INSIGHT Into Diversity recently spoke with three nursing professionals about various issues within nursing education and practice. They offered insight into the increased demand for diversifying the profession, the call for more highly educated nurses, and more.
Cherie Rebar, PhD, RN, is a professor in the Division of Nursing at Kettering College in Ohio, as well as an adjunct professor of nursing at Indiana Wesleyan University. She is also co-founder and co-president of RN2ED, an organization dedicated to bridging the gap between clinical nursing practice and education. She has written and edited many nursing textbooks and other resources.
Peter McMenamin, PhD, is senior policy adviser for the American Nurses Association (ANA), where he serves as the organization’s health economist with expertise on the economic value of nurses and nursing services. He previously served as director of healthcare financing policy for the American Medical Association and has worked in or with a number of government civilian health agencies.
David Vlahov, PhD, RN, is a professor and dean of the University of California, San Francisco (UCSF) School of Nursing. He previously served as a professor at Johns Hopkins University and Columbia University, as adjunct professor at several prestigious nursing and medical schools, and as co-director of the Robert Wood Johnson Foundation’s Health and Society Scholars program.
The nursing profession has seen an increase in the number of non-white nurses in the last decade, with minorities now making up 25 percent, according to a 2013 report from the Health Resources and Services Administration. What obstacles does the profession face on the path toward recruiting more minority nurses, and what strategies do you recommend?
Rebar: I think marketing methods and outreach campaigns are important — and strategic planning. Because these are not things that we can grow overnight, there has to be a strategic plan in place over a period of time to meet the challenge. For example, the University of Maryland School of Nursing applied for and received a $1.2 million contribution of cash services and grants to develop a marketing campaign to have a more ethnically diverse mix of men and women in its nursing program. [The university saw] a 37 percent increase in applications from last fall, which shows that when you plan for something, you can produce.
Another thing that is so important is that we appeal to prospective students at a middle school level whenever possible; we are seeing that we need to be speaking to students much earlier. … Middle school is an ideal time to start painting a picture of what nursing looks like. Internships are also important.
That is just recruitment. [Once they’re in college], these students need support. They need to be plugged in to mentors — and this is true for all nursing students; this is not just for men or minorities. … Many times students have families, they have relationships, they have jobs; sometimes they are older, sometimes they are the first generation in their family to go to college. That is why I think it is so important that we partner with them on their avenue to success.
McMenamin: If you look at nurses age 60 and older — both men and women — 81 percent are white, and for those under age 40, 72 percent are white, [according to data from 2006 through 2010]. If you look at the overall employed population in the U.S., it is 68 percent white. So over the course of 30 years, the distribution of nurses in the U.S. had been moving in the direction of where the employee population is. The youngest group is much closer to the nation’s overall demographics, so diversity is increasing.
Vlahov: One of the things that I looked at was American Association of Colleges of Nursing (AACN) data to see what has happened to enrollment in colleges of nursing and what has been the trend. In the U.S. population overall, about 36 percent of people are categorized as minority, and if we look at AACN data for 2014 — for bachelor of science in nursing (BSN) students — 29 percent were minorities. For the master of science degree, it was 30 percent, and for the PhD degree, about 30 percent. So I think the increases that we are seeing are the results of efforts by schools to do outreach and have sensitivity training on how to address microaggressions and deal with unconscious bias, as well as really work toward creating an environment for people from diverse backgrounds to come and get the most out of their education.
According to U.S. Census Bureau data from 2013, only 9.6 percent of registered nurses (RNs) are men. What is being done to increase the percentage of male nurses, and why is their representation crucial to the practice?
Rebar: Strategic marketing is the most important thing to reflect on. … There have been many institutions, especially of higher learning, that have taken on strategic marketing to attract men specifically into the practice of nursing, as well as minorities. One is Johnson & Johnson. It has what it calls a “Campaign for Nurses,” and it airs strategic television [commercials] that portray nurses from many different backgrounds, of both genders, caring for people from diverse populations. I think this is a wonderful thing, because people can see that and build an interest.
Another example is the University of Texas (UT) Health Science Center at Houston. It was looking specifically at [increasing the number of] men, so it convened a forum of male nurses to ask them what would have attracted them even more to the profession and what [they thought] would attract more men to the profession. One of the things these men said they wanted to see was more males within different settings in nursing, such as emergency and trauma. So UT started advertising its nursing program on the sports page of the newspaper. I think that is a wonderful thing to show a balance, rather than only using what they call the “flowery, feminine language” of nursing. Interestingly enough, UT’s nursing school population jumped 29 percent after this campaign.
Vlahov: I think the American Association of Men in Nursing (AAMN) … has done quite a bit to develop recruitment materials and [increase] communications that go out to high school students and undergraduates to talk about nursing — how great it is for men and what a rewarding career it can be.
A lot of the people whom I meet that apply or consider applying to the UCSF nursing school came to nursing either because their own relatives said it is a great idea, or they met [other] male nurses; [they] also talked about the communications they had received from the AAMN. So I think that strategy has been helpful, but I also think it can become more extensive.
While women make up the majority of the RN workforce, they earned an average yearly salary that was $9,600 less than that of male RNs, according to 2011 Census Bureau data. What do you believe are the reasons for the gender pay gap, and how do you propose this inequity be addressed?
Rebar: The study that I am most familiar with, which was conducted recently, looked at 88,000 RNs from the National Sample Survey of Registered Nurses — who practiced from 1988 to 2008 — and 205,825 RNs from the 2001 through 2003 American Community Surveys; this study represented males and females. It found an overall adjusted earnings difference of approximately $5,148 across the board. Of course, this is different in different demographics, and it is different for different specialties. There are also some limitations to this study because there are specialties that were not included. A study conducted by nurse researchers and published in the Journal of the American Medical Association (JAMA) showed there had been no narrowing of that pay gap across settings, specialties, and job titles over a quarter of a century.
I think [fixing] this comes down to very grassroots efforts by institutions or locations of practice. The only way that is going to change is by institutions being mindful of the skills, qualities, and abilities that nurses — not male nurses or female nurses — but nurses, bring to the forefront.
McMenamin: Nobody believes that there is explicit gender discrimination, but there is inadvertent gender discrimination. … I think the challenge is basically twofold, and it involves childrearing and family responsibilities. Labor economists have also found that workers of both genders who take time off from their career for whatever reason, when they come back, they don’t come back to where they would have been if they had stayed — in terms of their salary; they come back to where they were. They fall behind and never quite catch up. This is true for both genders.
The other thing is culture and family responsibilities. For whatever reason, in this country and many others, women take over family responsibilities. That means that they are less available for working overtime or doing extra shifts. The Census Bureau does have information that suggests that male nurses are more likely to be moonlighting — have two or more jobs as opposed to just one.
Men do take off a little time for paternity leave but typically only for a couple days or weeks as opposed to women, who often take off weeks, months, or even years.
Vlahov: Men tend to go toward the higher-paying specialties, so that could be part of it. [They] also tend to move toward higher levels of education.
When I was going into nursing, I knew that I was going to go through and get a PhD. I had that ambition right from the beginning; I wanted to fast-track to leadership. So I think some of that is selection.
One of the things that we do at UCSF periodically is look at equity salary surveys and [determine whether] there has been an unconscious bias in any possible way and how we correct that. I think that is a practice that we’re going to see more widespread in different employment scenarios.
In order to respond to the “demands of an evolving healthcare system and meet the changing needs of patients,” the Institute of Medicine recommended in 2010 that 80 percent of RNs obtain a bachelor of science degree in nursing by 2020 and that the number of nurses with doctorates double in that time. Why do you believe it is important that RNs hold a higher degree? What should nursing schools be doing to increase the number of RNs with a baccalaureate or advanced degree?
Rebar: I believe it is important for RNs to hold a higher degree because research and literature show that there are better outcomes for patients when they are cared for by nurses who hold [an advanced] degree.
One thing that I think is so important is being prepared to educate more nursing faculty. We are seeing a decrease in the available number of nursing faculty as [their] average age increases. And there are applicants for programs who often go unaccepted, not because they are not qualified, but because there are not enough seats or enough clinical sites; that often comes down to not enough faculty to accommodate the interest that exists.
It would also be wonderful if educational institutions were able to partner with employers needing nurses with baccalaureate or advanced degrees to offer tuition incentives or partnerships for nurses to [easily] go back to school to pursue a higher degree while still [practicing] nursing.
McMenamin: Contemporary data increasingly demonstrate the growing depth and breadth of value of a BSN-grounded education. If you are going to be a responsible nurse, you ought to be constantly asking yourself, “How can I improve? How can I better my skills? What can I do to make my contribution to patient care more than it is today?”
It should be part of the ethics of any profession to continue to improve, [but] it probably doesn’t make sense for the oldest of associate degree nurses to be going back to school — simply because the cost of getting the additional education will not be repaid if they are only going to be in practice for five to 10 more years. Those nurses will retire, and when they do, the BSN needle is going to move a lot faster; the opportunities are going to be there to move into those jobs. But I worry about those nurses because I think there is a tradeoff between the BSN background and the experience, and I worry that hospitals that are going in that direction are being shortsighted.
I think what hospitals should be doing is taking their most senior nurses, the ones who are going to retire soon, and offering them the opportunity to extend their careers — maybe with less direct patient care and more time spent being mentors to new graduates. And if hospitals hired a few more new grads and used the senior nurses to mentor them, they could build their own experienced workforce.
Vlahov: How do we value education? It is not technical training; that you can get on the job. I look at higher education as teaching the philosophy of the work, and that is providing framework that can organize people’s thinking, and then providing life-long skills, in terms of developing critical thinking. Higher education’s purpose is really to prepare people for critical thinking, for thinking regarding how does all of this fit into a larger framework — whether it is in the workplace or through education. I think advanced education really creates a much more thoughtful, powerful, and effective workforce.
There is a movement now toward making education more widely available and accessible through online programs, and there are [online] RN-to-BSN programs. I think these are all good ideas in terms of increasing access, but we have to be very thoughtful about the quality of the programs and [their] content, as well as what the strategies are in terms of instructional design and the most effective use of educational technology. … It’s not just online education for its own sake.
Some studies have been done that show that online [education], if done well, can be very effective and maybe as effective for getting across the didactic information. So there is a place for it.●
Alexandra Vollman is the editor of INSIGHT Into Diversity.