Why Representation Matters In Nursing

The case for diversity in nursing comes down to one fact: patients do better when their care team reflects the community it serves. A National Medical Association review of 16 studies found that diverse healthcare teams produce better patient outcomes. The same review linked diversity to stronger retention, communication, innovation, and quality of care.

The workforce does not match the population yet. As of 2019, non-Hispanic Black nurses made up only 7.8% of nurses while 13.4% of the U.S. population identified as Black or African American. Representation also extends beyond race, ethnicity, and gender to nurses who are LGBTQ+, live with disabilities, or practice different religions.

Why It Improves Care

The National League for Nursing defines diversity as affirming the uniqueness of and differences among persons, ideas, values, and ethnicities. Research ties representation among nurses and providers to better outcomes and smaller health disparities, including infant mortality, and to fewer cultural barriers between patients and their care teams.

The Oakland Men's Health Disparities Project showed how much this matters. African American men have the lowest life expectancy of any group studied. In a sample of just over 1,000 participants, the men were more likely to accept preventive care when it was recommended by Black doctors.

Karen Innocent, DNP, RN, points to unconscious bias and structural racism as drivers of these disparities. "Lack of representation between populations and the healthcare organizations serving the community can result in variability in patient care," she says. "There is overwhelming evidence that healthcare workers should be hired in proportion to the diversity of the communities that they serve. Increasing diversity among nurses and physicians is a means of reducing health disparities because patients have better outcomes with healthcare professionals of the same race."

Edna Aurelus, DNP, FNP-BC, adds that representation lets patients reach "someone who can be empathetic with one's situation as well as someone who can understand the person's viewpoint."

The American Association of Colleges of Nursing recognizes the shortage and treats active recruitment of men and of African American, Hispanic, Asian, American Indian, and Alaska Native students as fundamental to building a skilled, trusted workforce.

What Gets in the Way

Several barriers slow progress. The nursing shortage is one, driven partly by a faculty shortage: AACN reported that nursing schools turned away 80,407 qualified applicants in 2019, and low faculty pay keeps nurses from teaching. Others include unequal access to education, financial and socioeconomic obstacles, and weak recruitment pipelines.

Implicit bias compounds all of it. "As a person of an underrepresented group serving in both clinical and higher education settings, I can frankly state that one of the challenges we routinely face is implicit bias," Aurelus says. Implicit bias is acting on a stereotype or prejudice you do not consciously hold.

What Is Changing

COVID-19 exposed health disparities among people of color and pushed organizations to act. Several efforts stand out:

• LaDonia Patterson, EdD, RN, and Gaea Daniel, PhD, RN, built the High School to Higher Education Pilot Pipeline Program, which mentors Black male high school and college students in metro Atlanta toward nursing careers.
• AACN appointed Vernell DeWitty, PhD, MBA, RN, as chief diversity officer and co-authored research on recruiting underrepresented nursing students. In 2018 it launched a Diversity, Equity, and Inclusion Group to guide schools toward their diversity goals.
• Hospitals and nursing schools have created chief diversity officer roles and standing inclusion committees.
• LGBTQ+ care has become a training priority, with classes and resources preparing students to care for the community.
• Faculty actively encourage underrepresented nurses to apply for higher-education positions and pursue graduate study.

The Bottom Line

Innocent is blunt about what works: "Achieving diversity is a process and cannot be improved unless healthcare leaders commit to addressing the root causes, including hiring practices and barriers to admission to schools of nursing."

The U.S. spends about $3.8 trillion on healthcare, roughly 17.7% of GDP, yet Americans carry a heavier chronic-disease burden than peer nations, and African Americans die from those diseases at higher rates. A workforce that mirrors its patients is one of the clearest paths to closing that gap. The work is far from done, and it takes everyone.