Federally Defined Minority Groups

Federally defined minority groups are African Americans, Hispanics, American Indians, and Asians or Pacific Islanders. The populations within the federally defined minority groups have grown faster than the population as a whole. In 1970, minority groups accounted for 16% of the population. If current trends continue, the U.S. Census Bureau (2010) predicts that by 2025 minorities will account for more than 55% of the population, thus making up a majority of the total population for the first time (U.S. Department of Health and Human Services [USDHHS], 2010; National Institutes of Health National Heart Lung and Blood Institute). (Visit www.nhlbi.nih.gov/about/factbook/chapter4.htm for more information.) Although tremendous strides have been made in improving health and longevity in the United States, statistical trends show a disparity in key health indicators among certain subgroups of the population. There is a racial gap between African Americans and whites of 5.6 years, with average life expectancy of 78 years for whites and 72.7 years for African Americans. The infant death rate for African Americans is twice that of whites (Nies and McEwen, 2011). Although the ranking of health problems according to excess deaths differs for minority groups, the six causes of death that are a priority are cancer, heart disease and stroke, chemical dependency, diabetes, homicide and accidents, and infant mortality (Nies and McEwen, 2011).

Marginalized Populations

Not only should the concern for culturally competent care focus on ethnic minorities and populations with a different heritage than Euro-Americans, but it should consider the needs of marginalized populations (Hall et al, 1994), which live on the periphery or in between. Examples of such populations include gays and lesbians, older adults, recently arrived immigrants (e.g., from Russia, Afghanistan, and Rwanda), and groups that have been in this country for some time (e.g., from South America and the Middle East) who are less visible than the federally defined minorities (Lenburg et al, 1995). Their lives and health care needs often are kept secret and are understood only by them. Marginalized populations usually have extreme insights about their health care needs, although they often seem voiceless. This is in part a result of the different ways in which they both communicate and are silenced. It also may be because they feel even more peripheral or shut out from mainstream society when they are ill or experiencing a crisis.

Poverty

Most families with racially or ethnically diverse backgrounds have a lower socioeconomic status than does the population at large. African Americans, Hispanics, and American Indians have much higher rates of poverty than non-Hispanic whites and Asians. The median family income of Asians is slightly higher than that of non-Hispanic whites and is consistent with Asians’ high levels of education and the higher percentage of families with two wage earners. However, opportunities for education, occupation, income earning, and property ownership that are available to upper- and middle-class Americans often are not available to members of minority groups (Stanhope and Lancaster, 2010).

The poor also suffer more than the population as a whole for nearly every measure of health. Substantial disparities remain in health insurance coverage for certain populations. Among the nonelderly population, approximately 30.7% of Hispanic persons have the highest uninsured rates of any racial or ethnic group within the United States. For African Americans, the percentage of uninsured in 2010 was 20.8%. Lack of health care coverage has major implications for health (U.S. Census Bureau, 2010). Visit www.census.gov/hhes/www/hlthins/2011/data/incpovhlth/2010/highlights.html for more information.

Minority members of society often live in poverty. This social stratification leads to social inequality. For instance, it is widely known that school systems and recreational facilities vary significantly between the inner city and the suburbs (Nies and McEwen, 2011). Residential segregation, substandard housing, unemployment, poor physical and mental health, and poor self-image are part of the cycle of poverty. This inequality is especially disturbing as it relates to health care. The United States has a history of providing the highest quality health care to those with the highest socioeconomic status and the worst health care to those with low socioeconomic status. Social, economic, and health problems have led to heated debates about the philosophy, scope and costs, and sources of funding for health care and insurance programs.

Violence

Changing economic and social conditions have contributed to the increasing level of violence in our society. Statistics indicate that homicide is the second leading cause of death among Americans 15 to 24 years of age and the leading cause of death among African-American males 15 to 34 years of age (Nies and McEwen, 2011). Businesses, schools, restaurants, playgrounds, and churches have become common settings for random acts of violence (Lenburg et al, 1995). Unemployment is associated with violence because it is an expectation in our society that people should be productive and gainfully employed. The inability to secure or hold a job may lead to feelings of inadequacy, guilt, and frustration, which in turn can precipitate acts of violence. Although the increasing incidence of violence affects all segments of society, women, children, older adults, and culturally vulnerable groups are especially at risk. Unemployment rates among young minority men in the United States are consistently high (Stanhope and Lancaster, 2010). This group also has the highest rate of violence, with homicide being a major problem for young African-American males. The differing rates of violence among races are more likely a result of poverty than race (Stanhope and Lancaster, 2010).

Intimate partner violence (IPV), formerly known as domestic violence, is the single greatest cause of injury to women 15 to 24 years of age. IPV crosses all ethnic, racial, socioeconomic, and educational lines. It includes battering, resulting in physical injury, psychological abuse, and sexual assault (Nies and McEwen, 2011).

Societal changes have increased the tension between the empowered culturally dominant groups and the less visible vulnerable groups. This tension and behavioral response to tension has major implications for health care delivery and the education of nurses and other health care professionals (Lenburg et al, 1995).

Current Status of Diversity in the Health Care Workforce

Although most nurses are white women, an increasing proportion of minority students is graduating from nursing programs. In a survey conducted by the American Association of Colleges of Nursing (AACN) in 2011, minority representation in baccalaureate programs was highest among those identified as black or African American (10.3%) and lowest among American Indian/Alaska Natives (0.5%). Graduates from Hispanic or Latino groups totaled 7% and Asians 7.8%. Native Hawaiian or other Pacific Islanders were 1% of the undergraduate students who responded to the survey. These totals lag behind the 72% reported white enrollment (Fang, Li, and Bednash, 2012).

The number of men who graduate from basic registered nurse (RN) programs is also increasing. In the AACN survey conducted in 2011, 11.5% of the undergraduate respondents were men. Men continue to represent a minority in nursing, although recruitment efforts have focused more on men and minorities. Ad campaigns have highlighted men who were formerly firefighters, emergency responders, and law enforcement officers who have made the decision to pursue nursing as a career (Fang, Li, and Bednash, 2012).

The racial and ethnic distribution of the RN population is substantially different from that of the U.S. population as a whole. Of the nurses who indicated their racial or ethnic background in 2008, 83.2% were white, non-Hispanic as compared with 65.6% of the U.S. population; 5.4% were black or African-American, non-Hispanic; 5.8% were Asian or Pacific Islander, non-Hispanic; 3.6% were Hispanic; and 0.3% were American Indian or Alaska Native (Health Resources Service Administration [HRSA], 2010) (Figure 10-2). These figures are staggering in light of the demographics of our society. Although the number of minority nurses is increasing, the numbers have failed to keep up with our increasingly diverse population.

Men constituted 6.6% of the RN population in 2008, a small increase from 5.8% in 2004. Only 4.1% of nurses who graduated in 1990 or earlier were male, while 9.6% of those who completed their initial RN education after 1990 were male. The initial nursing preparation for more male RNs was an associate’s degree. The percentages of male and female RNs completing a baccalaureate or higher degree initial nursing program were similar, 32.7% and 31.5%, respectively (HRSA, 2010).

Recruitment and Retention of Minorities in Nursing

It is clear that we have been slow in preparing nurses to be reflective of our population, just as we have been unaware of the need for culturally sensitive patient care and sometimes less than welcoming to students different from the preponderant population (Sullivan, 1998). Recruitment and retention of students from minority populations must not be separated. In other words, recruitment programs must have retention as their primary focus because there is no point in recruiting minorities into nursing programs and then not helping them succeed.

Before World War II, the only known effort to recruit minority students into nursing on a national scale was made by the National Association of Colored Graduate Nurses (NACGN), which had had recruitment of African Americans into nursing as one of its objectives since its inception in 1908. During World War II, the federal government set into motion a mechanism to produce additional nursing personnel by financing basic nursing education. This was done through the Cadet Nurse Corps. The corps had a number of recruiters, two of whom were African Americans. These two African-American nurses confined their recruiting to 82 African-American colleges and universities. By the end of the war, 21 African-American nursing schools had participated in the corps, and more than 2000 African-American nurses had acquired their basic nursing education through this mechanism.

After the war, recruitment efforts for African Americans at the national level reverted to the NACGN, an organization that voted itself out of existence in 1949 and was dissolved in 1951. However, individual African-American schools in the North and South continued to recruit. In the South, law segregated the nursing schools, and in the North they were segregated by custom. In 1954, the unanimous Supreme Court decision—​Brown v. the Board of Education—asserted that “separate educational facilities were inherently unequal,” making racial segregation in public schools unconstitutional. This decision was interpreted to mean that all kinds of educational discrimination would be considered, including nursing.

It was around the time of the Brown decision that schools of nursing were being accredited by national standards, and many schools, both African-American and white, just did not measure up to the standards. As a result, many schools closed. With integration permitting African-American students to be admitted to formerly all-white schools, quality African-American schools had difficulty attracting enough students, and many of the schools closed. However, the white schools that began admitting African-American students did not admit the number that would have been admitted by the African-American schools. For example, many white schools admitted only one or two African-American students per class.

In the late 1960s, many efforts were made to help the economically disadvantaged in this country. Although not all people of minority groups are economically disadvantaged, the vast majority of disadvantaged people are members of ethnic minority groups. Nursing too became concerned about the disadvantaged and began concerted efforts to recruit more members of minority groups into nursing schools. The Sealantic Fund, one of the Rockefeller Brothers’ funds, was one of the first foundations that helped minorities enter nursing school. Sealantic funded projects in 10 universities in different parts of the country to recruit students from minority groups and help them achieve success. The best example of an ongoing project, funded by the division of nursing since 1971, is the National Student Nurses Association’s breakthrough in nursing to accelerate the recruitment of minorities, including men.

In 1997, the American Nurses Foundation published a report of a project it had funded titled Strategies for Recruitment, Retention and Graduation of Minority Nurses in Colleges of Nursing. Through survey and interview analysis, Bessent and a cadre of knowledgeable leaders investigated the most effective approach to increase the nursing profession’s representation of minority nurses (Bessent, 1997). Members of Chi Eta Phi, a national African-American nursing society with chapters throughout the country, serve as mentors to minority nursing students. As mentors, sorority members provide intellectual and inspirational stimulation along with counseling.

In 1997, the AACN published a position statement stating that diversity and inclusion had emerged as central issues for organizations and institutions. The AACN encouraged leadership in nursing to respond to these issues by finding ways to accelerate the inclusion of groups, cultures, and ideas that traditionally had been underrepresented in higher education.

As the demographics of the population rapidly changed in the twenty-first century, there were numerous strategies to recruit and retain minority nursing faculty, students, and practicing nurses in the profession to better reflect the population demographics. Just as contributions of diverse cultural groups were increasingly valued, the profession began to value the need for diversity in their students and faculty and view this diversity as strength.

Strategies for Recruitment and Retention of Minorities in the Health Care Workforce

All national nursing organizations, the federal Division of Nursing, hospital associations, nursing philanthropies, and other stakeholders within the health care community agree that recruitment of underrepresented groups into nursing is a priority for the nursing profession in the United States (AACN, 2010). For more information, visit http://www.aacn.nche.edu/media-relations/fact-sheets/enhancing-diversity. Nursing shortage reports, including those produced by the American Hospital Association, the Robert Wood Johnson Foundation (RWJF), the Joint Commission, and the Association of Academic Health Centers, point to minority student recruitment as a necessary step to addressing the nursing shortage. For more information on these reports, visit http://www.aacn.nche.edu/media-relations/fact-sheets/nursing-shortage.

A lack of minority nurse educators may send a signal to potential students that nursing does not value diversity or offer career ladder opportunities to advance through the profession. Students looking for academic role models to encourage and enrich their learning may be frustrated in their attempts to find mentors and a community of support. Academic leaders are working to address this need by working to identify minority faculty recruitment strategies, encouraging minority leadership development, and advocating for programs that remove barriers to faculty careers.

There also is a need to increase the number of nurse educators and researchers who are from diverse, marginalized, and vulnerable populations. Raising consciousness involves increasing the level of awareness of nurses and other health care professionals about the issues surrounding diversity. This can be accomplished by encouraging participation in forums related to different aspects of various cultural phenomena, such as environmental control, communication, and health beliefs. Such forums might be offered by state and local professional nurses’ organizations and health care facilities.

Another successful strategy for recruiting and retaining minorities in education and clinical practice is matched mentoring, which involves matching same-culture mentors either in the same institution or different institutions. A different mentoring strategy involves teaching and modeling by nurses who have been trained in cross-cultural care. Cross-cultural nursing consultants in the care of specific groups are available to agencies, professional groups, licensing bodies, and individual nurses. (Organizations should contact the Transcultural Nursing Society at www.tcns.org to obtain the names of consultants in the field of transcultural nursing.)

Audiovisual media should be used to teach the importance of human health conditions cross-culturally. Video conferencing can provide international links for students and faculty who cannot travel. Students from various cultures can share their clinical experiences. One of the greatest benefits is the discovery that thinking, values, and decision making differ in various cultures. Collaborative arrangements should be encouraged between colleges and universities so that exchange programs can be offered to students. Such exchanges can provide firsthand in-depth experience with a culture that is different from their own. Interactive media can be used to gain a clearer perspective than can be obtained through the print medium on particular cultures.

Strategies such as mentoring by the same-culture professional are effective in recruiting and retaining minorities in nursing. In addition, the value of workshops, continuing education programs, and the use of consultants to promote culturally competent care should not be overlooked.