A Diverse Nursing Workforce Depends on Purging Minority Nurses' Education and Employment Barriers

Nursing schools must 'turn performance into possibility' and look beyond test scores before turning away minority applicants, CNO says.

Growing a diverse nursing workforce is crucial to improving healthcare for everyone, but the educational and professional journeys of many nurses of color can leave invisible wounds and aftereffects that may linger throughout their career, says one chief nursing officer who has experienced racial negativity first-hand.

Beginning with nursing school admissions processes that exclude potential students of color and extending to micro-aggressions in both nursing education and careers, the barriers that minority nurses face serve to inhibit their career trajectory, says Stephanie Wroten, BSN, MSN, LNC, chief nursing officer for Roanoke Chowan Community Health Center, which serves rural eastern North Carolina.  

"We've made some progress, but the problem is definitely still alive," Wroten says.

Indeed, 63.6% of those who received a Bachelor of Science in Nursing in 2019 were white, while 8.7% were Black, 10.2% were Hispanic, and 7.9% were Asian, according to The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity.

But a nursing workforce that reflects its patient demographic makes healthcare more comfortable for every patient, several studies, including a Joint Commission report on cultural diversity, have shown.

Wroten spoke with HealthLeaders about the challenges that minority nurses face, beginning with efforts to get into nursing school and extending throughout their career.

This transcript has been lightly edited for brevity and clarity.

HealthLeaders: What are some of the challenges that students of color experience as they begin to seek a career in nursing?

Stephanie Wroten: The inequities faced by students of color really start at the admission process in the whiteness of nursing and not having nurses of color at the table to better understand and help facilitate the admissions process.

By not including African-American and other nurses of color in the admissions process, we start out with inequity in selection and so most classrooms in nursing programs have less students of color.

HL: How, specifically, would having faculty nurses of color in the admissions process help boost those numbers?

Wroten: It would make a difference in that those who are making admission decisions would dive deeper and understand more the educational inequities that students of color sometimes face and that the playing field is not level.

I'll use the TEAS test as one example. [The Test of Essential Academic Skills is a standardized, multiple-choice exam for students applying for nursing school in the United States.] Oftentimes, students of color may not perform well on those standardized tests for a myriad of reasons, so they're not selected based on those poor scores.

Having minority admissions faculty would provide a layer of support to turn performance into possibility; whereas, a student may have underperformed on a standardized test, maybe their coursework from their prerequisite courses is strong enough to make the case that we can place them in support programs to ensure their success, once admitted.

HL: Once minority students are admitted to nursing school, what are some adversities they face?

Wroten: Minority students are not taught about the first individual who was a nurse from their cultural standpoint. We were taught about Florence Nightingale. She is a very important part of nursing history but she's not the only person who is important from the ethnic standpoint.

Mary Eliza Mahoney, the first Black nurse, is part of my history and I feel it's important to increase knowledge and access and education around understanding how she fought against discrimination in the profession early on and throughout her career. [Nursing schools must] support the narrative that nursing history isn't narrow around just having stories and lectures about Florence Nightingale. We have Hispanic nurses, we have nurses of Asian descent, and they also have very strong stories that need to be told and threaded throughout nursing curriculum.

What I've also seen is poor retention of the minority student. I've seen failure to matriculate due to academic failure, and oftentimes the academic big failures aren't so much associated with lack of ability but [rather] with life circumstances and an inability to manage life when it hits you.

I'll frame it as social determinants. Oftentimes, we're dealing now with adult students who have children or are caring for parents, and no one's taught them how to manage those things that come up—"I don't have a babysitter; I don't have a backup babysitter; I don't have money; I'm having to work; no time to study." All of those things can impact negatively academic success and progression.

I'm not saying that these experiences are only those of students of color. I'm not saying that white people cannot have these experiences, but more often it involves students of color.

HL: What effects can those experiences produce, as students graduate and begin their career?

Wroten: The micro-aggressions from nursing education can leave long-standing scars that interfere with confidence and mental fortitude to progress. And they also lead to internal silences that are infused by fear because you don't want to draw attention to yourself, so you may not speak to that white professor about the experiences you're having or difficulties, and especially if you're in a class where you're the only [minority].

And so, "only syndrome" can lead to long-standing inability to engage in a way where Black nurses and other nurses of color don't have trust that they are understood in a way that makes them successful.

HL: What form do micro-aggressions take for nursing students and nurses?

Wroten: They're covert. There are just implicit biases that students of color sometimes face in that there's not an understanding of who we are, and so we're treated differently because there is this lack of professionalism around race. There are assumptions from explicit bias where individuals, teachers, and colleagues have these mindsets about who we are.

The racism can be more subtle than overt because there's no awareness from our white counterparts around our education, around our ability. Even being an educated person standing in front of someone, whether it's a patient or colleague, we're often looked at as not being the most educated, prepared person in the room.

I'll give you an example. I'll be in my white coat as the nursing instructor and I'll walk into a room with white students and patients may say, "Would you get your instructor?" or "Could you get the nurse?"  The assumption is the white person is the nurse.

HL: How do such experiences affect a nurse's career?

Wroten: It feels like a never-ending fight to practice, a never-ending fight to prove yourself, a never-ending fight to measure up; but I'm asking, to measure up to what? I've passed the test; I've done the work. It feels like ongoing slights, and they hit you in a way where you have to decompress from that, but not allow it to get in your way to meet your own professional goals.

HL: How does that hinder practicing nurses from pursuing leadership roles?

Wroten: The whiteness of nursing sometimes interferes with providing and making accessible leadership opportunities for African-American nurses and nurses of color because they're not represented at the table, so they have a fair chance for their professional goals and trajectories to be realized. Their white counterparts are given those opportunities instead of looking at each candidate or applicant who has applied, equally, so those inequities come through.

Our white counterparts [seem to] have more opportunities to be at those important tables or to get mentorship in those critical exposures that would serve as the catalyst to help nurses of color understand leadership and to be groomed to become our next leaders.

I had a conversation just last week with an African-American nurse who said, "You know, it doesn't feel possible for me to explore or have a position in leadership. How are we considered?" Well, No. 1, you have to apply.

But if there is doubt that there will be no opportunity or chances given, how can we have a movement if there's still resistance? So, I make it a point, and I made it a point my first year here, to ensure that I'm at the table for interviews because we must address the equity around hiring practices.