Diversity in nursing education

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    When we get sick, we want to feel we are getting the best possible treatment. If you are White, your chances of receiving the right amount and type of care are relatively high. If you belong to a minority group, however, your chances go down. Even when controlling for factors like insurance type and accessibility, minorities consistently receive lower quality care.

    One of the most important factors that contribute to the kind of care you receive as a minority race or ethnicity is the race or ethnicity of your care provider.

    One of the most important factors that contribute to the kind of care you receive as a minority race or ethnicity is the race or ethnicity of your care provider. Referred to as concordant patient-clinician relationships, when providers share the same background, language, and skin tone as their patients, they are better able to address the healthcare processes and outcomes influenced by culture and language barriers. Patients in concordant relationships are similarly more likely to report more satisfaction with the care they receive and follow doctors’ orders.

    Minority patients prioritize finding a provider from the same racial or ethnic group as themselves. As the evidence builds of the advantages of this approach, so does the need to prioritize representation among nurses. There is a history of lower than population-level diversity in nursing, and boosting minority representation in nursing programs is key to rectifying this imbalance.

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    The Build Back Better Act (SEC 31006) proposes the allocation of $1 billion towards enhancing and modernizing nursing education programs, and emphasizes the need to recruit students from disadvantaged backgrounds “including racial or ethnic groups underrepresented in the nursing workforce.

    Types of nursing

    With a predicted 100,000 positions, nursing position vacancies in 2022 are anticipated to surpass all other professions. While replacing so many jobs each year seems like an unmanageable task, it is important to keep in mind that there are many different roles and educational levels in nursing. The profession is divided into 3 categories:

    • nursing assistants and orderlies
    • nurse anesthetists, nurse midwives, nurse practitioners
    • registered nurses

    The educational requirements for these 3 groups are also aligned to nursing certifications, which vary by state. Each category requires education beyond high school and satisfactory completion of a state certification or licensing exam. These categories can be traced to 4 general nursing credentials:

    1. Certified Nursing Assistant (CNA)
    2. Licensed Practical Nurse (LPN)
    3. Registered Nurse (RN)
    4. Advanced Practice Registered Nurse (APRN)

    CNAs and LPNs require a certificate to begin working, while RNs need an associate or bachelor’s degree. Beyond the bachelor’s degree, RNs can become APRNs by completing a master’s degree (MSN), post-master’s certificate, or a doctorate degree in areas such as nurse practitioner, nurse midwife, nurse specialist, and nurse anesthetist.

    Representation in nursing today

    The American Association of Colleges of Nursing (AACN) released a statement in April 2019 calling for a more diverse workforce in the nursing profession. According to the AACN, though “nursing has made great strides in recruiting and graduating nurses that mirror the patient population, more must be done before adequate representation becomes a reality.”

    Indeed, the most recent (2017) National Council of State Boards of Nursing report shows that Hispanic and Black populations are extremely underrepresented compared to census data averages.  This disparity is shown in the table below.

    Diversity breakdown: general population vs nursing population

    White Hispanic/Latino Black Asian
    U.S. census 60% 18.4% 12.4% 5.6%
    RNs 80.8% 5.3% 6.2% 7.5%

    Diversity by enrollment

    Increased diversity in higher education enrollments and graduation rates from nursing programs is a necessary prerequisite to greater diversity in nursing. To secure a job, every nursing occupation requires some form of post-secondary education to become certified or licensed. It is important to evaluate the role that higher education plays in changing the diversity narrative.

    Higher education institutions today are more diverse than ever before. To stay in compliance with the Higher Education Act, colleges and universities must report race and ethnicity to the National Center of Education Statistics’ Integrated Postsecondary Education Data System (IPEDS). Race is reported in the following areas:

    1. American Indian or Alaska Native
    2. Asian
    3. Black or African American
    4. Hispanic
    5. Native Hawaiian or other Pacific Islander
    6. White
    7. 2 or more races
    8. Race/ethnicity unknown
    9. Nonresident alien

    Comparing undergraduate responses on their race and ethnicity from 2010 to 2020, diversity is definitely trending upwards. The increase in diversity is clear when we look at the exact percentages, shown below.

    Nursing diversity in 2010 vs 2020

    White Hispanic/Latino Black
    2010 53% 13.7% 14.4%
    2020 47.3% 20.9% 12.7%

    It is important to note that the undergraduates who reported being 2 or more races was 3.8% in 2020 compared to 0.7% in 2010. This trend follows data indicating that the number of multiracial black respondents increased 36.2 million since 2000. These developments could account for the decrease in black student enrollments.

    However, at the graduate level student enrollments in 2010 reflected a less diverse population in comparison to undergraduate students. These figures did not change significantly in 2020, as shown in the table below. While undergraduate enrollments are more reflective of the United States population, graduate enrollments are not.

    White Hispanic/Latino Black
    2010 55% 6.3% 10.6%
    2020 49.2% 10% 11.4%

    Diversity by graduation

    While it is not possible to break enrollments down further than degree level, we can examine graduation rates by race and ethnicity for academic programs and degree levels. Graduation data is perhaps the most relevant information to evaluate whether higher education is meeting the AACN goal for workplace diversity.

    What data do we use to understand the progress that universities are making to close the race and ethnicity gaps in nursing programs? The primary data point is the number of students graduating with a certificate, undergraduate, or graduate degree in an academic program classified by one of two Classification of Instructional Programs (CIP) codes, each which corresponds to a different category of nursing programs:

    1. 38—registered nursing, nursing administration, nursing research, clinical nursing
    2. 39—practical nursing, vocational nursing, nursing assistants

    In the 2020 academic year, more students graduated in the first category (51.38) than the second (51.39). The change in graduation numbers over the past 5 years is reflected in the table below.

    Nursing graduation trends awarded by level

    2016 2017 2018 2019 2020 5-year change
    Certificates 95,842 92,943 92,832 95,266 88,806 -7.3%
    Associate degree 83,574 81,599 81,812 84,879 86,488 3.5%
    Bachelor’s degree 138,829 145,014 150,483 154,973 160,256 15.4%
    Master’s degree 42,009 45,563 48,419 51,213 50,422 20.0%
    Doctorate degree 5,647 6,852 7,921 8,783 10,033 77.7%

    Across all nursing programs, Hispanic and Black students have been graduating at a higher representative number of all graduates. As seen in the table below, Hispanic graduates have increased 20.5% while Black graduates increased 16.4%. As a representative number of all nursing graduates in 2020, Hispanics represent 14.2% and Blacks 12.9%. This representation has grown for both groups, where Black students represented 12% and Hispanics 12.8% of graduates in 2016. These recent graduation numbers reflect that higher education is graduating nursing students at a level that closer mirrors the patient population.

    Nursing graduation trends by race and ethnicity

    2016 2017 2018 2019 2020 5-year change
    White 225,950 227,840 231,459 235,508 233,418 3.3%
    Black 44,340 45,854 47,539 50,796 51,606 16.4%
    Hispanic 47,143 49,322 51,975 55,246 56,814 20.5%
    Total 368,175 374,386 384,549 398,501 400,274 8.7%

    Of the 400,274 nursing degrees awarded in the 2020 academic year, the majority were in registered nursing (CIP code 51.3801).As seen in the table below, across the previous 5 years, while the number of White students graduating with an associate degree as a registered nurse decreased, this group still earned the majority of degrees. While more bachelor’s degrees were earned across all categories, Black graduates made up a smaller portion than White and Hispanic students.

    Nursing undergraduate degrees awarded by race and ethnicity, registered nurses

    Associate degree

    2016 2017 2018 2019 2020 5-year change
    White 52,127 49,904 49,044 49,590 50,060 -4.0%
    Black 8,544 8,544 9,259 10,044 10,316 20.7%
    Hispanic 10,781 11,241 11,389 11,933 12,661 17.3%
    Total 80,410 78,654 81,677 81,677 83,592 4.0%

    Bachelor’s degree

    2016 2017 2018 2019 2020 5-year change
    White 84,354 87,871 90,654 91,454 92,867 10.1%
    Black 12,439 12,944 13,399 13,978 14,921 20.0%
    Hispanic 14,728 16,378 17,473 18,840 20,670 40.3%
    Total 131,996 138,211 143,599 146,866 152,243 15.3%

    The number of students graduating with a master’s or doctorate in nursing has also grown over the past 5 years, as reflected in the table below. for nurses to become licensed as nurse practitioners.

    According to the American Association of Nurse Practitioners, a “master’s, post-master’s or doctoral preparation and national board certification is required for entry-level practice.” This change was adopted to support rural areas where there was a shortage of doctors. To fill this need, nurse practitioners stepped in, increasing in representation among primary care providers from 17.6% in 2008 to 25.2% in 2016.

    The biggest achievement gap is at the graduate level. Hispanic students have been less represented than Black students, yet both have been making strides to change that narrative over the past 5 years. Hispanic students only comprised 5.7% of all nursing doctoral awards in 2020, the lowest percentage of all award level categories.

    Nursing graduate degree trends by race and ethnicity, all CIP codes

    Master’s degree

    2016 2017 2018 2019 2020 5-year change
    White 26,530 28,331 29,936 31,065 30,329 14.3%
    Black 5,169 5,761 6,016 6,438 6,216 20.3%
    Hispanic 2,838 3,614 4,129 4,844 5,127 80.7%
    Total 42,009 45,563 48,419 51,213 50,422 20.0%

    Doctorate degree

    2016 2017 2018 2019 2020 5-year change
    White 3,742 4,601 5,099 5,603 6,255 67.2%
    Black 711 860 1,077 1,299 1,565 120.1%
    Hispanic 278 336 455 520 571 105.4%
    Total 5,647 6,852 7,921 8,783 10,033 77.7%

    A critical component of this analysis is identifying which institutions had the highest percentage of degrees awarded to Black and Hispanic students. The table below shows the top 5 higher education institutions awarding nursing degrees and the percentage of those degrees awarded to Hispanic and Black students in the 2020 academic year.

    Degrees awarded in the top 5 nursing programs by race and ethnicity

    Total degrees awarded % Hispanic % Black
    Western Governors University 14,442 8.1% 8.0%
    Chamberlain University-Illinois 11,910 11.3% 13.4%
    Grand Canyon University 6,743 14.7% 18.9%
    Walden University 5,220 2.7% 27.7%
    University of Texas at Arlington 5,121 21.7% 15.9%

    Further research on institutions that graduated at least 500 nursing students in the 2020 academic year reflects that there were 3 with more than 50% Hispanic graduates:

    1. University of Texas at El Paso with 65.9%
    2. Miami Dade College with 59.0%
    3. City Colleges of Chicago-Malcolm X College with 52.5%.

    In comparison, there was only a single university where at least 50% of graduates were Black: Jersey College, with 59.8%.

    As we evaluate the data, it is clear that nursing programs are providing educational opportunities to Hispanic and Black students. There are areas for improvement, especially at the graduate level, but the consistent growth over the past 5 years is encouraging for students, patients, and professionals.

    Diversity in nursing and healthcare is an issue that needs our continued attention. Fortunately, there is a consensus among both health and educational institutions that representation is needed among doctors, nurses, and other healthcare providers. Building an increasingly diverse workforce from the ground up, we can level the playing field and help minority patients get the attention they need and deserve.

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