Reflection & Dialogue #3 - A Commitment to Diversity in Nursing and Nursing Education, January 2009

A Commitment to Diversity in Nursing and 
Nursing Education
January 2009 

Diversity is most commonly described as recognizing individual differences in the context of ethnicity and gender. The NLN has expanded this definition, within its mission, goals, and core values, to include the development of a culture where individuals and institutions move beyond simple tolerance, where they embrace and celebrate the richness of debate and dialogue based on difference. This Reflection & Dialogue offers a way to seed the ground to cultivate that vibrant culture. It represents an embarkation point for our journey to the richly diverse workforce of faculty, researchers, and pedagogical scholars that can mentor and serve as role models for future nurses and nurse educators from many backgrounds.

Working toward an inclusive environment and increasing diversity in all types of nursing programs is consistent with the mission and values of the National League for Nursing and countless schools of nursing. With diversity as a core value, NLN strategic planning addresses the Leagues mission to promote excellence in nursing education to build a strong and diverse nursing workforce. 

Though institutionalizing a commitment to diversity has posed formidable challenges, it has also provided exciting opportunities in todays academic environments. Across the United States, there has been considerable effort to find ways to increase diversity in all kinds of health professions education programs and to increase the number of students from underrepresented and underserved communities available for service in the nations health care system (Institute of Medicine, 2004; Sullivan Commission, 2004).

The Nursing Education Climate and Diversity

Finding the courage to create a caring society is the spiritual work of nursing. The appreciation of diverse individual knowledge, characterized by inclusion and justice, can support changes in the environment necessary for development of a diverse and culturally competent nursing workforce.

There are powerful examples nationally of how faculty have created innovative models to build more inclusive environments within programs of learning. These address issues of inclusion, justice, and diversity in a world that is increasingly without borders (Bosher & Bowles, 2008; Bull & Miller, 2008; Slade, Thomas-Connor, & Tsao, 2008).

A common thread of most approaches to diversity education involves stimulating reflective learning and tacit knowledge. Reflection includes various levels of dialogue and discussion of events as a means to develop understanding of values and beliefs. Emancipatory reflection provides a systematic means of critiquing the status quo in the complex and varied relationships in the workplace, in school, and in the world. It offers raised awareness to bring about positive social and political change (Sherwood & Freshwater, 2006). 

The focus of this important and valuable work has been on form, on bringing more faces of color to nursing. There is, however, more work to be done. Nursing must focus on substance - the quality of the experience, the cultural humility that must be taught to all nurses and thus integrated into nursing practice, and the cultural safety that must be provided to all of our colleagues and recipients of care. 

Establishing and maintaining environments that are inclusive, open, and flexible is a complex undertaking. It requires understanding, acknowledging, and affirming differences among ourselves and in our experience. It requires being supportive of the ecological, sociopolitical, cultural, and faith-based differences in behavior, social constructions, and social identity development. Significant insights about the experience of difference occur when supportive and collegial dialogue, inquiry, and reflective practices are employed.

Considerations

• As per the data gleaned from the NLN Nursing Data Review 2005-2006 there has been a marked increase in the percentage of graduating pre-licensure nursing students who are members of racial or ethnic minority groups, with the increase distributed across all racial and ethnic categories: Asians, African Americans, Hispanics, and American Indians (National League for Nursing [NLN], 2008). This is important because these data mark the first significant growth in minority student representation in half a decade. NLN research also revealed that the percentage of men graduating from basic RN programs has shown a small but steady growth trend to just over 12.1 percent of nursing graduates. (Unfortunately, because of a low response rate from LPN/LVN programs, data on diversity among LPN/LVN students are not currently available.)
• Despite growing evidence that there has been an increase in graduations of racial and ethnic minorities from all types of nursing programs, there continues to be slow growth in the number of ethnically diverse registered nurses in the United States. Currently only 10.7 percent of all RNs come from one or more of the identified racial and ethnic minority groups (US Department of Health and Human Services, Health Resources and Services Administration [DHHS], 2006). The picture differs vis à vis LPNs since the ethnic diversity of LPNs has grown over time.
• In 2000, 26 percent of the LPN workforce was African American, with Hispanics accounting for 3 percent, Asians for 2 percent, and American Indians for less than 1 percent of the LPN workforce (DHHS, 2004). Seven years later, 22.4 percent of LPNs were African American, 3.9 percent were Asian, and 5.8 percent were Hispanic (US Dept. of Labor, BLS, "Employment by detailed occupation, sex, race, and Hispanic ethnicity, 2007 annual averages").

Recommendations

• It is time for the higher education community to commit to the creation of diverse environments. It will take tremendous effort on all of our parts and some very candid examination and assessment of decades of practice and tradition that favored some and excluded others.
• Injustices flourish where the implicit is not made explicit. Micro-inequities need to be exposed as a pattern of flaws that may (unintentionally) exist in our schools and within colleagues and students. We need to make a commitment to expose subtle gestures, looks, or comments that may create bias or misunderstanding.
• Quality, safety, and diversity are intertwined. We must acknowledge that quality and safety are adversely affected by a lack of diversity and address the consequent disparities in access to health care services that preclude quality care for all.
• It is imperative that colleagues - faculty, staff, and students - maintain and refine their cultural humility. We must understand that none of us can be culturally competent with every culture. But we should focus on the culture or cultures with which we are primarily involved, learning their history, communication style, territorial and space needs, timing issues, social organizations, community concerns, and even food patterns and biological variations (Giger & Davidhizar, 2008).

Conclusion

It will take all nurses, working together as colleagues, to create safe, diverse environments of healing. Faculty have the potential to be instruments of hope. Experts tell us that it takes at least five to seven years to transform an organizations culture. Curriculum change takes even longer. The late Em Bevis reportedly said that "changing a curriculum is akin to moving a cemetery." But transform through progressive change we must if we are to continue to prepare nurse leaders, faculty, and practitioners who can meet the demands of the diverse populations who expect us to care for them with sensitivity and cultural competence. Transformation can begin anywhere at any time. So let us transform the conversation and begin a new dialogue of hope, integrity, caring, and excellence.

Colleagues, these are our thoughts at this point, please join us in this dialogue and of course, the reflection….. 

• How will we gain understanding so that all nurses will be able to provide safe care to all people? How will we provide cultural safety in our learning environments for students, faculty, staff, and others?
• If diversity is a priority, what does it take to treat it like our other priorities? What kind of principles and values do we say we promulgate? What action steps are needed in our programs of learning to provide trusting environments and common direction?
• What difference does difference make in our admissions, recruitment, and retention policies and procedures? Are we lowering standards to be more diverse?
• As our student population changes and their academic needs provide new challenges, how will nurse educators meet teaching needs while including a more diverse cadre of faculty?

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References

Bell-Scriber, M.J. (2008). Warming the nursing education climate for traditional-age learners who are male. Nursing Education Perspectives, 29(3), 143-150. 

Bosher, S., & Bowles, M. (2008). The effects of linguistic modification on ESL students comprehension of nursing course test items. Nursing Education Perspectives, 29(3), 165-172. 

Bull, M.J., & Miller, J.F. (2008). Preparing teacher-scholars to reduce health disparities. (2008). Nursing Education Perspectives, 29(3), 156-160. 

Freshwater, D., Horton-Deutsch, S., Sherwood, G., & Taylor, B. (2005). The scholarship of reflective practice. Indianapolis, IN: Sigma Theta Tau International. 

Giger, J., Davidhizar, R.E. (2008). Transcultural nursing: Assessment and intervention(5th ed.). St. Louis, MO: Mosby. 

Insight Education Systems. (2007). MircroInequities: At a glance. [Online]. Available:www.insighteducationsystems.com?AtAGlance.htm

Institute of Medicine. (2004). In the nations compelling interest: Ensuring diversity in the health care workforce. Washington, DC: Author.

National League for Nursing. (2006). Nurse educators 2006: A report of the faculty census survey of RN and graduate programs. New York: Author. 

National League for Nursing. (2008). Nursing data review, academic year 2005-2006: Baccalaureate, associate degree, and diploma programs. New York: Author.

Slade, D., Thomas-Connor, I., & Tsao, T. M. (2008). When nursing meets English: Using a pathography to develop nursing students culturally competent selves. Nursing Education Perspectives, 29(3), 151-155. 

Sullivan Commission on Diversity in the Health Care Workforce. (2004). Missing persons: Minorities in the health professions, Washington, DC: Author.

US Department of Health and Human Services, Health Resources and Services Administration. (2006). The registered nurse population: Findings from the March 2004 National Sample Survey of Registered Nurses. [Online]. Available:ftp://ftp.hrsa.gov/bhpr/workforce/0306rnss.pdf. 

US Department of Health and Human Services, Health Resources and Service Administration. (2004). Supply, demand and use of licensed practical nurses. [Online]. Available: http://bhpr.hrsa.gov/healthworkforce/reports/lpn/LPN1_5.htm.

Wong, S.T., Seago, J.A., Keane, D., & Grumbach, K. (2008). College students perceptions of their experiences: What do minority students think? Journal of Nursing Education, 47(4), 190-195.