Enhancing Diversity in the Nursing Workforce

Transcription

1 Wisconsin Center for Nursing Enhancing Diversity in the Nursing Workforce A Report by the Wisconsin Center for Nursing Diversity Taskforce May 2013

2 Acknowledgements The Wisconsin Center for Nursing formed the Diversity Taskforce in February, As many as 23 individuals participated in the work of the Taskforce throughout the length of the project. This report culminates their work between March 9, 2012 and December 19, WCN gratefully acknowledges the contributions by the members of the Taskforce who volunteered their time for this important project: Rebecca Cleveland, RN, BSN, MSN Assistant Director, Student Academic Affairs UW Oshkosh College of Nursing Elizabeth Collins, RN, BSN Graduate Student Cardinal Stritch University Wendy Crary, PhD, RN, CNE Director, Nurse Educator & RN to MSN Programs Concordia University of Wisconsin Debbie Danforth, RN, BSN Oneida Community Health Center John Gladney Associate Degree Student Milwaukee Area Technical College Judith Hansen, MS, BSN Executive Director Wisconsin Center for Nursing Melinda Hetzel, RNC, BSN Bellin Hospital, Green Bay Dessie Levy, PhD, RN, APNP Dean - School of Health Sciences Milwaukee Area Technical College Maichou Lor, MSN, BSN, RN PhD Student, UW Madison School of Nursing Allison Mentink, RN, BSN Baldwin Area Medical Center Fabienne Ouapou-Lena, MD, MPH Minority Health Program Director WI Division of Public Health Marion Quimnales, RN BSN completion student Cardinal Stritch University Gloria Rhone, RN MSN Academic Support Coordinator for Minority Students Marquette University College of Nursing Tim Ringhand, RN, MPH Public Health Nursing Consultant WI Division of Public Health Western Region Sandra M. Schuyler, RN, BSN Director of Nursing Oneida Community Health Center Kate Siegler, RN MSN Academic Dean, Allied Health Wisconsin Indianhead Technical College Vanessa Song, RN, BSN Director of Nursing United Extended Home Health Care, Jackson Mary Schwartz, RN, MS Director of Acute Care Service St Clare Hospital, Baraboo Zakiyyah Sorensen, RN, BSN UW Madison School of Nursing Audrey Tluczek, PhD, RN Assistant Professor UW Madison School of Nursing PaDou Vang, RN Sisters of St Mary s Healthcare System Teri Vega-Stromberg, MSN, RN, ACPHN, AOCN Clinical Nurse Specialist Wheaton Franciscan Healthcare, Milwaukee Marilyn R. Yellowbird, RN HoChunk Nation Tribal Clinic 2

3 Table of Contents 4 Executive Summary 5 Introduction 8 Literature Review 10 Environmental Scan Project 16 Discussion 18 Summary & Recommendations 21 References 22 Additional Resources 3

4 Executive Summary In February, 2012, the Wisconsin Center for Nursing created a taskforce for the purpose of identifying issues surrounding the lack of diversity in the nursing workforce, and the development of strategies to enhance diversity in Wisconsin nurses. A known lack of diversity in nursing in relation to the general population is well-documented with workforce data: Minorities in Wisconsin comprise 6.4% of the RN workforce; 11.8% of the LPN workforce 93.1 % of Wisconsin RNs are female; 6.9% are male Wisconsin general population is reported as 83.1% white; 16.1% as racial/ethnic minorities. The work of the Diversity Taskforce included a comprehensive review of nursing literature related to identified barriers and strategies in education, recruitment and retention to alleviate the paucity in nursing diversity. Members of the Taskforce also performed environmental scans on seventeen organizations, including healthcare systems, educational institutions, nursing associations and the Wisconsin Area Health Education Center system, to assess a crosssection of the current diversity initiatives in the state, and their various approaches at viable solutions to issues surrounding diversity in the nursing workforce. Although not guided by rigorous research methods, the results of the environmental scans were consistent and aligned with findings in both the literature and discussions by expertise represented on the Taskforce. Although significant work is occurring in Wisconsin, progress has been slow, and there is much to be done. Key findings from the environmental scans included: 47% indicated their organizations practiced having an inclusive environment. Six organizations reported diversity is reflected in their strategic plan. Cultural competency training was provided by nearly half the organizations. 41% reported having specific departments and/or positions for diversity. 100% of academic institutions provide support services for diverse students. 18% reported community outreach as a recruitment mechanism. 78% of schools reviewed NCLEX success rates on graduates, but only one program separated out findings by diversity. After thorough review of the literature and findings of the environmental scans, the Wisconsin Center for Nursing Diversity Taskforce developed five overarching recommendations and accompanying guidelines for improving the status of nursing diversity in Wisconsin: 1. Make diversity an organizational priority & systemwide approach. 2. Provide a variety of support mechanisms for underrepresented populations in both academic and practice settings. 3. Train all staff and students to ensure higher levels of cultural competency. 4. Develop a standardized system with agreed upon benchmarks for tracking data on under-represented populations in nursing programs & health systems throughout the state. 5. Join forces for a statewide initiative to increase funding for nursing scholarships for underrepresented populations. Diversity in the nursing workforce plays a critical role in improved healthcare access and patient outcomes (Sullivan Commission, 2004). In order to enhance diversity in the nursing profession, concerted efforts must be made to address barriers which prevent underrepresented groups from entering the profession, as well as advancing to levels of nursing leadership, including becoming educators. This transformation in healthcare delivery can only be accomplished with systematic adherence to dedicated strategies which have already been identified as producing positive outcomes for increasing diversity. New and innovative approaches must also be a focal point, and can result from collaborative partnerships with key stakeholders who have a shared interest in improving population health in our state. 4

5 Introduction The Wisconsin Center for Nursing (WCN) has as its mission the assurance of an adequate, competent, and diverse nursing workforce for the people of Wisconsin. This is achieved through systematic collection, analysis and dissemination of nursing education and workforce data as mandated by Wisconsin Statute Reports on nursing workforce data are used to inform current issues in the workforce, as well as address areas of need, such as the need for more diversity in the nursing workforce. It is well documented that enhanced diversity within the healthcare professions will provide greater capacity for the delivery of culturally competent and sensitive care (Sulllivan Report, 2004). A nursing workforce that is diverse, and reflective of the population it serves, is an important asset to improve patient outcomes. Greater diversity among all healthcare professionals not only increases access to care with enhanced choices for patients, but also ultimately achieves greater satisfaction in their care (IOM, 2004). Healthcare systems that are well aware that it is critical to both recruit and retain diverse employees can better meet the needs of increasingly diverse populations (Salisbury & Byrd, 2006). WCN created the WCN Diversity Taskforce in February, 2012, to address the paucity of underrepresented populations in the nursing profession in our state. This issue is recognized nationwide as a serious and pervasive theme as population demographics continue to shift towards increased numbers of minorities, while nursing has made negligible inroads for the profession to mirror the diverse populations for which it provides care (Table 1). Two additional charts provide visual confirmation that the break-down of nursing race/ethnicity in Wisconsin shows less diversity in registered nurses (RNs) (Fig. A) than that of licensed practical nurses (LPNs) (Fig. B), and that LPNs more closely mirror Wisconsin s general population, including the percentage of African- Americans (Table 1). Nursing also continues its time-honored tradition of being a female-dominated profession, with a significant deficit in the number of males in the profession (Table 2). Fig. A. Race/Ethnicity of Wisconsin RNs 1.4% 2% 3% Fig. B. Race/Ethnicity of Wisconsin LPNs 1.7% 6% 4.1% 93.5% White Black/African American Hispanic Other 88.1% Source: WCN - DWD 2012 RN Survey Summary Source: DWD 2011 LPN Survey Summary 5

6 TABLE 1 Race/Ethnicity: White African American Hispanic Other Wisconsin RN 93.5% 2.0% 1.4% 3.0% Source: WCN DWD 2012 RN Survey Summary Wisconsin LPN 88.1% 6.0% 1.7% 4.1% Source: DWD 2011 LPN Survey Summary Wisconsin Population 83.1% 6.5% 6.1% 3.5% Source: 2011 U.S. Census Bureau U.S. Population 63.4% 13.1% 16.7% 6.4% Source: 2011 U.S. Census Bureau Members of the Taskforce were invited to participate based upon their expertise and experience, interest level, organizational representation and location, as well as their own diversity, and included as many as twenty-three members who participated in meetings and the work of the Taskforce throughout the project. Members who participated were from throughout Wisconsin, with representation from public and private baccalaureate (BSN) and associate degree nursing (ADN) education programs, rural and urban healthcare systems, governmental public health agencies, African-American, Hispanic and Hmong nursing associations, the Wisconsin Tribes, and BSN, ADN and graduate nursing students. Although diversity is often thought of as only something you can see, it is widely accepted that diversity has far greater meaning than skin color, and encompasses much more than that. Diversity includes all possible differences in individuals and has a direct impact on how we interpret and behave towards others. Thus, a nursing workforce that is inclusive and embraces diversity will enrich both productivity and innovative approaches to care (Salisbury & Byrd, 2006). The WCN Diversity Taskforce embraced the American Association of Colleges of Nursing (AACN) 1997 Position Statement which states: Diversity includes consideration of socioeconomic class, gender, age, religious belief, sexual orientation, and physical disabilities, as well as race and ethnicity. Diversity and equality of opportunity recognize that individuals learn from exposure to and interaction with others who have backgrounds and characteristics different from their own. Promoting diversity facilitates equality of opportunity (Tenorio, Glenn, Rodriques-Fisher, McBride & Gorenberg, 1997). Thus, for the purpose of their work, members of the Taskforce defined diversity as being inclusive of those individuals from all racial, ethnic, gender, generational, geographical, or any other under-represented groups. TABLE 2 Gender Female Male Wisconsin RNs 93.1% 6.9% Source: WCN DWD 2012 RN Survey Summary Wisconsin LPNs 95.4% 4.6% Source: DWD 2011 LPN Survey Summary 6

7 Additionally, the Taskforce was committed to recommendations for increasing nursing diversity put forth in the Institute of Medicine (IOM) Report, The Future of Nursing: Leading Change, Advancing Health (2011). The Report stresses the need for a nursing workforce that is racially and ethnically diverse, and with greater numbers of males in the profession, to meet changing needs of patients in healthcare systems. Levels of educational attainment must then first focus on increasing the diversity of the student body (2011). The primary purpose of the WCN Diversity Taskforce was to assess diversity initiatives from a sampling of educational or practice settings, and provide recommendations for strategies to promote and enhance nursing diversity in the state. The Taskforce developed four key objectives to frame their work: 1) Assess current diversity initiatives in Wisconsin utilizing an environmental scan process, 2) Identify strengths and limitations of the reviewed initiatives, 3) Identify strategies and/or promising practices to reduce barriers and increase nursing diversity, and 4) Compile the findings and recommendations in a report to inform a statewide nursing workforce plan. Although the principal activity of the Taskforce was these four objectives, extraneous activities were also undertaken to enhance the work of the group. An extensive literature review was accomplished, as well as the review of multiple resources on nursing diversity. Additionally, the expertise and perspectives of group members created a perfect platform for focused and robust dialogue during monthly meetings to identify barriers to diversity in nursing, and brainstorming possible solutions to them. These activities served to support and complement the findings of the environmental scan project, and the resulting recommendations to achieve a workforce that is more representative of the increasingly diverse population of Wisconsin. 7

8 Literature Review Members of the WCN Diversity Taskforce grounded their work in published literature related to the need for diversity in nursing. To ensure that a comprehensive literature review was conducted, two members of the taskforce searched major education and health science databases including: the Education Resources Information Center (ERIC), the Cumulative Index to Nursing and Allied Health Literature (CINAHL) Plus, and the U.S. National Library of Medicine National Institutes of Health (PubMed). GoogleScholar was also utilized as a database. The search was limited to nursing education, the English language, and publications during to ensure that it was the most current and widest range of data. Key search terms included minority, men, recruitment, nursing diversity, nursing education, and retention. Hand searching was also done by several members for manuscripts specific to diversity enhancement strategies that aligned with the purpose of the Taskforce. Findings in the literature that support the need for diversity in nursing are numerous and present a strong argument for this critical requisite in our profession. The literature also revealed significant barriers to enhancing nursing diversity as well as strategies to inform the resulting recommendations of the Taskforce. As early as 2004, the Sullivan Commission reported: The fact that the nation s health professions have not kept pace with changing demographics may be an even greater cause of disparities in health access and outcomes than the persistent lack of health insurance for tens of millions of Americans. Today s physicians, nurses, and dentists have too little resemblance to the diverse populations they serve, leaving many Americans feeling excluded by a system that seems distant and uncaring. Failure to reverse these trends could place the health of at least one-third of the nation s citizens at risk. To achieve that new vision, care must be provided by a well-trained, qualified, and culturally competent health professions workforce that mirrors the diversity of the population it serves (p. 1). The concern of the Sullivan Commission for safe care and quality outcomes through the provision of care by culturally competent and diverse providers is also supported by Ardoin & Wilson (2010), who report it is essential to have knowledge of particular cultural populations to assist in decision-making for safe treatment. Swinney & Dobal (2008) report that racial/ethnic balance between clients and providers is associated with greater participation, higher satisfaction, and greater compliance with treatment regimes. In 2006, Salisbury & Byrd reaffirmed the concern touted by the Sullivan Commission, and recommended healthcare organizations go beyond awareness, and address the need for conscientious integration of inclusive practices (p. 93) to support cultural competence and in doing so, achieve higher levels of quality care for patients. Staff must be aware of critical elements in how diverse health beliefs influence the behaviors of the population served. To achieve this integration, several authors recommend that organizations begin with the inclusion of dedication to building diversity within their mission statements, and then strategically plan for recruitment, education, promotion and retention in partnership with members of under-represented populations (Salisbury & Byrd, 2006; Noone 2008). The formation of academicpractice linkages to provide diversity-enhancing strategies is also recommended for organizations (Noone, 2008; Swinney & Dobal, 2008). Barriers to achieving greater diversity in nursing education, and ultimately the profession, are clearly identified in the literature and center on the realms of financial need, academic support, feelings of isolation by members of under-represented populations, language, and potential for racism and discrimination (Barton & Swider, 2009; Johnston & Mohide, 2009; Nairn, Hardy, Harling, Parumal & Narayanasamy, 2012; Noone, 2008). Martinez (2003) proposes the utilization of adaptation models for insight into minority students feelings of isolation and lack of 8

9 integration, but overall, that achieving success in diversity in nursing requires support in two critical areas: recruitment and retention. Recruitment strategies can be implemented that start earlier, involve the community and target certain populations. Several authors suggest growing the pipeline in nursing by expanding the marketing campaign with community-based activities, and consistent messages for earlier exposure to nursing for younger students, including high school or middle school (Barton & Swider 2009; Martinez, 2003; Noone, 2008; Swinney & Dobal, 2008). This recommendation is supported by Whitehead, Mason and Ellis (2007) whose study revealed that high school students held traditional views, which were often stereotypical, or with very little accurate knowledge about the nursing profession. A singular approach to achieving diversity in the form of specific, targeted recruitment and outreach is recommended by Noone (2008). A vast amount of retention strategies have been put forth in the literature. Availability of faculty for minority students and provision of their feedback to them, is especially recommended by Baker (2010). But most often the literature suggests recommendations that fall into well-established and familiar categories such as provision of financial aid, mentoring by faculty with similar cultures, elimination of educational stereotypes, academic support systems such as tutoring and study groups for under-represented populations, cultural competency, and faculty seminars for teaching-learning strategies (Baker, 2010; Bednarz, Schim, & Doorenbos, 2010; Martinez, 2003; Noone, 2008; Omeri, Malcolm, Ahern & Wellington, 2003; Swinney & Dobal, 2008; Wilson, Sanner & McAllister, 2010). Although many authors focus on diversity as it relates to race, ethnicity and gender, Earle, Myrick, & Yonge (2011) pay special attention to the importance of preceptorships, particularly in view of intergenerational diversity. Meadus & Creina Twomey (2011) focus their efforts in dispelling the pervasive notion that nursing is still not commonly viewed as a profession for males, and the importance of eliminating gender-based stereotypes. Noone (2008) and Swinney & Dobal (2008) propose the availability of opportunities for supportive social networks as critical to ensure that students will indeed graduate. Although retention efforts should empower students through these networks, Swinney & Dobal (2008) additionally recommend, and advocate for, both responsibility and commitment on the part of the students themselves to further solidify potential for program completion. Finally, the use of systematic data collection to assess the needs of any community to make well-informed decisions for care and services is advocated by Salisbury & Byrd (2006). An identified gap in the literature was the critical need to collect data on the recruitment and retention of the under-represented groups themselves, in order to observe trends over time regarding progress being made in the diversity composition of the nursing workforce. The importance of this is reflected in the work being done by WCN in the analyses of both nursing workforce and nursing education data in Wisconsin. 9

10 Environmental Scan Project The Taskforce arrived at consensus on a process to gather information on Wisconsin activities. It was agreed this would be an informal process to gather information via environmental scans, in lieu of rigorous research, given the time constraints and resources of volunteer membership. A questionnaire format was developed to gather standard information from a sampling of organizations and academic institutions in Wisconsin to include: program or activity type, key features and processes, guiding protocols or policies, target populations, key success strategies, outcomes measurement, follow-up postgraduation or job retention and specific obstacles or barriers to diversity in nursing. Taskforce members volunteered to obtain the information, or arrange interviews with knowledgeable personnel from within their own organizations or institutions, or other programs of which they were aware. The organizations invited to participate represented the geography of the state, public and private educational programs, rural/urban and small/ large healthcare systems, minority nursing associations, and the statewide Wisconsin Area Health Education Center system. In total, information was gathered from seventeen (17) different organizations. These included five (5) health systems, two (2) minority nursing associations, four (4) public baccalaureate or greater degree academic institutions, the state technical school system for associate degree nursing education, and one (1) Area Health Education Center system. Since these entities represented all geographical regions of the state, as well as organizations of all sizes and interests, the Taskforce members concluded there was considerable reliability in this cross-section, and that it was substantially representative of the diversity initiatives taking place throughout Wisconsin. Project Review Methods Review of the environmental scans revealed a plethora of program and activity approaches already being undertaken to augment diversity in the nursing workforce. These responses were aligned, and consistent with, categories in the environmental scan questionnaire format. A small workgroup of members then grouped the responses from the questionnaires under the general categories of Program Description, Development, Outcomes, and Evaluation, to look for emerging common themes. Another category Other was added to allow for inclusion of any outlier information. All the responses were then collated under these categories to analyze and determine emerging common themes. Six major themes emerged from the analysis: 1) Organization/Institution support for diversity, 2) Specific programs to provide support to underrepresented populations, 3) Funding support, 4) Marketing and outreach activities, 5) Evaluation and outcomes measurement, and 6) Limitations and barriers. From these overarching themes, numerous examples of specific activities directed at increasing nursing diversity were identified (Table 3). 10

11 TABLE 3 Diversity Initiative Environmental Scans Organizations, Health Systems or Academic Institutions in Wisconsin (n=17) Emerging Theme: Organization/Institution Support for Diversity Specific Programs to Support Under-Represented Groups Examples (# responses) Dedicated departments, positions, committees & established support programs for under-represented populations (7) Inclusion in organization strategic plan (6) Staff/faculty cultural competency training, workshops, seminars (8) Diversity events (6) Partnerships across departments or within the community (7) Undergrad course for cultural awareness, competency (3) Hosting minority student associations (4) System-wide interpreter & translator tools (2) Practice inclusive environment; i.e. recruiting diverse staff/faculty/students, compliance with EEO laws, multi-lingual, diverse leaders/board members, diversity and inclusion reflected in mission or core values of organization, staff held accountable (8) Open enrollment (1) Formal mentor programs with faculty, staff or peers (8) Internships (3) Nurse residency program (1) Academic support services, such as: student advisement, study skills, writing & communication, ESL & language support, time management, resource centers, testing accommodation, tutors, flexible faculty, services specific for first generation college students. (10) Immersion & community-based training (2) Disability testing (1) Ability-based curricula (1) Reduced credit load (1) Annual program-specific guided cohort for under-represented populations (1) Formal process for student commitment (1) Funding Support Scholarships for under-represented populations (9) Grants to support work in diversity work or mentorship (3) Paid internships (1) Funding for membership in nursing organizations (1) Minority Scholars program with funding support (2) Marketing & Outreach Pre-college entry preparation programs (2) Middle school, High school recruitment (4) Recruitment via community events (3) Employee recruitment through job service (2) Direct marketing to target groups (3) Personalized recruitment (1) Recruitment of minorities via sponsorship of nurse-managed clinics to underserved populations (1) 11

12 Evaluation & Outcomes Measurement Alumni surveys (9) Demographic data on under-represented populations (6) NCLEX success rates on all grads (7); tied to diversity (1) Annual or program reports (3) Focus groups (1) Data on nursing organization memberships (2) Tracking scholarship awards (1) Tracking program completion (1) Faculty surveys (1) Recognized changes in climate, attitudes, faculty transparency; resulting in policy changes (1) Barriers and/or Limitations No specific diversity initiatives taking place (1) No data collection or outcomes measurement (7) No written guidelines or target benchmarks (1) Program incompletion (2) Decreases in available funding (8) Geographical disadvantage to recruit diverse students, employees (5) Lack of staff to dedicate to diversity (6) Decline in job availability, saturated job market(3) Ineffective marketing (3) Increased demands on students; i.e. family, finances, working, lack of family support, language issues, readiness for rigor of curriculum (5) Project Results Reviewers noted that despite the volume of activities underway, the scans revealed significant gaps in consistent or standardized approaches across the state. This process in and of itself, provided many ideas for enhancing diversity, and the evidence is clear that much is being done in Wisconsin to promote nursing diversity. For the most part however, there is a great variation in the types or formality of the approaches that were reported. The exception is that which is required by law for equal opportunity requirements, which although a basic assumption, was specifically mentioned by eight of the participating organizations as an institutional initiative. Specific project findings are shown in Table 3 and discussed in the following paragraphs of this section. Under the first theme of Organization/Institution Support for Diversity, it is notable that eight (8) out of 17 respondents (47%) indicated their organizations practiced having an inclusive environment and as such, their dedication to diversity was reflected in the core values and mission of the organization. But only six (35%) reported that planning for diversity was included in their organizational strategic plans. Cultural competency training for staff was provided by nearly half of all the organizations. Diversity events were hosted in six organizations to create awareness and encourage employees or students to embrace diversity. However, of the nine academic respondents, only three (33%) had specific coursework for cultural competency required at the undergraduate level, and only four (44%) reported hosting minority student organizations on their respective campuses. 12

13 A clearly dedicated approach to diversity was seen in 41% of the organizations which reported having specific departments, positions, committees and councils that had been established and fiscally supported to address the needs of under-represented populations. Along with these, established partnerships with community organizations, or across departments for collaborative approaches and to share resources was also reported to achieve synergistic results to enhance diversity. Within the thematic area of Specific Programs to Support Under-Represented Groups, a multitude of services were identified. Academic support services were provided by 100% of the academic institutions, as well as the statewide Area Health Education Centers. Provision of such services as student advising and special training to improve communication skills were commonly reported as being available to students of traditionally under-represented groups. Also reported were several types of accommodations to support student success such as preparation for test-taking, or provision of tutors. Student internships, some of which included compensation, were reported by less than 20% of the respondents; and a nurse residency program was reported by only one health system as a measure to support minority nurses. Cultural immersion and community-based training programs as a means of promoting and growing diversity were reported by only two (2) of the 17 respondent organizations. Funding Support was another predominant theme in the findings. The provision of scholarships for under-represented populations was reported by 100% of the academic institutions. Grants to support work in diversity or mentorships was reported in only three (3) out of the 17 scans. In fact, several respondents mentioned many such grants had been eliminated in recent years. Only two organizations reported they had a formal minority scholars program that included funding support for its participants. A fourth theme, Marketing and Outreach Activities was reported as being done during the interviews. Pre-college entry preparation programs, middle or high school recruitment was reported by 30% of participating organizations. Outreach into the community and/or direct marketing were touted as effective mechanisms, but only reported by three (3) out of 17 respondents (18%). Recruitment of any sort was emphasized as not being necessary by several of the organizations, blaming job market saturation as the reason for its not occurring. Evaluations and Outcomes Measurement was an important area addressed in the scans, with questions relating to the collection of data on traditionally underrepresented groups in either nursing staff, or nursing students. All schools that participated in the scans completed surveys on their alumni. Seven (7) out of the nine (78%) academic respondents reviewed NCLEX success rates on graduates, but only one program separated out the findings by diversity. Six (6) out of 17 organizations (35%) collected demographic data on under-represented populations, and two tracked additional information on memberships in minority nursing associations. Only three respondents indicated they provided annual reports of organizational activities on diversity. One organization reported anecdotally that although formal data was not collected about their diversity efforts, there were significant recognized changes that took place within the organization in the form of climate and attitudes, which they believe resulted in constructive policy changes. The final emerging major theme in the environmental scans was that of Barriers and/or Limitations. This section revealed far and away the most consistency in predominant and frequent responses. The first most common from eight (8) out of 17 respondents (47%) was concern expressed about decreased funding for any type of diversity support mechanisms, and the impact this has on the capacity for organizations to make progress on diversity initiatives. This lack of funding is also reflected in the six organizations that reported no funding available to hire staff to work on diversity issues. 13

14 A significant limitation which may be assumed to impact the ability to obtain funding was that there was no data collection or outcomes measurement on diversity, or even any guidelines for benchmarks to do so. This was reported by the same percentage (47%) of respondents. In fact, in one academic institution, there were no established programs to increase diversity, primarily due to lack of resources. Lack of ability to recruit diverse candidates was attributed to being at a geographical disadvantage (5), or a saturated job market (3). However, this was reported to be of little significance because the organization had documented and lived core values of inclusivity, and believed this credo would, in essence, ensure success with diversity inclusion and growth. Ineffective marketing was also attributed to a lack of diversity recruitment success by three organizations. Another comprehensive approach to achieve diversity that was reported utilized, yet ultimately does not always ensure it, is the policy of open enrollment. Despite being an effective method for initial recruitment of minorities, the concern remained that this did not necessarily equate with retention and program completion, and thus was actually cited as a significant limitation. The last, and quite formidable, barrier were the increased demands on students which negatively impacted their chances to succeed. Despite 100% of academic institutions responding affirmatively to providing multiple student support services, 29% of the respondents also cited continually increasing demands on these students (family, finances, jobs, language) being a barrier to their success within the rigors of a nursing curriculum. Other Findings The scans also revealed what became designated as outlier information. For the purpose of compiling information collected in the environmental scans, taskforce members considered singular responses (1) in any area to be an outlier, having no occurrence reported by another organization or academic institution (Table 3). The number of these outliers was considerable, giving credence to the myriad types of efforts currently going on to enhance nursing diversity. At the same time, it may also demonstrate inconsistency in these multiple approaches. It was also felt that these isolated responses may indeed be the source of unique concepts or programs that could be shared as potentially innovative approaches to increase diversity in the nursing profession. Thus, some of these outliers were of merit as possible successful approaches, while others clearly were not. An example of one that may not achieve or ensure desirable levels of diversity in nursing is the concept of open enrollment. Although it may be helpful to ensure entry level registration, it was clearly stated during the interview that this did not necessarily equate with, or guarantee, program completion by students, and therefore was not viewed as a successful strategy for long-term sustainability to increase diversity in the nursing workforce. An example of a specific approach that was a successful strategy to ensure program completion was a model involving the annual selection of targeted participants for a cohort in a nursing education program. This cohort is then guided and mentored throughout the entire educational process with a variety of support mechanisms in place to ensure success in the program. Despite the volume of support services available by many institutions, only one reported tying in student readiness assessment with disability testing to inform development of an ability-based curriculum or reduced credit load, which could well serve a minority student with language or other types of challenges. 14

15 Curricular adjustments could work in tandem with the implementation of a formal process for student commitment and/or paid internships, each of which was only reported by one organization. Providing a minimal resource like funding for membership dues in minority nursing organizations could serve as a vital support network to a student or nurses from an underrepresented group. Two interesting approaches to recruitment were also reported. One was in the form of direct, personalized recruitment, which could be considered akin to the type of recruitment done on high performing students or athletes. Another novel approach to recruitment was one that also greatly served the community. This was done through the provision of sponsored nursemanaged clinics to underserved populations in their own neighborhoods and in many cases, attached to schools. As such, these clinics provide superior exposure to nurses as role models and leaders, and serve as an inspiration for youth of all ages to stimulate interest in choosing nursing as a career path. Significant outliers found in the area of outcome measurements could provide useful tools for promoting nursing diversity and measurements of success. This included such things as: focus groups, tracking scholarships awarded, tracking program completion, tracking NCLEX pass rates by minorities, and also faculty climate and knowledge surveys. Organizations that do not provide benchmarks for achieving diversity targets could also negatively impact rates of employee awareness, engagement and rates of recruitment success. 15

16 Discussion The Taskforce fully espoused the declaration of the Future of Nursing Campaign for Action, which states, Racial and ethnic minorities make up approximately 30 percent of the U.S. population, but just under 15 percent of registered nurses, and just seven percent of RNs are men. It is essential that the nursing population evolves to reflect America s changing population, and advocates, supporting the importance of a diverse workforce and helping to prepare the discipline of nursing to care for a substantially increasing diverse population; ultimately to help narrow the health care disparities gap (Future of Nursing Campaign for Action website, 2012). As a complement to the literature review and environmental scan project, the Taskforce held numerous brainstorm sessions which revealed insights from the members expertise and experiences. Critical issues such as the lack of available funding were discussed, as well as the need for greater awareness and marketing of what funding is still available to support education of underrepresented groups, and how important information can be easily accessed by students. Members also agreed that a great deal of isolation of minority students still exists, and that professionals and faculty members need to be allowed time to support and address this crucial issue. In addition to lack of racial/ ethnic diversity in nursing, a major concern voiced was the current female gender domination in nursing education and nursing practice, and the pervasive message that prevails to both potential nursing students and consumers in the media. Members surmised that providing diversity concepts as a fully integrated focus in the curricula, rather than treating it as a sidebar could do much to improve messaging to students. This included recognizing the need for concerted efforts of cultural immersion for students, not just the presence of represented minorities, such as the intentional, purposeful creation of cross-cultural, gender groups in clinical placements. From a practice perspective, deliberate application of cultural information in the clinical setting should be promoted as an asset to improve communication and levels of care for better outcomes and improved patient satisfaction. An identified strength was the great diversity in opportunities already present in the types of nursing career paths as a means to provide appeal to equally as diverse nurses. Members of the Taskforce found clear and consistent similarities between identified barriers and suggested strategies within the literature search, and what was perceived or known as valid in their discussions. These were also found to be in alignment with the environmental scan project, in which the same issues continued to surface. The Diversity Taskforce members fully acknowledged any limitations of the assessment of the environmental scan project. Although it was not rigorous research with standard methods for data analysis, it provided for a gathering of information from which to learn and make inferences about current efforts in the state. Yet, the members of the Taskforce felt confident that the project was significant in that it provided a good overview of examples of initiatives with an array of strategies that were taking place in Wisconsin to support and enhance nursing diversity. Furthermore, the examples came from a wide variety of organizations, large and small, and along with public and private educational programs throughout Wisconsin. The members felt this provided a compelling argument as an accurate representation of what was going on in Wisconsin at any given point in time. Clearly, there is a concerted effort in our state to positively impact the status of nursing diversity. 16

17 Although the environmental scans offered some new knowledge of innovative programmatic approaches, the members agreed that nothing really new emerged from the literature, their group perceptions, or the reality of what was taking place. Despite the fact that much of this information has been established for a considerable amount of time, there has been little, or minimal, progress in achieving a truly diverse nursing workforce that matches the demographics of the population to date. This is not only true in Wisconsin, but from a national perspective as well. Encouraging results which can potentially mitigate the diversity imbalance comes from the 2010 and 2011 Wisconsin nursing education surveys conducted by WCN, in which the current enrolled nursing student demographic characteristics closely approximated the population of Wisconsin, as well as national distributions. (Dean-Baar, Cook & Laurent, 2011). The need for a culturally diverse nursing workforce is well-documented, and it would appear that although many of the strategies already in place have begun to move things in the right direction, it is marginal at best. These findings led the Taskforce members to pose the question of why, then, haven t we made more progress in this critical area of nursing workforce development over such a significant length of time? The answer may rest, with not just the application of a singular approach or recommendation to be followed, but for many or all of them to be applied together in a more comprehensive and standardized approach to achieve the desired outcome. In 2012, the survey once again showed that Wisconsin s population demographics approximated the makeup of students in all types of nursing programs in the survey, with licensed practical nurse programs having the greatest diversity, and 8.6% African-American students in associate degree programs surpassing that of the state population of 6.5% (U.S. Census Bureau 2011). This increase in African-American students also represented a greater percentage than the 7% reported in the 2010 Education Survey (Dean-Baar, Cook & Ke, 2013). Once again, the ongoing data collection supports that existing efforts for increasing diversity are indeed, having a positive impact for the future workforce. 17

18 Summary and Recommendations Despite the significant efforts, and in some cases, unique strategies being applied in the various initiatives going on in Wisconsin, for the most part these continue to be fragmented and dependent upon available resources and varying degrees of commitment by the organization. In short, we can do better to grow a more diverse nursing workforce in Wisconsin. Although some progress is being made, it continues to be too slow to impact the needs of ever changing demographics and increasing health disparities. After thorough review of the literature, collated environmental scans, and extensive dialogue by the Taskforce members, consensus was reached on five overarching recommendations to make nursing diversity efforts in our state more standardized, cohesive and successful: 1. Make diversity an organizational priority & system-wide approach More emphasis can, and should, be placed upon efforts to heighten awareness and commitment to diversity by organizations that would negligibly impact their resources. At a very minimum, all organizations should view enhancing diversity along with an inclusive environment as part of its mission, core values and strategic plan in view of today s rapidly changing populations. From a business perspective, organizations can no longer repudiate need for increasing diversity as a means to improve patient outcomes, or that it can occur without dedicated efforts to achieve it. 2. Provide a variety of support mechanisms for under-represented populations in both academic and practice settings. Specific initiatives, such as mentoring, peer support groups or minority associations, have already demonstrated successful outcomes, and can be implemented in a variety of settings with the myriad resources that are available for their development. The impact of these can be strengthened through collaboration with other disciplines, and the exploration of innovative sources of funding to support this work. 3. Train all staff and students to ensure higher levels of cultural competency. At this point in our state s changing profile, the provision of cross-cultural, competency training and/or required coursework for such, should be mandatory for all students, faculty and healthcare staff. The burden of resources for this should not be borne by individual organizations or schools, however. Much can be accomplished with community-academic partnerships, and interprofessional collaboration among providers. Activities such as campus-community events can be rich sources of heightening cultural awareness, as well as a means to include members of the culture itself in the planning and development of educational opportunities. 18

19 4. Develop a standardized systemwith agreed upon benchmarks for tracking data on under-represented populations in nursing programs & health systems throughout the state. The value of standardized nursing workforce data collection has been promoted at both state and national levels for some time. Formalizing and standardizing approaches to the systematic collection and analysis of data specific to traditionally under-represented groups should be a strategic priority for all health systems and schools. Data on graduation rates, licensure, recruitment, employment and retention should be monitored to reveal trends over time and provide valuable insight to strategies to overcome barriers to increasing diversity in the workforce. The Taskforce also formulated guidelines to accompany the recommendations and generate activity ideas for organizations which could make a significant contribution to increasing diversity in the nursing workforce. The five recommendations with their respective suggested guidelines are shown in Table 4. The transformation of healthcare, of which a diverse workforce plays a major role, cannot occur in isolation and accomplished by nursing alone, but rather by forging synergistic partnerships with key stakeholders for this effort. This clearly means nursing must go beyond its boundaries to embrace collaborative efforts with non-nursing entities such as other healthcare providers, healthcare systems, consumers, policymakers, business and philanthropic organizations, in order to ultimately improve the health of populations for a more productive society. 5. Join forces for a statewide initiative to increase funding for nursing scholarships for under-represented populations. A common concern reported by all Taskforce members, and also demonstrated repeatedly in the environmental scans, was that not only had funding to support minority education severely decreased, but also funding streams for new diversity positions and programming. During these times of economic constraints and uncertainty, the Taskforce members proposed the use of creative partnerships and tapping new resources that have been unlikely alliances for nursing in the past. 19

20 TABLE 4 WCN Diversity Taskforce Recommendations for Healthcare Organizations & Schools of Nursing in Wisconsin 1. Make diversity an organizational priority & system-wide approach. Include diversity in the mission statement, core values and strategic plan of each institution. Support diversity specific departments, positions or councils. Establish an organizational structure that ensures accountability for recruiting and retaining a diverse nursing student body/staff. Focus on recruitment for students at earlier stages of educational progression. Create mechanisms, programs to support success and retention of under-represented populations. Establish collaborative academic-practice-community partnerships between schools, healthcare organizations, community, and consumer organizations. Dedicate efforts to seek funding to support diversity growth through innovative approaches and outreach to new philanthropy sources. Set goals for attainment of specified metrics in diversity; track data and evaluate outcomes. 2. Provide a variety of support mechanisms for under-represented populations in both academic and practice settings. Provide specific programs which provide support to underrepresented populations i.e. mentoring, coaching, student/ employee academic & employment resources, social networks. Develop support systems for assimilation of underrepresented populations into the workplace. Offer funding support for academic education, and continuing education of staff. 3. Train all staff and students to ensure higher levels of cultural competency. Require cross-cultural, competency training and/or courses for all students, faculty and staff, including specific courses and programs on cultural awareness and building and maintaining positive interracial relationships. Establish interdisciplinary approaches for collaboration with admissions, human resources and other educational departments for obtaining data on enrolled underrepresented students to assess the types of support needed by underrepresented populations. Establish peer mentoring for faculty, students and staff to encourage and support diversity initiatives, and maintain effective interpersonal behaviors. Host system-wide diversity events. 4. Develop a standardized system with agreed upon benchmarks for tracking data on under-represented populations in nursing programs & health systems throughout the state. Formalize an inclusive tracking system of numbers for all nursing students (public, private, ADN, BSN and higher) enrolled in, and completing programs. Collect, analyze and monitor data to include demographics, program participation, NCLEX results and acquired employment post-graduation. Formalize an inclusive tracking system of numbers for all diverse faculty in public, private, ADN, BSN and higher nursing education programs. Standardize employment metrics on practicing nurses from under-represented populations, including recruitment, employment and retention. 5. Join forces for a statewide initiative to increase funding for nursing scholarships for under-represented populations. Embrace IOM recommendations in Future of Nursing Campaign for Action to support academic progression, nursing leadership and future faculty development. Utilize academic practice linkages for collaborative efforts. Collaborate with healthcare and private sector entities for collective approaches to advocate for and provide, increased funding to support under-represented populations in the nursing profession. Develop a statewide scholarship repository. 20