A Developing Proposal for Policies to Diversify the Nursing Workforce

1. A Developing Proposal for Policies to Diversify the Nursing Workforce Catherine L. Gilliss September 24, 2010 American Assembly for Men in Nursing

2. Adapted from a manuscript now under review… • “Recruiting and Retaining a Diverse Workforce in Nursing: From Evidence to Best Practices to Policy” • Co-authors: Dorothy L. Powell, EdD, RN, FAAN, and Brigit Carter, PhD, RN, Duke University School of Nursing • With special thanks to Judy Seidenstein, Director for Diversity and Equity Programs, Duke University Office of Institutional Equity

3. The faces of today and tomorrow…

4. Snapshot of Nursing in 2009Source: 2008 National RN Sample Survey, DHHS, HRSA, 2010 • 3,063,163 licensed RNs in US (up 5.3% from 2004) • 84% actively employed; 63% employed FT • 853 employed RNs/100,000 US population • 34% BS prepared (up 3%); 46% ADN prepared • Mean age = 47 yrs (45% are over 50 yrs) • 16.8% non-white (up from 12.3% in 2000) • Between 2005-2008, 22.5% of basic program grads were non-white (up from 12% 20 yrs ago)

5. Gender Profile • Overall, women outnumber men in nursing, 15:1 (or 6.7%). • Among those entering nursing since 1990, the ratio shifts to 10:1 (or 10%).

6. Distribution of registered nurses and the U.S. population by racial/ethnic background, 2008

7. Why does this matter? • Assumption of a common, social good • Assumption of greater cultural competence within a diverse work force • Assumption that greater diversity could reduce health care bias and disparities • Assumption of a greater commitment to service in underserved communities, under represented in the health professions

8. What’s the evidence?Source: HRSA (2006). The rationale for diversity in the health professions: a review of the evidence. Wash, DC: USGPO. (hrsa.gov/bhpr/workforce/diversity.pdf) • Service Patterns: That health professionals from racial and ethnic minority and socially disadvantaged backgrounds are more likely to serve racial and ethnic minority and socially disadvantaged populations, improving access and health outcomes. • Concordance: That increasing the number of racial and ethnic minority health professionals provides greater opportunity to see someone of your own racial/ethnic group and improves communication quality, comfort, trust, partnership and decision-making. • Trust in Health Care: That greater diversity within the health care workforce will increase trust in the delivery system and increase likelihood of using the system. • Professional Advocacy:That health professionals from racial and ethnic minority and socioeconomically disadvantaged backgrounds will be more likely to advocate for policies and programs aimed at improving care to those in need – increasing access and quality and, ultimately, health care outcomes.

9. One way to think about about bias…Adapted from: Scott Page (2007). The Difference: How the Power of Diversity Creates Better Groups, Firms, Schools, and Societies. Princeton: Princeton University Press. • Everyone has biases; we call them preferences. • We have fundamental preferences or preferences about outcomes. These represent our values. • We have instrumental preferences, or preferences about how we get what we want. These represent preferences about our actions to accomplish outcomes. • When we think our instrumental outcomes are better than those of others, we limit available options to accomplish our outcomes.

10. Best Practices: Develop a Pipeline • Start earlier than you expect – career decisions are forming in middle school. • Develop Magnet Health Professions Schools. • Offer summer programs during college. • Strengthen performance and resilience while in college. • Improve funding options. • Improve networks. • Improve academic preparation. • Create bridge programs.

11. Best Practices: Focus on Admissions • Examine the relationship between admission requirements and program success. • Develop alternative profiles for qualification. • Develop admission requirements that value future potential in addition to past achievements. • Yield those who are admitted – by providing the needed supports to ensure success.

12. Best Practices: Retention • Invest in a supporting infrastructure. • Financial aid • Program flexibility • Networks • Academic supports • Aspirational supports

13. Best Practices: Utilization • Appoint persons from diverse backgrounds to key leadership and decision-making positions. • Make diversity visible. • Seek advice from diverse sources and use it.

14. Developing OpportunitiesSources: Affordable Care Act [PL111-148] and Health Care Education and Reconciliation Act of 2010 [PL 11-152] • State Workforce Development Grants (section 5102): Competitive grant program that will fund innovative approaches to increase the numbers of skilled health care workers and create career pathways. • Nursing Student Loan Program (section 5202): Expands loans amounts available. • Nurse Education, Practice and Retention Grants (section 5309): Awards grants to nursing education and training programs to improve nurse retention. • Loan Repayment and Scholarship Program/Nurse Faculty Loan Program (sections 5310-11): Expands debt reduction opportunities for those who enter teaching careers in nursing. Download this information from the web… http://dpc.senate.gov/healthcarereformbill/healthbill96.pdf

15. More developing opportunities… • Workforce Diversity Grants (section 5404): Expands allowable uses of nursing diversity grants to include bridge programs, degree completion, advanced degrees, pre-entry prep and retention. • Allied Health Loan Repayment and Retention (section 5205): Will focus on HPSA and MSSAs. • National Health Service Corp (section 5207): Increases the authorization for appropriations for FY 2010-2015. • Cultural Competence (section 5307): For cultural competency curriculum development, implementation and testing. • Grants to Promote the Community Health Workforce (section 5313): Supports the development of community workers for medically underserved areas. Download this information from the web… http://dpc.senate.gov/healthcarereformbill/healthbill96.pdf

16. And even more… • Centers of Excellence (section 5401):Develops a minority applicant pool and other supports for retention; funding expanded. • Health Professions Training for Diversity (section 5402): Provides scholarships for disadvantaged students who commit to working in medically underserved areas as primary care providers and expands loan repayment opportunities for faculty. • Demonstration Projects to Address Health Professions Workforce Needs (section 5507): Targets TANF recipients to support their entry into health careers in areas where shortages are anticipated. Download this information from the web… http://dpc.senate.gov/healthcarereformbill/healthbill96.pdf

17. One unfolding example… • Duke University School of Nursing’s Making a Difference in Nursing Program. • HRSA funded to Dorothy L. Powell. • Modeled after the U MD, BC campus Meyerhoff Scholars program, designed to promote the entry to African American students into the STEM fields. • Three elements: • Summer Socialization Program; • Connectivity leading to application and admission; and • Retention and support for program success and completion.

18. What work remains? • The fundamental question of evidence has not been answered. • We have an anecdotally based literature that offers direction to how the education system might improve. • We have not tested the hypotheses about whether increasing diversity, collectively will, ultimately, influence access to care or ameliorate health disparities. • Important health services questions remain unaddressed regarding program development, cultural competence and racial/ethnic concordance.

19. Thought for the day… You must be the change you wish to see in the world. - Mahatma Gandhi