishing traditional 13-week assignments, the organization asked nurses to work 20-week and 26-week assignments. In addition to bringing in travel nurses of color, the external agency provided recommendations to revamp orientation material by incorporating more cultural awareness training for all clinical staff caring for patients. The top 10 zip codes for their patient population were identified, and department orientation now includes an overview of race/ethnicity, language, socio-economic and health indicators for the top 10 neighborhoods to provide greater context for staff. Lastly, the agency worked with nurse leaders and human resources (HR) to develop facility-specific cultural awareness training by pulling verbatim comments shared by patients of color in surveys that shed light on cultural awareness opportunities. Although travel nursing is a mature model, using external agencies to better align nursing demographics with patient demographics and support internal DEI efforts is a novel approach.
Implementing DEI education and training with goals and performance monitoring are also tactics to address inequities. Organizations also have a responsibility to create safe spaces for open and candid dialogue with the intent to learn. A Texas BSN nursing program is expanding simulation exercises to include DEI conflicts and cultural awareness. The nursing program worked with a local healthcare system’s People of Color Employee Resource Group (POC-ERG) to develop new scenarios for nursing student simulation exercises. Members of the POC-ERG also volunteer to play the role of diverse patients and family members during the simulation. Following the simulation exercise, POC-ERG volunteers debrief with nursing students and share their real-life experiences. The nursing school/healthcare system partnership is mutually beneficial. Nursing students hear directly from nurses and healthcare employees and the healthcare system is provided with a unique opportunity to support nurse education and establish a reputation as an employer of choice. The nursing school simulation exercise is being reworked to support the healthcare system’s internal DEI training programs. Conversations on race and DEI in healthcare can be uncomfortable, but it is important for all aspects of the healthcare industry to engage in the uncomfortable conversations to improve outcomes.
By 2045, the U.S. will become a majority minority nation, which means people of color will account for more than 50% of the U.S. population. Although racial diversity in the nursing workforce has increased over the last 20 years, it is not keeping pace with the U.S. population. Healthcare organizations, particularly those in extremely diverse geographies, must (1) identify areas where there are substantial differences between nurse and patient demographics; (2) develop strategies to better align nurse demographics with patient demographics; and (3) build the cultural competence of their workforce. If your local nursing talent pool does not reflect your patient mix, explore options to import talent that will diversify your nursing population. Organizations that are taking thoughtful approaches to address nurse/patient demographic differences will be better positioned to address healthcare disparities.
- 2020 National Nursing Workforce Study. January 2021. National Council of State Boards of Nursing (NCSBN). https://www.ncsbn.org/workforce.htm.
- National Health Center Program Uniform Data System (UDS) Awardee Data. 2021. Health Resources & Services Administration (HRSA). https://data.hrsa.gov/tools/data-reporting/program-data/national.
- Leveraging Your Survey & Analytic Strategy to Support Equity. Deirdre Mylod, PhD, June 29,2021. Press Ganey. https://info.pressganey.com/press-ganey-blog-healthcare-experience-insights/leveraging-your-survey-analytic-strategy-to-support-equity.
- Maternal Mortality Rates in the United States, 2020. Donna L. Hoyert, PhD, February 23, 2022. Centers for Disease Control and Prevention (CDC). Link to article.
Benjamin J. Foster, MBA, is the CEO/Founder of Nurseify, Inc. He also is a member of the CMSA editorial board. You can reach Benjamin via email at [email protected].
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