Improve Patient Outcomes with a Diverse Nursing Workforce
By Marion Davis
The question of how to improve patient outcomes is prevalent within many healthcare organizations. Lower nurse-to-patient ratios, better technology in the workplace, and higher salaries for healthcare workers–there are many suggestions for this highly nuanced topic.
However, one contributing factor to patient outcomes is often overlooked: diversity numbers within the nursing workforce.
The Current Diversity Data on the RN Workforce and the General US Population
The following sections will review the demographics of the RN workforce in comparison to the demographics of the general US population.
RN Demographics
In a 2022 report, the American Association of Colleges of Nursing (AACN) noted that the RN population is made up of 80.6% white nurses. According to 2019 US Census data, about 2.1 million out of a total of slightly more than 2.5 million nurses identify as female. As a rough calculation, this means that approximately 68% of the entire RN workforce consists of people who identify as white women compared to 35% of the total US population consisting of people who identify as white women.
In addition to the underrepresentation of ethnoracial minorities, disability inclusion is lacking. No current data exists on disability numbers within the RN population. In fact, a culture of ableism beginning within nursing school often discriminates against disabled nursing students. This ableism spills over into the workforce where highly-qualified disabled nurses face difficulty finding employment.
In an interesting turn of events, several nurses who are wheelchair users finally had a chance to demonstrate their capability when COVID forced the hiring managers’ hand to bring all hands on deck. It shouldn’t have taken a pandemic to push hospital HR to hire diversely.
Patient Demographics
Scant information is available on the general patient population across the US. Typically, patient demographic information is collected and reviewed specific to private practice locations or healthcare groups.
Without access to healthcare group demographic information, readers can look instead to general and local population numbers in comparison to the healthcare worker numbers.
For instance, even if the patient population were an exact replica of the general US population, there clearly exists an ethnoracial diversity problem in healthcare with the overrepresentation of white women in nursing.
Additionally, though disability numbers in nursing remain a mystery, the lack of inclusion ensures that disability representation is likely far below the disabled community which comprises 26% of the US population.
The Research on Healthcare Worker Diversity and Improved Patient Outcomes
Diversity and inclusion are a must within the medical field where patients’ lives are at stake.
The Need for Diversity and Inclusion
Diversity, equity, and inclusion (DEI) measures are important within healthcare education and the workforce, and the belongingness experienced by minority healthcare workers is reflected in their care of minority patients. Greater representation of marginalized communities is needed in the healthcare field to improve patient outcomes.
As the backbone of the healthcare system, the nursing workforce especially should be representative of the communities with which they interact.
In a foundational 2010 report, The Institute of Medicine called for greater diversity in the nursing workforce to improve patient outcomes and reduce healthcare inequities.
Within a decade, ethnoracial minorities grew in representation in nursing to 20% but are still underrepresented compared to the general population. Furthermore, intersectional representation–across disability, gender identity, and so forth–is lacking even more so.
Why Representation Matters
As a case study on why representation matters, the state of Georgia ranks forty-ninth in the US in maternal mortality rates. This statistic is primarily because Black mothers are more likely to die in Georgia than in any other state in the US with this likelihood of mortality increasing in rural areas of Georgia. These deaths are typically highly preventable incidents, stemming from a lack of prenatal care to the dismissal of cardiovascular complaints.
While issues of non-affordable healthcare do come into play for Black women, stories like that of Serena Williams give all Americans pause. One of the most influential and wealthy Black women in the US had her concerns about blood clots actively dismissed after her C-section despite her history of pulmonary embolisms. Patients with chronic conditions know their bodies well. Following childbirth, one of the most vulnerable moments a human can experience, Serena had to advocate for herself and fight for her life to be heard.
In a study conducted by Emory University in Atlanta on Georgia’s high Black mother mortality rates, the researchers noted that medical racism plays the largest role, discriminating widely regardless of Black patients’ socioeconomic status. The failure to listen to Black voices is the primary cause of these poor patient outcomes.
Georgia has the fifth-highest Black population per capita in the US with Black residents making up 33% of the state’s population. Despite this, only 10% of nurses in Georgia are Black. Patients tend to have more positive experiences when the healthcare workers involved in their care identify similarly. For this reason, several universities have begun offering scholarships to target this disparity in the state’s healthcare workforce as part of several initiatives to address Black mother deaths in Georgia.
Representation is crucial to improve patient outcomes. Black mothers tend to have better experiences with Black healthcare workers involved in their prenatal, labor, and postnatal care.
Having similarly-identifying healthcare workers involved in their care increases advocacy for Black women and the seriousness with which their health concerns will be addressed.
Approaches to This Problem of Lack of Diversity
To improve patient outcomes, healthcare groups must first acknowledge the problem of a lack of diversity in the healthcare workforce. Hiring managers in healthcare can then set diversity hiring goals as an initial step followed by continual evaluation and pursuit of supporting employee belongingness.
Hire Diversely
To address the problem of lack of diversity, healthcare groups can set goals of hiring diversely.
There are minority nurses who are already RNs who face an uphill battle to find employment due to discrimination.
In one case, Andrea Dalzell, a Black disabled nurse who is a wheelchair user reported that hiring managers were initially excited about her resume and qualifications when they first talked remotely–until she arrived for the interview as a visibly disabled person. The hiring managers did not attempt to disguise their immediate disinterest upon seeing her mobility aid. Dalzell went to 76 interviews in a healthcare setting and received zero offers. She instead had to seek employment in non-bedside jobs such as a school nurse position. That is until COVID hit, and she was finally able to secure a position in a hospital due to high demand.
Hiring managers must address their internal biases related to beliefs that minority nurses are not capable of performing their job duties. Several disabled nurse content creators readily answer questions on platforms such as Instagram and TikTok. Andrea Dalzell is now a public figure and a disability educator.
Emphasize Belongingness
Simply hiring diversely is not enough. To retain a diverse nursing workforce to improve patient outcomes, healthcare organizations must emphasize inclusion and strive toward a goal of employee-reported belongingness.
Approaches to supporting belongingness can include providing further education opportunities for healthcare workers. Organizations would do well to track diversity numbers to ensure equal opportunity in accessing these support programs.
Offer Further Education Opportunities
A college-level healthcare education can be inaccessible to many individuals from lower socioeconomic backgrounds as they do not have the financial resources for tuition and additional costs nor are they able to attend school full-time. Members of marginalized groups tend to have multiple factors of marginalization that correlate with lower socioeconomic status due to systemic oppression.
Vocational medical schools are an alternative entrance into the healthcare workforce. Certified nursing assistants (CNAs) and licensed practical nurses (LPN) have a slightly higher representation of ethnoracial healthcare workers than in the college-educated registered nurse (RN) population with an ethnoracial minority CNA population of 33.5% and an ethnoracial minority LPN population of 36.3% versus an ethnoracial minority RN population of 30.9%.
However, working as a CNA is stressful with low wages, ranging from $8.89 to $24.76 per hour with a nationwide median of $16 per hour. In comparison, RNs make an average of $17.31 to $62.26 per hour with a nationwide median of $37 per hour.
One of the most impactful tools for retention is the support of career advancement. Especially with the current nursing shortage, healthcare groups would do well to support their CNAs and LPNs in becoming registered nurses.
As intersectional identity minorities tend to enter the CNA workforce in slightly greater numbers due to education accessibility, healthcare groups specifically supporting graduates of vocational schools in becoming college graduates would be making a wise investment that increases diversity in the workplace.
Final Thoughts
Diversity within the nursing workforce significantly influences minority patient outcomes, and minority patients are the most likely to suffer poor outcomes due to dismissals of patient concerns. To create strong advocacy for those most vulnerable, healthcare organizations would benefit from retaining similarly-identifying staff. However, biases against marginalized groups plague both healthcare education and medical workplace culture, leading to greater attrition of some of the most valuable members of the healthcare team. To improve patient outcomes, healthcare groups can emphasize inclusion and strive for the belongingness of a diverse nursing workforce that advocates for and empathizes with the patients most at risk.
Marion Davis is a contributing writer at EmployDiversityNetwork.com. She is a disabled DEIA consultant and writes on the value of diversity and inclusion across multiple industries, specifically as relates to disability and intersectionality.
