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DataWatch

Racial/Ethnic Disparities In Nursing

Abstract

 
The racial and ethnic composition of the registered nurse (RN) workforce in California is not at parity with the composition of the population. We find that the underrepresentation of African Americans in nursing in California appears to be due to lower overall educational attainment among African Americans. Underrepresentation of Latinos is due to lower overall educational attainment and, to a lesser extent, a lower percentage of college-educated Latinos pursuing careers in nursing. Improving the overall educational attainment of minority students is critical to increasing the number of minorities in nursing.

Two possible explanations for the lack of diversity in nursing concern differences in pursuit of higher education among racial/ethnic groups. The first is that lower rates of high school graduation and college entry among minorities reduce the number of minority students who pursue careers in nursing and other fields that require college degrees.³ The second is that racial/ethnic minorities who pursue higher education may be less likely than whites are to obtain a degree in nursing. This hypothesis is supported by the observation that minorities are much less represented in nursing than in other female-dominated professions that require a similar level of education, most notably teaching.⁴ An assessment of these hypotheses has implications for policies and programs directed at increasing racial/ethnic diversity in the nursing workforce.

To more systematically evaluate the relative contribution of the two factors, we conducted a study of nursing and general educational attainment in a single state, California. California is the most populous state in the nation and has one of the most racially and ethnically diverse populations, making it particularly revealing as a case study of diversity in nursing. However, our findings are relevant throughout the nation, because the number of nonwhite Americans is projected to rise by 50 percent between 2000 and 2020.⁵

Data And Methods

Top Data And Methods Study Results Discussion NOTES

 
Our study consisted of three components. The first component compared the racial and ethnic composition of the registered nurse (RN) workforce in California with that of the overall California population and working-age Californians (ages 20–64). The National Sample Survey of Registered Nurses, administered by the Division of Nursing of the U.S. Bureau of Health Professions every four years, provided data on the demographics of RNs in California in 1996. Population estimates were obtained from the California Department of Finance.

Next, we evaluated the highest educational level attained by California residents ages twenty-four through thirty-nine according to racial and ethnic group. The age limitation was based on the assumption that most college-educated persons enter college by the selected ages. Data on educational attainment were obtained from California respondents to the March 1999 iteration of the U.S. Bureau of the Census Current Population Survey (CPS). These data were supplemented with information from the California Department of Education on 1998 high school graduates, dropout rates, and percentages of high school graduates who completed a college preparatory curriculum.

The final component of our study examined degrees awarded to college students in California. We analyzed college degrees awarded in 1998 according to the race/ethnicity of the graduate and type of degree. Degrees were grouped in the following categories: nursing, other health field, physical and biological sciences, and other.⁶ Information on college degrees awarded was obtained from the California Postsecondary Education Commission (CPEC). CPEC is California’s designated state agency for collection of data for the U.S. Department of Education’s Integrated Postsecondary Education Data System (IPEDS) and collects data in accordance with the IPEDS classification system.

Our analysis of persons receiving degrees in nursing was limited to those receiving associate or bachelor’s degrees in nursing.⁷ Persons completing educational preparation for licensure as licensed practical/vocational nurses were excluded.

Study Results

Top Data And Methods Study Results Discussion NOTES

 
Racial/ethnic gaps. African Americans and Latinos are underrepresented among RNs relative to the entire and working-age populations in California (Exhibit 1). The gap is most pronounced for Latinos, who account for 28 percent of working-age adults in California but only 5 percent of RNs. Data on recent nursing school graduates indicate that some progress has been made in increasing the numbers of African Americans and Latinos in RN educational programs but that both of these groups remain underrepresented among RNs. Across all racial/ethnic groups, women far outnumber men among RNs. Women accounted for 93.5 percent of all RNs in California in 1996 and 85.7 percent of persons receiving nursing degrees from California colleges and universities in 1998.

Differences in curricula. We also analyzed differences in curricula across racial and ethnic groups, because all high school graduates do not receive the same quality of education. Completion of a college preparatory curriculum signals better preparation for nursing programs, particularly for required mathematics and science courses. To estimate the percentage of students who were "well prepared" for college, we used data on the percentage of students who were University of California (UC) or California State University (CSU) eligible. The UC and CSU systems have specific science and math course requirements for admission.⁹ Twenty-six percent of Latina graduates of California public high schools in 1998 were UC/CSU eligible, compared with 31 percent of African American, 45 percent of non-Latina white, and 62 percent of Asian female graduates. Males were generally less likely to be UC/CSU eligible, but differences across racial/ethnic groups were similar.

Likelihood of receiving a nursing degree. Of women receiving college degrees in California in 1998, 5.8 percent of African American women, 5.3 percent of non-Latina white women and 3.4 percent of Latinas received a degree in nursing (Exhibit 3). Although in absolute terms these may appear to be small differences, in relative terms they are substantial. For example, white female college graduates were 56 percent more likely than Latina graduates were to receive degrees in nursing. Latina graduates were also less likely than non-Latina white graduates were to receive degrees in other health fields and science fields. While male college graduates completed degrees in nursing at significantly lower rates than females, we found that males and females generally showed similar trends across racial/ethnic groups.

The case of Latinos. The results shown in Exhibit 3 indicate that the underrepresentation of African Americans in nursing in California is not due to a lower percentage of African American college students receiving degrees in nursing. African Americans obtaining college degrees are actually entering nursing at higher rates than whites are. However, Latino college students are entering nursing at a lower rate than non-Latino whites and African Americans are, contributing to the lower proportion of Latinos in nursing.

Raising the number of Latino nurses. We sought to determine which factor has the greatest impact on the underrepresentation of Latinos in nursing: overall educational attainment or the proportion of college students majoring in nursing. Taking two hypothetical groups of high school freshmen, 1,000 non-Latino whites and 1,000 Latinos, we used the data from Exhibits 2 and 3 to predict how many would complete a degree in nursing under each of three scenarios. We chose to compare Latinos and non-Latino whites because the Latinos are the most underrepresented group in nursing. Data on educational attainment for U.S.-born Latinos were used in these scenarios for projections for the Latino cohort (Exhibit 4).

Scenario 1 projects the number of Latino and non-Latino white high school freshmen who would earn nursing degrees, based on current rates of educational attainment and receipt of nursing degrees. Under this scenario, non-Latina white women are almost three times as likely to earn a nursing degree as Latinas are. This disparity is the result of both the lower probability of Latinas to enter college and earn a degree, and the lower probability of those Latinas completing college to receive a degree in nursing.

Scenario 2 estimates how many of the hypothetical 1,000 Latinos would become nurses if, once in college, they received degrees in nursing at the same rate as whites. While the number of Latinas obtaining a nursing degree would increase by 50 percent, white women would still be almost twice as likely to obtain nursing degrees. White men would still be three times as likely to have a nursing degree than Latino men.

Another possibility is that the overall educational attainment of Latinos is increased to that of whites (Scenario 3). This would almost double the number of Latinas with nursing degrees (assuming that the proportion of Latina college students obtaining degrees in nursing remained constant). Although this rate is still below that of white women, it would be a substantial increase. Raising the educational attainment of Latino men would yield an even greater proportional increase of the number of Latino men who would obtain a nursing degree.

Discussion

Top Data And Methods Study Results Discussion NOTES

 
Our study indicates that improving the representation of African Americans and Latinos in nursing will require policies that enhance the overall educational attainment among these groups. Once African Americans enter higher education in California, they appear to be as likely as whites are to obtain degrees in nursing. Although efforts to recruit African American college students to nursing should continue, attention must also be given to increasing the number of African Americans graduating from high school and entering higher education. On the other hand, increasing the number of Latino nurses requires a dual strategy that enhances overall educational attainment and more effectively recruits and retains college-bound Latinos in nursing programs.

Ensuring diversity. In its 1994 report, Balancing the Scales of Opportunity, the Institute of Medicine (IOM) recommended systemic changes in the structure and environment of K–12 and higher education. ¹¹ In particular, the IOM report called for the adoption of "an achievement model" for the education of minority students under which students would be challenged to complete rigorous science and mathematics courses and would receive strong encouragement and mentoring from teachers, family, and community members. The IOM report contrasted this comprehensive approach to "isolated interventions aimed primarily at helping students or faculty from underrepresented groups fit into, adjust to, or negotiate the existing system" (p. 60).

Few of the interventions described in the nursing literature appear to fulfill the vision articulated by the IOM. Most are isolated efforts targeted toward minority applicants to nursing schools such as holding personal interviews, offering scholarships, and holding preadmission meetings to help applicants into nursing programs.¹² A few studies concern multifaceted programs aimed at retention of minority nursing students.¹³ There are even fewer examples in the nursing literature of ways to help prepare high school students for nursing education. One type of program links high school students with nursing programs and hospitals, exposing them to nursing and providing counseling about the college application process.¹⁴ Moreover, most of the literature in this arena is descriptive; studies do not assess the effectiveness of specific program components. Further research is needed to determine which strategies are most effective in increasing the number of minority nurses.

Study limitations. Our study has several limitations. Findings may not be generalizable to the United States as a whole because our study was limited to one state. Another limitation is that data on college degrees awarded cover only one year, 1998. CPEC data for 1996 and 1997 were not as detailed or complete as the 1998 data were, but they showed patterns similar to those for 1998. For the three years combined, the percentage of degrees awarded in nursing to African American, Latina, and white women was 5.6 percent, 3.5 percent, and 5.1 percent, respectively, compared with 5.8 percent, 3.4 percent, and 5.3 percent for 1998 alone. Findings for men were also consistent.

Another limitation concerns interpretation of the CPEC data on degrees in nursing by racial/ethnic group. These data do not enable us to determine why Latinos were less likely than other racial/ethnic groups were to receive degrees in nursing. The low likelihood of Latino college students completing nursing degrees may reflect factors such as a cultural perception of nursing as a low-status career; lack of role models; or lack of support from family members, high school counselors, and nursing faculty.¹⁵ This finding may also be associated with lower rates of completion of college preparatory curricula. Latinos who have not taken rigorous math and science courses in high school may be inhibited from pursuing a degree in nursing or may have difficulty completed required courses. Further research is needed to determine which factors most strongly influence college-bound Latinos’ decisions regarding choice of field of study and to design effective interventions to increase the number pursuing degrees in nursing.

Although college students in some racial/ethnic groups are less likely to complete degrees in nursing than whites are, gaps in educational attainment have a greater impact on the underrepresentation of racial/ethnic minorities in nursing. Closing these gaps will require a comprehensive and coordinated approach such as that proposed in the IOM report. Nursing schools should partner with K–12 schools and other health professions schools to develop and sustain comprehensive outreach and support programs. These programs should combine rigorous academic preparation with exposure to career opportunities in nursing and support services for minority nursing students.

Editor's Notes

 
Janet Coffman is associate director and Emily Rosenoff is a research assistant at the Center for California Health Work force Studies, University of California, San Francisco (UCSF). Kevin Grumbach is director of the center and a professor in the UCSF’s Department of Family and Community Medicine.

The authors thank Catherine Dower, Tina McRee, Carmen Portillo, and two anonymous reviewers for their comments on an earlier version of this manuscript. This research was funded by a cooperative agreement (no. 5U76MB 10001–02) with the National Center for Health Workforce Information and Analysis, U.S. Bureau of Health Professions, Health Resources and Services Administration.

NOTES

Top Data And Methods Study Results Discussion NOTES

 

1. See, for example, S.N. Keith et al., "Effects of Affirmative Action in Medical Schools—A Study of the Class of 1975,"New England Journal of Medicine 313, no. 24 (1985): 1519–1525[Abstract]; J.C. Cantor et al., "Physician Service to the Underserved: Implications for Affirmative Action in Medical Education," Inquiry 33, no. 2 (1996): 167–180[Medline]; M. Komaromy et al., "The Role of Black and Hispanic Physicians in Providing Health Care for Underserved Populations," New England Journal of Medicine 334, no. 20 (1996): 1305–1310[Abstract/Free Full Text]; and H. Rabinowitz et al., "The Impact of Multiple Predictors on the Generalist Physicians’ Care of Underserved Populations," American Journal of Public Health 90, no. 8 (2000): 1225–1228.[Abstract/Free Full Text]
2. H.W. Nickens et al., "Sounding Board: Project 3000 by 2000," New England Journal of Medicine 331, no. 7 (1994): 472–476[Free Full Text]; Komaromy et al., "The Role of Black and Hispanic Physicians";; J.C. Cantor et al., "Effect of an Intensive Educational Program for Minority College Students and Recent Graduates on the Probability of Acceptance to Medical School," Journal of the American Medical Association 280, no. 9 (1998): 772–776[Abstract/Free Full Text]; and P.I. Buerhaus and D. Auerbach, "Slow Growth in the United States of the Number of Minorities in the RN Workforce," Image—The Journal of Nursing Scholarship 31, no. 2 (1999): 179–183.
3. Institute of Medicine, Balancing the Scales of Opportunity: Ensuring Diversity in the Health Professions (Washington: National Academy Press, 1994); and National Association of Hispanic Nurses, Bridges and Barriers: Educational Mobility of Hispanic Nurses (Washington: National Association of Hispanic Nurses, 1998).
4. Buerhaus and Auerbach, "Slow Growth."
5. U.S. Census Bureau, Population Division, Population Projections Branch, "Population Projections of the U.S. by Age, Sex, Race, Hispanic Origin, and Nativity: Middle Series 1999 to 2100," <www.census.gov/population/www/projections/natsum-15.html> (2 November 2000).
6. "Other health" includes dental services, communication disorders sciences, health and medical assistants, health and medical administrative services, public health, rehabilitation/therapeutic services, diagnostic and treatment services, lab technologies, mental health services, and ophthalmic/optometric services.
7. Persons completing master’s entry programs in nursing were excluded because CPEC data do not distinguish between master’s degrees awarded to persons completing entry-level master’s degree programs in nursing and those completing master’s degree programs who already have an associate or bachelor’s degree in nursing. There are no diploma programs in nursing in California.
8. California Department of Education, Educational Demographics Unit, "Number of Dropouts in California Public Schools, Grades 9–12 by Grade Level by Ethnic Groups and by Gender for the Year 1997–98," <data1.cde.ca.gov/dataquest> (2 February 2000).
9. Individuals who have not pursued a college preparatory curriculum can enroll in associate degree nursing programs at community colleges. However, these students often have to take equivalent preparatory courses as prerequisites for admission to an associate degree nursing program, which increases the amount of time needed to earn a nursing degree.
10. U.S. Department of Education, The Condition of Education 1998 (Washington: U.S. Department of Education, 2000), 251.
11. IOM, Balancing the Scales of Opportunity.
12. See, for example, M.K. Memmer and C. Worth, "Retention of English-as-a-Second Language (ESL) Students: Approaches Used by California’s Twenty one Generic Baccalaureate Nursing Programs," Journal of Nursing Education 30, no. 9 (1991): 389–396[Medline]; A.R. Campbell and S.M. Davis, "Faculty Commitment: Retaining Minority Nursing Students in Majority Institutions," Journal of Nursing Education 35, no. 7 (1996): 298–303[Medline]; M.A. Dowell, "Issues in Recruitment and Retention of Minority Nursing Students," Journal of Nursing Education 35, no. 7 (1996): 293–297[Medline]; V.M. Fitzsimons and M.L. Kelley, The Culture of Learning: Access, Retention, and Mobility of Minority Students in Nursing (New York: NLN Press, 1996); A. Hesser et al., "Evaluation of a Supplementary Retention Program for African-American Baccalaureate Nursing Students," Journal of Nursing Education 35, no. 7 (1996): 304–309[Medline]; and C. Thompson, "Meeting the Learning Needs of Diverse Students in BSN Programs," Nurse Educator 23, no. 2 (1998): 25, 33, 37.[Medline]
13. Hesser et al., "Evaluation of a Supplementary Retention Program."
14. S.M. Underwood and T. Fay, "The UWM Health Careers Bridge Program: An Innovative Approach for Improving the Recruitment, Retention, and Graduation of Minority Students in Nursing and Health Careers," Journal of Nursing Education 35, no. 4 (1996): 179–181.[Medline]
15. National Association of Hispanic Nurses, Bridges and Barriers: Educational Mobility of Hispanic Nurses (Washington: NAHN, 1998).

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