Abstract
New York City Health + Hospitals (NYC H+H) is the largest public health care system in the United States, safeguarding some 1.4 million patients annually; its 9600+ nurses are charged with delivering essential healthcare to the most vulnerable and disadvantaged members of society. NYC H+H is forging foundational transformation with an innovative, 3-tiered nurse mentorship program addressing the current imbalance between the demographics of the general population and the corresponding racial and ethnic composition of the nursing profession, as well as supporting the goals of promoting diversity and inclusion; eliminating health disparities, and serving disparate demographic populations with care and compassion.
Key Points
- •The percentage of minority nurses remains much lower than the percentages of minorities in the population.
- •NYC H+H administration and nursing leadership recognizes that an active, purposeful, and vigorous commitment to recruitment, mentorship, and professional development is necessary to attract and retain higher numbers of minority nurses.
- •NYC H+H is creating a robust and thriving 3-pronged mentorship program.
Nursing is regularly called the most trusted profession in America, topping annual Gallup
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polls for 19 years in a row and registering a “high or very high” trust rating of 89% in 2020. However, there is a fundamental and growing disconnect between many nurses and the populations that they serve, causing a looming crisis in the nursing profession that could spell suffering and tragedy for communities of color throughout the United States.Saad L. U.S. ethics ratings rise for medical workers and teachers. December 22, 2020. Gallup, Inc. Available at: https://news.gallup.com/poll/328136/ethics-ratings-rise-medical-workers-teachers.aspx.
Put simply, trust is based on understanding…and achieving understanding is difficult when health care workers and patient populations come from radically different cultures, communities and backgrounds. This “trust gap” is widening as US racial and ethnic demographics undergo radical change: there exists a huge imbalance in the percentage of nurses who are minorities.
Currently, US Census Bureau
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figures for 2020 estimate the total population at slightly more than 329 million people, of which the “White alone” and “White in combination with another race” accounts for 71% of the total population. The “Hispanic or Latino” population accounts for 18.7%; “Black or African American alone” and “Black or African American in combination” accounts for 14.2%; “Asian alone” and “Asian in combination” accounts for 7.2%; American Indian and Alaska Native Population “alone or in combination” accounts for 2.9%; and the Native Hawaiian and Other Pacific Islander “alone or in combination” accounts for 0.5%.US Census Bureau, Population Division. Annual Estimates of the Resident Population by Sex, Race, and Hispanic Origin for the United States: April 1, 2010 to July 1, 2019. NC-EST2019-SR11H. [Excel]. June 2020. Available at: https://www2.census.gov/programs-surveys/popest/tables/2010-2019/national/asrh/nc-est2019-sr11h.xlsx. Accessed April 29, 2021.
The decade from 2010 to 2020 represented the first time in US Census history that the White population declined in numbers, with 2020 figures revealing that the White alone population declined by 8.6% since 2010. Furthermore, the Census Bureau estimates that the percentage of the population identified as “White” will slip below 50% by 2045 or earlier.
According to 2018 and 2020 analyses of Census data by the nonprofit Brookings Institution,
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,- Frey W.H.
The U.S. will become minority white in 2045, census projects. March 14, 2018. Metropolitan Policy Program, The Brookings Institution.
https://www.brookings.edu/blog/the-avenue/2018/03/14/the-us-will-become-minority-white-in-2045-census-projects/
Date accessed: November 9, 2020
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the US White population is declining faster than expected, and the nation is becoming much more racially diverse, with national population growth coming from non-white ethnicities.- Frey W.H.
New census data shows the nation is diversifying even faster than predicted. July 1, 2020. Metropolitan Policy Program, The Brookings Institution.
https://www.brookings.edu/research/new-census-data-shows-the-nation-is-diversifying-even-faster-than-predicted/
Date accessed: November 9, 2020
Minorities Under-represented in Nursing
Even as racial diversity increases and minority populations rise, the percentage of minority nurses remains much lower than the percentages of minorities in the population; minorities have struggled to achieve parity and prominence in nursing and other health care professions.
The 2018 National Sample Survey of Registered Nurses
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from the National Center for Health Workforce Analysis reported 3,957,661 licensed registered nurses in the United States. Of those, the largest category were White, non-Hispanic RNs at 73.3%, followed by Hispanic/Latino RNs at 10.2%, Black, non-Hispanic RNs at 7.8%, Asian, non-Hispanic RNs at 5.2%, and multiple races at 1.7%.US Department of Health and Human Services
Health Resources and Services Administration, National Center for Health Workforce Analysis. 2018 National Sample Survey of Registered Nurses: brief summary results.
Health Resources and Services Administration, National Center for Health Workforce Analysis. 2018 National Sample Survey of Registered Nurses: brief summary results.
https://data.hrsa.gov/DataDownload/NSSRN/GeneralPUF18/2018_NSSRN_Summary_Report-508.pdf
Date: 2019
Date accessed: November 30, 2020
These ongoing discrepancies between nurses and the populations they serve are magnified even further at the leadership level: Although no firm statistics are available on minorities in nursing leadership, a national survey of more than 6300 US hospitals conducted by the Institute for Diversity in Health Management
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revealed that minorities accounted for 32% of patients, but only 14% of hospital board members, 11% of executive leadership positions, and 19% of first- and mid-level managers. That survey found that hospitals have made little progress towards meeting diversity goals and recommended that hospital leadership and governance be diversified to better reflect the communities being served.Institute for Diversity in Health Management. Diversity and disparities: a benchmark study of U.S. hospitals in 2015.
https://ifdhe.aha.org/system/files/media/file/2020/03/Diverity_Disparities2016_final.pdf
Date: 2016
Date accessed: November 30, 2020
The problem is exacerbated by the fact that the imbalance of minorities extends to the training and education of nurses and nurse leaders: the 2019 Faculty Census Survey
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from the National League for Nursing found that just 9% nursing faculty are African American, 3.4% are Hispanic and 2.9% are Asian, compared to 82% of nursing faculty who are White.Leading health care–focused think tanks and organizations contend that increasing the number of minority health professionals is a key to eliminating health disparities. For example, a report from the Sullivan Commission on Diversity in the Healthcare Workforce
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pointed out that African Americans, Hispanics, and American Indians suffer disproportionately high rates of cancer, heart disease, diabetes, HIV/AIDS, and mental health disorders, while at the same time, receiving less and lower quality health care, resulting in substantially higher mortality rates among minority communities.The Sullivan Commission on Diversity in the Healthcare Workforce, W.K. Kellogg Foundation, Duke University School of Medicine. Missing persons: minorities in the health professions.
https://campaignforaction.org/wp-content/uploads/2016/04/SullivanReport-Diversity-in-Healthcare-Workforce1.pdf
Date: 2004
Date accessed: December 3, 2020
This demographic disconnect has far more significance than simple numbers might reveal: Because the majority of nurses and nurse leaders are White, there exists a huge imbalance in terms of community and cultural understanding in serving the needs of minority patients. This imbalance leads directly and inevitability to health disparities; a lack of effective connection, communication and health education among minority populations; and in turn, increased morbidity and mortality of minority patients.
Minority nurses and nurse leaders bring a substantially different and much-needed perspective to the health care system; a unique vision that is based on a culture of community care, primary care and disease prevention programs.
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Furthermore, minority nurses often serve as a driving force within their communities for promoting screenings, health fairs, and other wellness activities designed to promote healthy lifestyles, and also serve as a bridge between underserved populations and public health care systems.Wesley Y. Gaining equity in health care: building the pipeline of black nurse leaders. In: Wright E II, Wallace EV, eds. The Ashgate Research Companion to Black Sociology. Milton Park, UK: Taylor & Francis; 2015:203-209. Available at: https://www.routledgehandbooks.com/doi/10.4324/9781315612775.ch14. Accessed November 17, 2020.
Implications for the Nursing Profession
Many of these sociopolitical, economic, and cultural factors are incompletely or inadequately addressed by the current professional and demographic composition of health care systems, thereby undermining efforts to address the social determinants of health and enhance overall community and population health. As a result, systemic racism continues to plague US health care systems, creating barriers that prevent minorities from entering the nursing profession and advancing into executive management.
The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity, released by the National Academies of Sciences, Engineering and Medicine,
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stresses the role of nurses in identifying, addressing, and alleviating health inequities and calls upon nurse leaders to address the social determinants of health among the patient population and guide frontline nurses in developing community health initiatives.Increasing the representation of minorities in both nursing and nurse leadership is critically important to addressing the social determinants of health, and reducing or eliminating the current health disparities inherent in health care. Having a diverse workforce enhances patient care by bridging the gaps in language and literacy, addressing patients with limited English proficiency, and connecting patient care to the community by having health care workers and leadership living and working in the same neighborhoods as the patients that they serve.
The shifting face of society also means that more research is needed to identify the unique health care issues and concerns facing minority communities, and more education and outreach is necessary to ensure that underserved and disparate minority populations receive appropriate treatment with care and compassion.
NYC Health + Hospitals: Creating a Blueprint for Change
Changing American demographics are significantly altering the type of care that patients need and their abilities to access that care. The current under-representation of minorities among nurses and nurse leaders means that minority populations may experience barriers to care, leading to increased morbidity and mortality. Overcoming these obstacles has led directly to the creation and implementation of new initiatives at New York City Health + Hospitals (NYC H+H), the nation’s largest municipal public health care system, serving more than 1.4 million patients annually at some 70 locations, including 11 essential hospitals; 5 post-acute care facilities; correctional health at all city jails; Gotham Health, a network of Federally Qualified Health Center clinics; and Community Care, comprehensive care management and social support services in patients’ homes and communities.
These new initiatives support the recruitment, advancement, and professional development of minority nurses. NYC H+H administration and nursing leadership recognizes that an active, purposeful, and vigorous commitment to recruitment, mentorship, and professional development is necessary to attract and retain higher numbers of minority nurses in order to ensure that nurses and nurse leaders reflect the diverse populations that they serve. Only through the implementation of both formal and informal programs to encourage more minorities to enter the nursing profession and pursue leadership roles will nurses and nurse leaders be prepared to engage disparate communities, provide culturally sensitive and appropriate care, alleviate health inequities, and meet the challenges of a dynamic and changing patient population.
First steps include recruitment initiatives to attract newcomers to the nursing profession, including a groundbreaking partnership developed in 2021 with the City University of New York (CUNY.) This expanded partnership places new, diverse, highly trained nurses throughout NYC H+H, drawing from more than 2000 CUNY nursing students who graduate each year.
NYC H+H also is increasing its outreach to minority students at colleges and universities in the greater New York metropolitan region, including ongoing relationships with Columbia University, New York University, Helene Fuld, and others.
Additionally, NYC H+H is developing a collaborative program with the NYC Department of Education on outreach to local high schools to encourage interest in nursing and predispose under-represented minority students to pursing degree programs in the nursing profession.
Building a Better Future: Crafting a Culture of Mentorship
Intentional, focused mentorship programs are one of the key components to help minorities remain in the nursing profession and ascend to leadership.
Workplace mentorship leverages existing resources and key personnel to help employees grow and thrive. Mentorship programs are widely recognized as a vital tool to assist employees in achieving their goals and enhance job satisfaction, which leads to growth and development for the mentored employees, and better retention for the organization. A survey of Millennials conducted by global consulting firm Deloitte Touche Tohmatsu
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found that employees who said they planned to stay with their employer for more than 5 years were twice as likely to have a mentor as those without a mentor—68% with a mentor planned to stay, versus 32% without a mentor.Deloitte Touche Tohmatsu Limited
The 2016 Deloitte Millennial Survey: winning over the next generation of leaders.
The 2016 Deloitte Millennial Survey: winning over the next generation of leaders.
https://www2.deloitte.com/al/en/pages/about-deloitte/articles/2016-millennialsurvey.html
Date: 2016
Date accessed: September 22, 2021
Mentorship is especially important within the nursing profession, where specialized training, education, and skills are continuously evolving to adopt the latest evidence-based best practices. Nursing mentorship programs provide the training and experience in professional practice that nurses need to be able to confidently and competently be responsible for the health, safety, and well-being of patients. Nursing mentorship programs also are valuable because they provide support, assistance, and guidance to nurses in challenging situations, such as the continuing pandemic crisis.
NYC H+H is creating a robust and thriving mentorship program, and is establishing ambitious projects designed to support and maintain a diverse and inclusive nursing workforce and leadership. One of the key goals of mentorship is to foster a culture of continuous growth and development, creating an environment that helps expand professional opportunities and retain skilled professionals.
To this end, NYC H+H nursing leadership is implementing a three-pronged approach to mentorship: an Entry Track, a Mezzo Track, and a Leadership Track. Each track encompasses a range of educational and mentorship components, including both existing and evolving elements.
The Entry Track centers on new nurses and includes programs focused on helping newly graduated nurses transition from an educational atmosphere to actual clinical, bedside practice. Key mentorship components for the Entry Track include a thriving Nurse Residency Program (NRP), established in December 2019. To date, more than 900 nurses at the system’s 11 acute care hospitals have enrolled in NRP, and the nurse retention rate has risen to 91.8%, nearly double the overall retention rate of 46% in 2018, prior to the program’s implementation.
Another closely related mentorship project debuted in 2021, the NRP Alumni Program, to provide nurse residents who have successfully completed the program with continued opportunities to participate in its growth and success.
Also in 2021, NYC Health + Hospitals unveiled a Mentorship Pilot Program tapping into the wealth of knowledge gained by recently retired nurses serving as mentors, drawing upon the experiences, training, talent, and wisdom of seasoned professionals who have demonstrated a passion and commitment for NYC H+H’s public health mission.
A final component of the Entry Track is a Preceptor Program, which is part of the expanded partnership arrangement with CUNY; NYC H+H is joining forces with nurses who are studying for their masters of Education degrees at CUNY, giving them the opportunity to precept new nurses as part of their degree requirements.
The Mezzo Track of the mentorship initiative focuses on the current nursing workforce, presenting nurses with opportunities to advance, enhance their skills and move into more responsible positions. Some of the existing components of the Mezzo Track include the BSN in 10 program, which supports nurses with associate’s degrees in continuing their education and earning bachelor’s degrees.
Also part of the Mezzo Track is the pioneering Clinical Ladder program developed in conjunction with the New York State Nurses Association (NYSNA). The Clinical Ladder program debuted in 2020 and grew to nearly 2000 participants in 2021, providing nurses with professional development and career advancement while allowing them to remain in a clinical setting. The program is designed to enhance, recognize, and reward professional development among staff nurses; retain staff nurses in direct patient care positions; enhance staff nurse employee satisfaction; facilitate recruitment of registered nurses by incentivizing nursing professional development; promote the vision of nursing at NYC H+H; and enhance nursing care and patient outcomes.
Another component to the Mezzo Track is the implementation of the Professional Shared Governance Evidence-Based Practice Model, empowering nurses at all facilities to have a voice and creating an inclusive culture where nurses and other health care workers feel valued and respected. Also developed in conjunction with NYSNA, Professional Shared Governance debuted in 2020 and to date has more than 168 Councils with 95% participation. Professional Shared Governance increases nurse engagement by ensuring that frontline care providers are actively-empowered participants in system-wide decision-making, leading to better patient experiences, improved patient safety, higher patient satisfaction rates, more favorable nurse job outcomes, and overall superior quality of care.
Still in development for the Mezzo Track is the creation of a formalized, volunteer mentorship program for current staff nurses. The vision for this component is to create a “pool” of nurse leaders who would be willing to serve as mentors for staff nurses and a system for pairing mentors with nurses throughout the system.
The third component of the mentorship initiative is the Leadership Track, which focuses on nurse leaders looking to enhance their leadership skills and encourages cross-pollination of leadership strategies throughout the system. The main component of the Leadership Track is a new Nurse Leadership Academy, which is an outgrowth of NYC H+H’s current system of Nurse Leadership Retreats and the system’s current Nurse Leader Workgroup.
The Nurse Leadership Academy expands upon the idea of establishing a formalized program of nurse leadership education and mentorship, including developing executive mentors from other segments of the system, including chief executives and senior executive leaders in non-direct-report roles. The initial step in creating the Nurse Leadership Academy was a survey/needs assessment; the next step will be to formalize the creation of the Academy and invite current nurse leaders to identify potential nurse leaders from within the organization, and funnel them into formalized mentorship.
The Nurse Leadership Academy focuses on helping existing nurse leaders hone their craft and share their personal success stories—creating a system where nurse leaders act as mentors for each other, in essence. The Academy also will enhance nurse leadership skills by inviting outside experts to discuss key management strategies.
Emphasizing Our Commitment To Diversity
Clearly, entrenched institutional racism and other forms of implicit bias are creating a distinct disincentive for minorities to enter the nursing profession, and preventing those already committed to nursing from ascending into higher-ranking, more responsible positions. Understanding and responding to the diverse demographics of the patient populations is fundamental to the mission of nurses to provide culturally competent, compassionate care. Without having equitable representation of minorities at every level, health care systems are doomed to fall woefully short of achieving their goals of providing inclusive health and wellness treatment based on evidence-based best practices and address the challenges of a changing and increasingly varied and multicultural society.
Health care systems must develop, implement, and maintain an active, purposeful, and vigorous commitment to recruitment, mentorship, and professional development of minority nurses. Only by ensuring that nurses and nurse leaders reflect the diverse populations that they serve can the health care profession fully understand and engage disparate communities, mitigate health inequities, alleviate suffering, and meet the challenges and transformative goals of the future.
References
Saad L. U.S. ethics ratings rise for medical workers and teachers. December 22, 2020. Gallup, Inc. Available at: https://news.gallup.com/poll/328136/ethics-ratings-rise-medical-workers-teachers.aspx.
US Census Bureau, Population Division. Annual Estimates of the Resident Population by Sex, Race, and Hispanic Origin for the United States: April 1, 2010 to July 1, 2019. NC-EST2019-SR11H. [Excel]. June 2020. Available at: https://www2.census.gov/programs-surveys/popest/tables/2010-2019/national/asrh/nc-est2019-sr11h.xlsx. Accessed April 29, 2021.
- The U.S. will become minority white in 2045, census projects. March 14, 2018. Metropolitan Policy Program, The Brookings Institution.(Available at:)https://www.brookings.edu/blog/the-avenue/2018/03/14/the-us-will-become-minority-white-in-2045-census-projects/Date accessed: November 9, 2020
- New census data shows the nation is diversifying even faster than predicted. July 1, 2020. Metropolitan Policy Program, The Brookings Institution.(Available at:)https://www.brookings.edu/research/new-census-data-shows-the-nation-is-diversifying-even-faster-than-predicted/Date accessed: November 9, 2020
- Health Resources and Services Administration, National Center for Health Workforce Analysis. 2018 National Sample Survey of Registered Nurses: brief summary results.(Available at:)https://data.hrsa.gov/DataDownload/NSSRN/GeneralPUF18/2018_NSSRN_Summary_Report-508.pdfDate: 2019Date accessed: November 30, 2020
- Institute for Diversity in Health Management. Diversity and disparities: a benchmark study of U.S. hospitals in 2015.(Available at:)https://ifdhe.aha.org/system/files/media/file/2020/03/Diverity_Disparities2016_final.pdfDate: 2016Date accessed: November 30, 2020
- Faculty Census Survey 2018-2019: distribution full-time nurse educators by race, 2019.(Available at:)
- The Sullivan Commission on Diversity in the Healthcare Workforce, W.K. Kellogg Foundation, Duke University School of Medicine. Missing persons: minorities in the health professions.(Available at:)https://campaignforaction.org/wp-content/uploads/2016/04/SullivanReport-Diversity-in-Healthcare-Workforce1.pdfDate: 2004Date accessed: December 3, 2020
Wesley Y. Gaining equity in health care: building the pipeline of black nurse leaders. In: Wright E II, Wallace EV, eds. The Ashgate Research Companion to Black Sociology. Milton Park, UK: Taylor & Francis; 2015:203-209. Available at: https://www.routledgehandbooks.com/doi/10.4324/9781315612775.ch14. Accessed November 17, 2020.
- The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity.National Academics Press, Washington, DC2021
- The 2016 Deloitte Millennial Survey: winning over the next generation of leaders.(Available at:)https://www2.deloitte.com/al/en/pages/about-deloitte/articles/2016-millennialsurvey.htmlDate: 2016Date accessed: September 22, 2021
Biography
Natalia Cineas, DNP, RN, NEA-BC, FAAN, is Senior Vice President, Chief Nursing Executive, and Co-chair of the Equity and Access Council at New York City Health + Hospitals, Central Office, Office of Patient Centered Care, Nursing Administration, in New York, New York. Donna Boyle Schwartz, MSJ, BSJ, is Assistant Director, Marketing, at New York City Health + Hospitals. She can be reached at [email protected]
Article info
Publication history
Published online: May 25, 2022
Accepted:
May 2,
2022
Received:
April 13,
2022
Footnotes
Note: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. No funding was received from any source outside of New York City Health + Hospitals. No potential or actual conflict of interest exists.
Identification
Copyright
2022 by Elsevier Inc. All rights reserved.
