Article

Racial and Ethnic Diversity of the U.S. National Nurse Workforce 1988–2013

Policy, Politics, & Nursing Practice 2014, Vol. 15(3–4) 102–110 ! The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1527154414560291 ppn.sagepub.com

Ying Xue, DNSc, RN1, and Carol Brewer, PhD, RN, FAAN2

Abstract The objective of this article is to examine the racial and ethnic diversity profile of the nurse workforce over time and by geographic region. We conducted survey analysis using the National Sample Survey of Registered Nurses from 1988 to 2008, and further supplemented our trend analysis using published findings from the 2013 National Workforce Survey of Registered Nurses. The gap in racial/ethnic minority representation between the RN workforce and the population has been persistent and has widened over time. This diversity gap is primarily due to underrepresentation of Hispanics and Blacks in the RN workforce, which varied across states and regions, with the largest gaps occurring for Hispanics in the South and West and for Blacks in the South. Greater levels of sustained and targeted support to increase nurse workforce diversity are needed and should be geared not only to specific underrepresented groups but also to the regions and states with the greatest needs. Keywords nurse workforce, diversity, minority, nursing shortage

The development of a diverse healthcare workforce has been recognized as a national priority by the Institute of Medicine (Smedley, Butler, & Bristow, 2004; Smedley, Stith, Colburn, & Evans, 2001; Smedley, Stith, Nelson, & Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care, 2002), the Sullivan Commission of 2004 (The Sullivan Commission, 2004), and by provisions of the Affordable Care Act of 2010. A culturally diverse healthcare workforce, one that meets the needs of an increasingly diverse population, is believed critical to provide culturally competent patient care, improve access to care, and help reduce health disparities, one of the nation’s most pressing public health concerns (Smedley et al., 2001, 2002, 2004; The Sullivan Commission, 2004). Strong arguments have been advanced supporting not only an empirical link between workforce diversity and reduction of health disparities (U.S. Department of Health and Human Services, 2006) but also the benefits afforded to civil rights, education, and business (Grumbach & Mendoza, 2008). Among the health professions, nurses are the largest group of healthcare providers, interacting and communicating closely with patients and caregivers to provide patient-centered care. The importance of cultivating a

diverse nurse workforce has been embraced by federal agencies and many nursing organizations, including the American Nurses Association, National League for Nursing, and the American Association of Colleges of Nursing. The Department of Health and Human Services has provided more than $173 million in funding to the Nursing Workforce Diversity Program (Sec. 821) since it was initiated in 1998 (authors’ calculation based on the awarded grants; U.S. Department of Health and Human Services, 2014). Although some progress has been made toward this goal (U.S. Department of Health and Human Services & Health Resources and Services Administration, 2010), the racial and ethnic minority composition of the nurse workforce, at 18%, lags far behind the overall U.S. population of 37% minority (Budden, Zhong, Moulton, & Cimiotti, 2013; U.S. Census Bureau, 2014). With minority groups projected to grow to 57% of the nation’s population by 2060 1 2

University of Rochester School of Nursing, NY, USA University at Buffalo School of Nursing, NY, USA

Corresponding Author: Ying Xue, DNSc, RN, University of Rochester School of Nursing, 601 Elmwood Avenue, Box SON, Rochester, NY 14642, USA. Email: [email protected]

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(U.S. Census Bureau, 2012), and as more resources are devoted to increase nurse workforce diversity, a comprehensive understanding of trends and geographic patterns in the racial and ethnic composition and characteristics of the nurse workforce is essential to inform national policy and to develop effective strategies to build a well-qualified diverse nurse workforce. Such initiatives are imperative to meet the healthcare needs of the U.S. population in the 21st century. This study examined the racial and ethnic diversity profile of the nurse workforce over time and by geographic region and explored the policy implications of these trends for addressing diversity, as well as projected shortages of the nurse workforce.

Methods Data Sources Several national data sources have been used in the literature to study the nurse workforce, such as the National Sample Survey of Registered Nurses (NSSRN), the American Community Survey (ACS), and the Current Population Survey (CPS). These data sources differ in scope of survey information, target population, and sampling methods, and each has its strengths and limitations (Auerbach, Staiger, Muench, & Buerhaus, 2012; Bates & Spetz, 2012; Spetz, 2013; U.S. Department of Health and Human Services & Health Resources and Services Administration, 2010). Both the ACS (which was designed to replace the census long form) and CPS (which is the primary source of labor force statistics) are national household sample surveys. Both have limitations in identifying the entire nurse workforce (Spetz, 2013). We used the NSSRN, a principal source of national nurse workforce data conducted every 4 years by the Department of Health and Human Services, for the analysis of trends in racial and ethnic composition and selected characteristics of the nurse workforce from 1988 to 2008. The NSSRN was selected for the following reasons: (a) It employed an advanced sampling design that produced a representative sample of all RNs with an active RN licensure at the time of the survey in the United States, which represents the entire nurse workforce we intend to study; (b) it has the most comprehensive data available to describe characteristics of the nurse workforce; (c) in contrast to the CPS, it contains an adequate sample size to permit analysis at both the national and state levels (Spetz, 2013); (d) it has been shown to produce more reliable estimates for states with small populations and for workforce characteristics, such as education, relative to the ACS (Bates & Spetz, 2012); and (e) it permits long-term trend analysis compared with the ACS, which began in 2001.

Although the advanced multistage sampling design of the NSSRN is deemed to generate robust, reliable, and representative estimates, the study findings should be interpreted in the context of the following limitations. First, the 2008 NSSRN adopted a slightly different sampling design than in previous years, which adjusted for nonresponse by age group, and improved the precision of national estimates, especially for age and race/ ethnicity characteristics. A comparison of the two sampling methods applied to the 2008 data showed only minimal differences in the estimates, indicating the appropriateness of including the 2008 data in trend analysis (U.S. Department of Health and Human Services & Health Resources and Services Administration, 2010). Second, there is a discrepancy between the NSSRN and ACS national estimates for the proportion of Black nurses represented in the workforce, for which the ACS estimate is about 4% higher than that of the NSSRN (Auerbach et al., 2012; U.S. Department of Health and Human Services & Health Resources and Services Administration, 2010). This discrepancy is very likely due to different target populations and sampling approaches. In addition, a recent report noted that ambiguities in self-reported occupation in the ACS, in which LPNs may have been misclassified as RNs, could account for the higher estimates in the ACS, given that a higher proportion of LPNs are from minority groups (U.S. Department of Health and Human Services & Health Resources and Services Administration, 2010). Since data beyond 2008 were not available in the NSSRN, we supplemented our trend analysis by incorporating comparable published findings from the 2013 National Workforce Survey of Registered Nurses (NWSRN) to provide more current estimates (Budden et al., 2013). We examined the compatibility of the two surveys. The 2013 NWSRN and the 2008 NSSRN utilized the same types of sources for their sampling frames (i.e., random samples drawn from state boards of nursing registries) and employed similar sampling designs (Budden et al., 2013; U.S. Department of Health and Human Services & Health Resources and Services Administration, 2010). The overall response rate for the 2013 NWSRN (39%) was lower than that for the 2008 NSSRN (62%); however, different response rates do not necessarily indicate differences in response bias. Nonresponse bias analyses were performed for both the 2013 NWSRN and 2008 NSSRN surveys, and both found some evidence of slightly lower response rates among minority RNs. These analyses, however, revealed no evidence of a difference in response bias due to differential response rates across the two surveys (Budden et al., 2013; U.S. Department of Health and Human Services & Health Resources and Services Administration, 2010). Although the two surveys are

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Table 1. Mean Age and Proportion of Nurse Workforce by Racial and Ethnic Group 1988–2013. White non-Hispanic % 1988 1992 1996 2000 2004 2008 2013

92.33 90.70 90.30 87.50 87.50 83.23 83.00

Age 41.72 43.16 44.41 45.36 47.04 47.56 50.85

All minorities

Hispanic

Black

%

Age

%

Age

%

Age

7.67 9.30 9.70 12.50 12.50 16.77 18.00

41.04 42.15 43.19 43.94 45.25 44.23 47.14

1.30 1.37 1.60 2.06 2.23 3.56 3.00

39.77 39.72 41.11 42.26 43.27 41.48 43.96

3.65 4.07 4.23 4.99 4.88 5.40 6.00

42.72 44.14 45.76 45.49 47.01 46.48 48.49

Asian/Pacific Islander % 2.31 3.41 3.40 3.75 3.46 5.84 7.00

Other

Age 39.03 40.41 40.79 42.41 43.71 43.20 46.00

%

Age

0.41 0.45 0.47 1.71 1.93 1.96 2.00

41.55 44.74 44.58 44.81 45.89 46.13 49.58

Note. Results from 1988 to 2008 are authors’ calculations based on data from the National Sample Survey of Registered Nurses 1988–2008. 2013 result is cited from the published report of the 2013 National Workforce Survey of Registered Nurses.

largely compatible in terms of survey methodology and potential response bias, trends observed across the two surveys should nonetheless be interpreted with caution. Annual census data on U.S. population demographics at the national and state levels were obtained from the Census Bureau.

Statistical Analysis All analyses were weighted using sample weights developed for NSSRN data to provide population estimates at the national and state levels. These sample weights were created to minimize bias in estimation by incorporating complex survey design features, the original probability of selection of the RN, adjustment for nonresponse, and multiple license assignment. Racial and ethnic minority status was defined as self-identified membership in a group other than White non-Hispanic, including Hispanic, Asian or Pacific Islander, Black, and other (American Indian or Alaska Native or multiracial). Early surveys of the NSSRN did not differentiate among American Indian, Alaska Native, or multiracial groups, and therefore, we could not include them as separate groups in our trend analysis. We calculated national estimates for nurses in each racial and ethnic group for each survey year. Differences in nurse characteristics by racial and ethnic group were examined for each survey year with White non-Hispanic as the reference group. To examine trends in characteristics over time, we modeled the time variable in the survey regressions. The racial and ethnic composition of the U.S. population at the national and state levels was calculated using the annual residential population census data corresponding to the survey years of the NSSRN. Because our goal was to compare the demographic composition of the nurse workforce with that of the entire U.S. patient population, we did not restrict U.S. Census data estimates to any particular age group. Analyses were performed using SAS version 9.2.

Results Persistent Gap in National Minority Nurse Representation Over Time The percentage of nurses who were minority increased from 7.7% to 18% from 1988 to 2013 (Table 1); during the same period, the proportion of minorities in the U.S. population rose from 23.5% to 37.3%. Although minority representation in the nurse workforce has grown, it still lags behind the minority share of the overall U.S. population. The gap in minority representation between the nurse workforce and the overall population has widened from 15.8% in 1988 to 19.3% in 2013 (Figure 1). Our analysis revealed several informative trends by racial and ethnic group at the national level. First, the proportion of nurses who are Asian/Pacific Islander has maintained parity with their share of the overall population, with a slight 1% overrepresentation beginning in 2008. Second, the gap in representation between the nurse workforce and the population for Blacks decreased only slightly from 8.1% to 6.4%. Third, the most pronounced diversity gap was observed among Hispanics, which nearly doubled from 7.2% to 14.1%. Thus, underrepresentation of Hispanics and Blacks in the RN pool primarily accounted for the overall gap in minority representation between the nurse workforce and the population, with the widening gap among Hispanics negating any gains made by other groups.

Considerable Geographic Variation in the Underrepresentation of Hispanics and Blacks Although national trends are informative, they could mask important patterns in the geographic distribution of diversity gaps in the nursing workforce. We therefore examined the racial and ethnic composition of the nurse workforce relative to the population at the state level, using the most recent data available from 2008, in the

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25 20 15 10

Hispanic Asian/Pacific Islander Black Others White Non-Hispanic All minority

5 0 -5 -10 -15 -20 -25 1988

1992

1996

2000

2004

2008

2013

Figure 1. Trends in the gap between the nurse workforce and the overall population in racial/ethnic representation 1988–2013. Note. Results on the proportion of nurses by racial and ethnic group 1988–2008 are authors’ calculations using data from National Sample Survey of Registered Nurses 1988–2008. The proportion of nurses by racial and ethnic group 2013 is from the published report of the 2013 National Workforce Survey of Registered Nurses. Results on the proportion of population by racial and ethnic group are author’s calculations using residential population data from the Census Bureau.

60 50 40 30 20

0

West West Midwest Northeast West West Midwest West West West South West West Midwest Midwest Northeast Midwest Midwest Northeast West West South South Midwest Northeast Northeast South Midwest Midwest Northeast Midwest Midwest Northeast South South South South South South South South South South South South South

10

MT UT NDNH ORNM IA HI WA AZ WVCO AK NEMN RI KS WIMACA NV KY OK IN CT PA TX MOOH NJ MI IL NY FL AR TN VA DE NC AL SC MDGA LA MS DC Populaon

RN

Figure 2. Regional and state variation in Black representation in the nurse workforce relative to state population, year 2008. Note. Results are authors’ calculations based on data from the National Sample Survey of Registered Nurses 2008 and residential population data 2008 from the Census Bureau. States and the federal district are ordered on the y axis from lowest to highest proportion of Black residents in the population. Four regions are identified based on Bureau of Labor Statistics designations. Several states with a low proportion of Black residents (Idaho, Vermont, Maine, South Dakota, and Wyoming) were not presented due to missing data.

NSSRN. These analyses revealed considerable variation across states in minority representation in the nurse pool relative to the population. The average gap in minority representation was 13.6%, with a range from 0.6% in Vermont to 25.6% in New Mexico. Consistent with findings at the national level, state level diversity gaps were primarily due to underrepresentation within nursing of Hispanics and Blacks. Further analysis revealed that, in general, states with the highest proportion of Hispanics or Blacks in the population also

had the greatest underrepresentation of these respective groups in the nurse workforce (Figures 2 and 3), despite also having a relatively high proportion of nurses who were Hispanic or Black. This resulted in a clear regional pattern. For example, the top 10 states (Mississippi, District of Columbia, Louisiana, South Carolina, Maryland, Delaware, Virginia, Alabama, North Carolina, and Tennessee) with the largest gap in Black nurse representation were in the South, and these states also have a relatively high proportion of Blacks in the

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50 45 40 35 30 25 20 15 10

South Northeast Northeast Midwest South South Midwest Midwest Northeast South West Midwest South South South Midwest Midwest Midwest Northeast Midwest Midwest South West South South South South South West Midwest South Northeast South West Midwest West West West Northeast Northeast West Midwest Northeast Northeast West South West West South West West

5 0

WVMEVTNDMSKY SDOHNHALMTMOLA TN SC MIMNIA PA WI IN AR AKMDDE VANCOKWYNEGAMADC HI KSWAID OR RI CT UT IL NJ NYCO FL NVAZ TX CANM Populaon

RN

Figure 3. Regional and state variation in Hispanic representation in the nurse workforce relative to population, year 2008. Note. Results are authors’ calculations based on data from the National Sample Survey of Registered Nurses 2008 and residential population data 2008 from the Census Bureau. States and federal district are ordered on the y axis from lowest to highest proportion of Hispanic residents in the population. Four regions are identified based on Bureau of Labor Statistics designations.

population; the top 10 states (California, Texas, New Mexico, Nevada, Arizona, Colorado, New York, New Jersey, Illinois, and Florida) that had the largest gap in Hispanic nurse representation were located primarily across the West, South, and in states with a large proportion of Hispanics in the population. Exceptions to this general pattern were also evident. For example, Georgia has a relatively high proportion of Blacks in the state but only a moderate underrepresentation of Blacks in the nurse workforce (Figure 2).

Increasing Racial and Ethnic Diversity Among New Nurses To assess whether minority representation has increased among new nurses who entered the nurse workforce between any adjacent survey years, we examined the racial and ethnic composition of nurses who had less than 4 years of nursing experience. The proportion of new nurses who were minority increased from 8.2% in 1988 to 23.4% in 2008, a higher rate than among nurses overall—7.7% in 1988 to 18% in 2008. Among new nurses, Hispanics increased from 2.2% to 6%, Blacks from 4.1% to 8%, and Asian/Pacific Islanders from 1% to 6% from 1988 to 2008. The greatest gains in the proportion of Hispanics and Blacks among new nurses have occurred since 1996. The 2013 NWSRN data showed similar racial and ethnic diversity among nurses who entered to the workforce between 2010 and 2013 as those in 2008, 6% for Hispanics, 8% for Blacks, and 9% for Asian/Pacific Islanders (Budden et al., 2013).

Characteristics of the Minority Nurse Workforce Age. The average age of nurses within each racial and ethnic group has increased over time (Table 1). From 1988 to 2013, the average age of Hispanic nurses increased from 39.8 to 41.5 in 2008 and 44 years in 2013; Asian/Pacific Islander nurses increased from 39 to 43.2 in 2008 and 46 years in 2013; Blacks increased from 42.7 to 46.5 in 2008 and 48.5 years in 2013; and White non-Hispanics increased from 41.7 to 47.6 in 2008 and 50.9 years in 2013. Notably, from 2004 to 2008, there was a slight shift toward decreasing average age among Hispanic, Black, and Asian/Pacific Islander nurses, which may reflect greater representation of minorities among new nurses as indicated earlier. However, the change in the sampling approach that occurred in 2008 might also have contributed to this result. The shift toward increasing age from 2008 to 2013 may reflect increased employment among older nurses who delayed retirement or rejoined the workforce since the economic recession began in 2007 (Buerhaus, Auerbach, & Staiger, 2009; Staiger, Auerbach, & Buerhaus, 2012). Gender. The proportion of nurses who were male increased from 3.2% in 1988 to 6.2% in 2008 among Whites non-Hispanic and from 4.51% in 1988 to 8.74% 2008 among minorities, with the most prominent increases in Hispanics. From 1988 to 2008, the proportion of nurses who were male increased from 6.6% to 12.9% in Hispanics, 4.3% to 8.3% in Asian/Pacific Islanders, and 3.5% to 5.9% in Blacks. Information on

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gender by racial/ethnic group is not available in the 2013 NWSRN report. Nursing education. The proportion of nurses who had baccalaureate and higher degree has steadily increased among both minority nurses (43% in 1988 to 59% in 2008) and White non-Hispanic nurses (33% in 1988 to 48% in 2008). On average, minority nurses were more likely to have baccalaureate and higher degrees than their nonminority counterparts. In 2008, 73.8% of Asian/Pacific Islander nurses were baccalaureate prepared, followed by Blacks (52.9%), Hispanics (52%), and White non-Hispanics (48.1%). Information on nursing education by racial/ethnic group in the 2013 NWSRN report is not comparable with the results of NSSRN and is therefore not discussed here.

Discussion Our study revealed several significant findings relevant to healthcare workforce policy. First, on the national level, minority representation in the nurse workforce lags well behind the population, and this gap widened from 1988 to 2013. This diversity gap was primarily due to the underrepresentation of Blacks and, especially, Hispanics in the nurse workforce. Second, there was considerable geographic variation in minority representation in the nurse workforce, with the largest gaps occurring for Hispanics in the West and South and for Blacks in the South. Third, the minority nurse workforce is well qualified. They were equally or more likely than their White non-Hispanic counterparts to have a baccalaureate or higher degree in nursing. The increasing number of baccalaureateprepared nurses, especially among Hispanics and Blacks, may be due, in part, to academic institutional recruitment and other state and national efforts designed to increase the nursing workforce diversity. The trend may also be due to efforts to enhance educational qualifications of new nurses, including facilitating access to higher education among nurses from diverse backgrounds including those of racial, ethnic, gender, and other minorities, nurses from rural areas, veterans, and those with previous experiences or degrees in other fields. Age differences exist across racial and ethnic groups, that may have implications for workforce policy on diversity and future potential shortages. The following sections focus on two issues based on the study findings: implications for strategically directing efforts and resources to reduce the diversity gap and the implications of increasing diversity in relation to addressing the nursing shortage.

Strategic Efforts to Reduce the Diversity Gap Despite a significant allocation of resources and concerted efforts aimed at increasing racial and ethnic

diversity in the national nurse workforce (American Association of Colleges of Nursing, 2013), and with attainment of some success in this regard, our findings nonetheless indicate that the gap between minority representation in the nursing workforce and that of the overall population has widened since 1988. Our analyses on the geographic patterns in nurse workforce diversity provide insights about how efforts should be directed strategically to target the groups and regions of greatest need to reduce the diversity gap. Resources and coordinated initiatives should be geared toward expanding Hispanic and Black nurse representation in the states with the largest diversity gaps, which were observed to exist in the states with the highest proportion of these groups. Empirical evidence supports local allocation of resources and domestic efforts to reduce the diversity gap. Nurses tend to work in the same areas in which they received their education, so the allocation of resources to support increased Hispanic or Black minority enrollment in nursing education programs targeted to specific states could have a considerable impact on increasing Hispanic or Black nurses in the targeted states (Tellez, Black, & Tinoco, 2011). Previous research has shown that reliance on nurse immigration to substantially increase the number of Hispanic and Black nurses has not been an effective option to address the diversity gap (Aiken, 2007). Domestic efforts are needed to achieve greater representation of Hispanics and Blacks in the nurse workforce. Evidence indicates that one of the primary factors accounting for underrepresentation of Hispanics and Blacks in nursing is lower overall educational attainment, including lower graduation from high school, and lower entry and successful completion of nursing programs (Coffman, Rosenoff, & Grumbach, 2001; Grumbach & Mendoza, 2008). Financial constraints have been identified as the most significant barrier to educational attainment in these groups (Evans, 2007). Thus, adequate and sustained funding to support educational attainment among Hispanics and Blacks, with recognition of considerable geographic variation in the underrepresentation of these groups, is a key strategy to reduce the diversity gap and build a diverse nurse workforce. Nursing education has been partially supported by federal, state, and private sources. The private sector has contributed significantly to nursing education and the expansion of the nurse workforce, with an emphasis on recruiting minority students—the Robert Wood Johnson Foundation’s New Career in Nursing program and Johnson & Johnson’s Discover Nursing program are two examples. On the federal level, the Nursing Workforce Diversity program was initiated in 1998 under Title VIII of the Public Health Service Act

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(Sec. 821) to support programs that provide an educational pipeline to increase nursing career opportunities to individuals with disadvantaged backgrounds, including racial and ethnic minorities. Evidence suggests that federally funded programs from various parts of the country were successful in outreach to minority students in middle schools, recruiting and helping them to successfully complete nursing programs (Condon et al., 2013; Evans, 2007). The initiative has supported a sizeable number of disadvantaged and minority students, for example, 11,638 in fiscal year 2008 and 10,361 in fiscal year 2010 (American Association of Colleges of Nursing, 2010, 2013). The effectiveness of these public and private programs may be reflected in our finding of increased diversity among new nurses, which is especially pronounced among Hispanic and Black nurses since 1996. Yet, our finding of an expanding diversity gap in the nurse workforce, especially among Hispanics and Blacks, also indicates the need for both more funding and more targeted funding to boost the entry of Hispanics and Blacks into the nurse workforce, especially in the states of greatest needs. Adequate and sustained federal funding is essential to achieve this goal. Funding for Nursing Workforce Diversity programs in the past decade has been flat at around 15 million dollars per year (U.S. Department of Health and Human Services, 2014). This level of funding is low considering the size of the nurse workforce and the substantial return on investment that would accrue from increasing diversity, which has been recognized by the American Association of Colleges of Nursing (2010). Programs that were successful in recruiting and retaining minority students were frequently hampered by short funding

cycles and the inability to continue supporting these programs when the funding was over (Evans, 2007). As the nation’s minority population continues to expand, it is vital to sustain funding to successful programs and expand funding to support more programs to increase greater representation of Hispanics and Blacks in the nurse workforce. These efforts would also ensure continuing progression of educational attainment in minority nurses, which is required for advancement of minority nurses into research, faculty, and administrative positions (Institute of Medicine, 2011). This, in turn, could help attract, recruit, and retain more minorities into the nursing workforce pipeline (Tabi, Thornton, Garno, & Rushing, 2013). In addition, more research is needed to comprehensively assess the effectiveness of current strategies designed to increase diversity of the nursing workforce, including whether the geographic distribution of resources is optimally directed.

Implications for Nurse Shortages Our analysis indicated that filling the diversity gaps in the nurse workforce may substantially alleviate future projected nurse shortages. Currently, nurse workforce forecasts are based on projections regarding future demand for nurses and the projected supply of nurses (i.e., number of nurses exiting and entering the nurse workforce). On the nurse supply side, existing forecast models do not currently account for differences in the rate of entry by racial and ethnic group. As minorities continue to increase as a proportion of the overall population (U.S. Census Bureau, 2012), the diversity gap will translate into fewer nurses entering the nurse workforce per capita. This is

140 120 100 Hispanic Asian/Pacific Islander

80

Black Others

60

White Non-Hispanic 40

All minority

20 0 1988

1992

1996

2000

2004

2008

Figure 4. New RN/100 K population by racial/ethnic group 1988–2008. Notes. Results are authors’ calculations based on data from the National Sample Survey of Registered Nurses 1988–2008 and residential population data from the Census Bureau.

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because minorities, who have a low rate of entry into the nurse workforce (Figure 4), will make up an increasingly greater proportion of the population, while the majority, with a higher rate of entry into the nurse workforce, will make up a smaller proportion of the population. Therefore, increasing the rate at which minorities enter the nurse workforce, along with strategies to retain minority nurses, will be critical for filling the diversity gaps and addressing future nursing shortages. A recent analysis on the forecast of nurse shortages at the state level found that the regions with the largest projected nurse shortages by 2030 will be the South and West (Juraschek, Zhang, Ranganathan, & Lin, 2012), which are the same regions that have the largest gaps in the underrepresentation of Hispanics and Blacks identified in our analysis. Hence, to a large degree, the future adequacy of the size of the nurse workforce will rely on our success in addressing the diversity gap within nursing. Yet, current projection models for the supply and demand of the nurse workforce do not accommodate trends in the racial and ethnic composition of nurses relative to the overall population (U.S. Department of Health and Human Services, 2002). Our analyses suggest that such factors will play an essential role in driving future nursing shortages, both at the national and state levels. Modeling approaches that integrate trends in nursing and population demographics, including racial and ethnic diversity, as well as nurse supply and demand at the state level, will provide more accurate information to help inform effective policies and strategies for nursing workforce development.

Conclusions In summary, greater levels of sustained and targeted support are needed to adequately address the widening diversity gap in the nurse workforce. Integrated national and state policies to invest in effective strategies to increase diversity of the nurse workforce should be geared not only to specific underrepresented groups but also to the regions and states with the greatest needs. An effective, strategic, and targeted approach to addressing diversity within nursing is crucial to meet the healthcare needs of the U.S. population in the 21st century; one that not only addresses culturally competent care and health disparities but also helps alleviate future nursing shortages. Thus, the future viability and capacity of the nurse workforce may largely depend on our success in increasing racial and ethnic diversity. Declaration of Conflicting Interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Dr. Xue received funding from Robert Wood Johnson Foundation—Nurse Faculty Scholars (#64191).

Acknowledgements The authors sincerely thank Joyce A. Smith, PhD, RN, and Katharine Schwartz, RN, for their research assistance.

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Author Biographies Ying Xue, DNSc, RN, is an Associate Professor in the School of Nursing at the University of Rochester. Integrating her expertise in nursing and health service research, Dr. Xue’s research focuses on nurse workforce issues, with the goal of developing empirical evidence to inform policies for workforce development and planning. She has investigated trends in racial and ethnic diversity, education, and job satisfaction among the national nurse workforce. She also studied the effects of organizational structure, work environment and the nature of the nurse workforce on patient outcomes. Carol Brewer, PhD, RN, FAAN, is a UB Distinguished Professor of Nursing and Associate Dean for Academic Affairs at the University at Buffalo School of Nursing. Dr. Brewer conducts research that examines RN workforce participation decisions. She is currently funded by the Robert Wood Johnson Foundation for a 10-year national panel study of early career RNs (see www.RNWorkProject.org). She has been funded by the National Council of State Boards of Nursing to examine RN perceptions of quality improvement knowledge, the Health Resources and Services Administration as a senior analyst for the National Sample Survey of Registered Nurses, and the Agency for Healthcare Research and Quality to examine longitudinal workforce behavior of RNs in Metropolitan Statistical Areas.

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Racial and ethnic diversity of the U.S. national nurse workforce 1988-2013.

The objective of this article is to examine the racial and ethnic diversity profile of the nurse workforce over time and by geographic region. We cond...
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