American Journal of Nursing 2000 March Volume 100, Issue 3

Eliminating Racial and Ethnic Disparities in Health Care

Cultural competence is lacking in a mostly white nurse workforce.

As of 1998, racial and ethnic minority groups made up 28% of the U.S. population. Current projections say that number will rise to 40% by 2030.¹ This growing diversity has strong implications for the provision of health care. Segregation, disparate treatment, and racism continue to contribute to the epidemiologic gap between minorities and whites. The significant underrepresentation of minorities in the health professions and in the health care industry is one reason behind the disparity in the health status of whites and minority groups—blacks, Hispanics, Asian Americans, American Indians, Alaskan natives, and Pacific Islanders.

The nursing profession provides a prime example of this underrepresentation. The 1996 National Sample Survey of Registered Nurses shows that approximately 246,363 RNs (an estimated 10% of the nursing workforce) came from minority backgrounds.² Nursing lacks the diversity needed to effectively provide services to a populace of increasing ethnic variety.

According to Karen Scott Collins, assistant vice president at the Commonwealth Fund, a group that has done much research in this area, “The United States as a nation has recognized and attempted to at least address racial, ethnic, and gender disparities in education, employment, and housing but has paid little attention to disparities in health care. No simple solutions will eliminate them. Issues such as routine access to preventive care, cultural competence in providing health care, and proportional representation of minorities in the health professions must also be addressed to eliminate inequities.”

Small steps are being taken to eliminate disparities in health status. In 1998 President Clinton announced a new plan, the Racial and Ethnic Health Disparities Initiative, which set a national goal of eliminating longstanding disparities in the health status of minorities by the year 2010. This is a first for the federal government. Nursing can support this effort by establishing affirmative action policies and initiatives to increase diversity in the profession and by incorporating cultural competence skills into the nursing curricula.

Creating a Diverse Nursing Workforce

Although the ANA supports affirmative action policies (as the June 1995 House of Delegates reaffirmed), the nursing profession has not demonstrated a commitment to such policies with an organized plan of action. Therefore, nursing continues to be a predominantly white profession. A recent meeting about workforce diversity in nursing, sponsored by a grant awarded through the Health Professions Partnership Act of 1998 (P.L. 105-392), focused on the paucity of minority students, faculty, and culturally specific curricula to meet the health care needs of the emerging majority. The act may spur the nursing profession to make a change.

“Funding will assist in expanding the numbers of minority nurses who provide culturally competent, linguistically appropriate health care services to underserved communities,” noted former ANA president Beverly L. Malone, PhD, RN, FAAN.

Although a good start, the P.L. 105-392 funding initiative is not extensive enough to address the issue of underrepresentation. Nurses must continue to work with other professional health care organizations, private foundations, health care institutions, community-based organizations, and elementary and secondary schools to improve educational and career opportunities for minorities by improving the academic preparation of younger students.

Specifically, the nursing profession should adopt recommendations of the Pew Health Professions Commission, “to create admissions policies in professional schools that have minimum academic standards for entry and that recognize other qualities such as ethnicity, cross-cultural experience, and community service as important admission criteria.” The commission also recommended that universities and their health centers help primary and secondary schools provide early exposure to the sciences and the health professions to populations who are underrepresented in those fields. Programs successful in recruiting, retaining, and graduating minority nurses should be replicated.

Fostering Cross-Cultural Competence

So how can nursing provide high-quality patient care to a diverse population? Cultural competence is one answer. Apprehending and appreciating cultural differences and similarities will require academic training and interpersonal skills of nurses—which means these topics must be integrated into nursing curricula. A lack of such skills in nurses can lead to misperceptions, longer patient stays, noncompliance with treatment, and miscommunication between patient and nurse. Unfortunately, many false notions still prevail among health professionals, including the following:

• Altering care or treatment procedures to accommodate cultural diversity is unnecessary because any person with basic common sense and intelligence can “adjust.”

• Minority issues can be handled appropriately only by those trained to recognize them or by those who are members of the same minority group.

• Professional sensitivity, knowledge, and skills are ineffectual with low-income and minority patients because they tend to have poor verbal skills, are uncooperative or insistent on immediate resolution, and are resistant to change.

• Treating people differently because of race, religion, ethnicity, or gender implies prejudice and discrimination.³

If the nursing profession is to address the needs of all patients, nurses must understand that cultural competence does not mean substituting one’s own cultural identity with another (which suggests that cultural traits can be easily shed), ignoring the variability within cultural groups, or even knowing everything about the cultures being served. Instead, a respect for difference, an eagerness to learn, and a willingness to accept that there are many ways of viewing the world will distinguish nurses who integrate cultural competence into their daily practice from those who merely understand it.

Affirmative action initiatives and cultural competence will help nurses to eliminate racial and ethnic disparities in health care. “A skilled health care workforce is critical to this country’s future,” Geraldine Bednash, PhD, RN, executive director of the American Association of Colleges of Nursing, said in 1996. “Corporate America has already accepted the marketplace reality that our population, and thus our labor pool, is becoming more diverse. To maintain global competitiveness, all workers need equal opportunity and access to education and training. The same reality applies to the health care workforce and the nation’s health care system.”

REFERENCES

1. Collins KS, Hall A. U.S. minority health: a chartbook. Commonwealth Fund; 1999.

2. U.S. Dept. of Health and Human Services, Bureau of Health Professions DoN. National sample survey of registered nurses; 1996.

3. Lynch EW, Hanson MJ. Developing cross-cultural competence: a guide for working with young children and their families. Baltimore, MD: P. H. Brookes; 1992.

Rose Gonzalez is an associate director of the ANA’s Department of Government Affairs. Malika Gooden is a staff specialist, and Cornelia Porter is director of the ANA’s Ethnic Minority Fellowship Program.