A process for increasing cultural diversity in nursing education

Strategic management: A process for increasing cultural diversity in nursing education

Hill, Mary H

Because of a growing culturally diverse workforce in the United States, nursing continues to face the challenge of managing and meeting the health care needs of individuals whose group identities differ from the majority population. In this article the author describes a process, strategic management, for increasing culturally diverse students’ representation in schools of nursing and, subsequently, in the nursing practice area. Strategic management is the vital link to increasing the number of practicing registered nurses who reflect the diversity of the population served.

KEY WORDS: Cultural Diversity; Diverse Workforce; Nursing Education; Strategic Management


The health care delivery system in the United States is undergoing revolutionary changes in response to society’s demands for increasing access, increasing quality, and decreasing cost of health care. Nursing, a system within the suprasystem – the health care delivery system – has traditionally responded to societal changes by reassessing its role in relation to environmental trends and implementing programs to meet the emerging health care needs. Reassessment, however, is more critical for nursing today than ever because nursing must design programs so that it will be positioned to meet the challenges associated with a revolutionized health care delivery system in the 21st century. According to Shortell et al. (1992), health care delivery in the 21st century will be characterized by transitioning from: (a) acute inpatient care to a continuum of care; (b) treating illness to maintaining wellness; (c) caring for an individual patient to accountable for the health status of defined populations; (d) commodity product to valueadded services; (e) market share of admissions to covered lives; (f) filling beds to care provided at appropriate levels; (g) managing organizations to managing a service network; (h) managing departments to managing a market; and, (i) coordinating services to actively managing quality (Shorell et al., 1992).

In addition to the transitioning of the health care delivery system, another concern for nursing, as the 21st century emerges, is the shifting trend in the population demographics of the United States. Although the workforce has gradually grown to be culturally diverse, nursing is yet faced with the challenge of managing and meeting the health care needs of individuals whose group identities differ from the current majority population. Population projection data, regarding demographic changes, indicate that between 1992 and 2050, the White population will decrease from 75 percent to 53 percent; the Black population will increase from 12 percent to 16 percent; the Hispanic population will increase from 9 percent to 21 percent; the Asia population will increase from 3 to 11 percent; and, the American Indian/Alaskan Native population will increase from 0.8 percent to 1.2 percent (Pollack, 1996). Therefore, in order to meet the health needs of a population with a changing demographic profile, it is vital that nursing, as a health care discipline, effects strategies to recruit individuals into the profession who reflect the diversity of the population served, and assure that the curriculum and clinical learning experiences are culturally relevant.

Currently, culturally diverse groups (Blacks, Hispanics, Asian/Pacific Islanders and American Indians/Alaskan Natives) are underrepresented in all nursing practice arenas service, education, and research. This trend, unfortunately, will only continue to escalate unless minority leaders, particularly faculty in historically White baccalaureate and higher degree programs, become intricately involved in the development and implementation of strategic management to increase the recruitment, admission, retention, and graduation of minority students in nursing. Duncan, Genter & Swayne (1995) state that strategic management is “a philosophy of managing the organization that is externally oriented and link strategic planning to operational decision making. Strategic management attempts to achieve a creative fit between the organizational’s external environment and its internal situation” (p. 21). A challenge for administrators of academic nursing programs is the development of a strategic management plan to increase culturally diverse students’ representation in academic nursing programs. The strategic management plan would be a vital link to increasing the number of practicing nurses who reflect the diversity of the population served.

Furthermore, it is essential that there should be the inclusion of minority faculty in the overall strategic management process (environmental assessment. situational analysis, strategy formulation, strategy implementation and strategy evaluation). Input from minority faculty in the development of a plan would play a critical role in bringing to fruition an increase in minority students’ representation in academic nursing programs. Minority faculty’s contributions would bring a uniqueness to the strategic management process characterized by diversity of ideas and approaches to problem-solving issues unique to minority students in social and academic settings. Moreover, minority faculty would posses an increased sensitivity to the needs of minority students which was acquired through “lived experiences” within the family and social community, secondary and postsecondary education programs, and nursing practice settings.


In 1996, the United States Department of Health Human Resources, Division of Nursing, conducted a survey to assess the number and characteristics of the registered nurse (RN) population and to facilitate the evaluation of trends in the availability of nursing resources. Results from the survey revealed that the total RN population is 89.7 percent white; 4.2 percent Black; 3.4 percent Asian/Pacific Islander, 1.6 percent Hispanic; and 0.5 percent Native American/Alaskan Native (U.S. Department of Health and Human Services, 1996). Census data for the United States for the same period revealed the total population is 72.3% white, 12.5 percent Black; 10.6 percent Hispanic; 3.7 percent Asian/Pacific Islander, and, 0.9 percent Native American/Alaskan Native (Bureau of Census, 1996). These data clearly indicate that practicing nurses do not reflect the cultural diversity of the population served. Consequently, the recruitment of minorities, as well as disadvantage students, into nursing is important because the population growth being experienced by most racial/ethnic minority groups provides a relatively untapped source of future registered nurses. In response to the current demographic trends in the population, the American Nurses Association is addressing cultural diversity in the profession and has identified it as a high priority. Furthermore, to achieve optimal health care outcomes, it is critical that measures are taken to ensure that practicing nurses are more diverse and provide culturally competent care. To this end, The American Nurse (1998) reports that the “Association currently is putting together a national advisory council on cultural diversity to help increase minority representation in nursing and assure cultural competency in the current workforce (p. 25).


Environmental Assessment

The strategic management process to increase the recruitment, admission, retention, and graduation of culturally diverse students in schools of nursing begins with an assessment of the general and academic environments of the nursing program. In this phase of the process, attention should be given to the organizations and individuals that generate macroenvironmental changes — technological, social, regulatory, political, economic and competitive information. Information generated from macroenvironmental changes will, in the long run, affect many entities, including trends in higher education. Some areas for assessment within the general environment may include health care organizations, businesses, religious institutions, research organization organizations and foundations, and individuals and consumers (Duncan, 1995).

Assessment findings reveal that the health care industry, over the past 10 years, has followed the business industry in initiating organizational change through restructuring and reengineering the workforce in an effort to provide cost-effective products, services, and customer satisfaction. Another trend that business organizations are responding to is the increase in the cultural diversity of the workforce. According to Michael Snead, Vice president of Executive Search Consulting at A. T. Kearney, there has been a steady increase in the number of companies with diversity programs over the past year. Research conducted by Snead found that 74 percent of Fortune 500 companies reported having diversity programs in place in 1996 as compared to only 62 percent in 1991 (Caudron, 1998).

In addition to taking notice of demographic trends, business organizations are also, emphasizing the importance of cross-functional teams in creating a basis for competitive advantage. Cox (1994) states that “The amount of change indicated by this combination of trends and events for the cultural milieu and intergroup relations of organizations is mind-boggling. It is, therefore, imperative for employers and for educational institutions seeking to prepare people for leadership in the 21st century to understand the effects of cultural diversity on human behavior in the workforce” (p. 5).

Government health care organizations should also be assessed to determine health care trends at the state and national levels. For example, Mississippi State Health Plan 1998 revealed that there are barriers to adequate health care for minorities that include a lack of access to the health care system, the cultural insensitivity of providers, the lack of health insurance services, and the attitude of health care providers. It was further stated that possible solutions include “promoting health education for providers, specifically minority providers, funding services and programs targeted for minorities, and evaluating the effectiveness of programs that minority groups need (p. III-150). Along the same line, at the national level Healthy People 2000 identified that minority and disadvantaged communities lag behind the United States population on virtually all health state indicators. It was further stated that “increasing the number of minority health professionals may offer a partial solution to this public health care crises. Several studies have shown that underrepresented minority health professional graduates are more likely to enter primary care specialties and to voluntarily practice in or near designated primary care health workforce shortage areas” (p. 542). Utilizing assessment data from a foundation, in the Third report of the Pew Health Professions Commission (1995), one of the competencies identified for successful health professional practice in the future is to “participate in a racially and culturally diverse society” (p. 3). The Pew Commission further stated that to provide appropriate care, “practitioners must be able to appreciate the growing diversity of the population and the need to understand health status and care through differing cultural values” (p. 6). In support of the Pew Commission’s position, Diane Dowing, Past President of the Public Health Nursing Section of the American Public Health Association states “it is important that schools of nursing attract a diverse student body, because if you study and work with folks from different backgrounds, then you begin to understand cultural patterns without having to practice on patients first” (Trossman, p. 25.

In assessing the academic environment in which a nursing program exists, assessment of the mission of secondary schools, especially those schools that are located near nursing programs, may result in information that could lead to joint ventures to increase minorities in nursing. Particular attention should be given to forming partnerships with secondary schools that have a strong curriculum in math and science. This kind of academic preparation would contribute immensely to preparing minority students to meet admission requirements for nursing and provide a foundation for academic success in nursing programs. According to Betty Smith Williams, National Black Nurses Association President, one way to increase African American representation in registered nursing is to “improve access to quality secondary schools that have strong basic science programs vital to success in nursing” Crossman, p. 25, 1998).

Situation Analysis

Situational analysis, analysis of factors in the external and internal environments, is necessary to clearly depict environmental threats and opportunities. Particular attention should be given to social, political, economic, demographic, and educational factors that would impact, positively or negatively, a nursing program’s endeavors to increase minority students’ representation. For example, based on the positions taken by various entities at the state and national levels, it would seem that schools of nursing would use this junction in history as a “window of opportunity” to effect opportunities for increasing minority representation in nursing practice settings.

As a part of the internal analysis, a nursing program needs first to first analyze the demonstrated degree of commitment by the educational institution to promoting diversity in the workplace and in the student population. A readily assessable way to assess this area is that of determining the percentage of minority faculty and the positions that they hold within the institution. Other ways include assessment of minority students’ admission and retention rates in general to the educational institution and specifically for the nursing program. Specific data for analysis could include application, admission, and graduation rates of minority students. Further evidence of an institution’s commitment to cultural diversity can be advanced in a variety of ways. First, there should be a determination of resources available to assist in the admission and retention of students once they are admitted to the nursing program. Second, a profile of minority students admitted and available support services to meet the students’ needs (based upon academic and personal profiles) would be excellent indicators of commitment to the support of minority students. Third, a curriculum that includes cultural diversity as a core concept indicates its value within the nursing program. Fourth, based upon behaviors of administrators, faculty, staff, and students inferences can be drawn regarding the degree of commitment to cultural diversity in the organization. Fifth, the role that a Minority Affairs Office, or a similar entity, plays in providing guidance and support for minority students needs to be determined. Lastly, there needs to be a determination of research initiates by faculty and students that focus on major health problems of the minority population.

Strategy Formulation

Duncan, Ginter, and Swayne (1995) state that “strategy formulation is concerned with making strategy decisions using the information gathered during the situational analysis (p. 204). The approach to formulating strategies to increase the number of minority health care providers, particular nurses, must be comprehensive and is urgently needed (Rosella, Regan-Kubinski & Albrecht, 1994). Based upon the information generated from the analysis of the external and internal environments, a school of nursing must first reaffirm, or establish, and reach consensus on its mission, vision, values, and directional strategies (objectives).

Decision making delineating the directional strategies provides the framework for further strategic initiatives. The specific types of strategies to consider include adaptive, market entry, positioning, and operational strategies. Within the strategic management process, the nursing faculty should decide upon the kinds of adaptive strategies for the school. Specifically, the nursing faculty need to decide if the nursing school will expand, contract or remain stable in terms of its enrollment and the types of programs offered. For example, one strategy may be expansion by market development, which is a strategy designed to increase minority students’ admission and completion of a nursing program through geographic expansion or by targeting new market segments within the geographic area. Market penetration could be evidenced by increasing minority students enrollments by targeting minority practicing licensed nurses. In view that the admission rate for minorities in schools of nursing is low (i.e. 16.1 percent for 1993-94), in comparison to the population served (37.7 percent), and minorities graduation rate is even lower (13.3 percent for 1993094), market entry strategies (gaining access to the best and brightest pool of potential students) could include cooperative initiatives with secondary and post secondary schools to increase enrollment and graduation rates (NLN, 1996; Prescott, 1995).

In the area of product development strategy, a nursing program can develop internally – and consequently the resulting refinement of its graduates could lead to an increase in the market share because students will recognize the attributes of a particular program and as a result will become ambassadors for marketing the program. Also, faculty development that results in the conveyance of an environment that fosters learning and success may be another strategy for recruitment.

It follows, then that as a positioning strategy, the nursing program will select a focus strategy. This strategy identifies a well defined “niche” in the total market that the organization will pursue (Duncan, 1995). For a nursing program the “niche” should include racial/ethnic individuals interested in pursuing a career in nursing.

Strategy Implementation

Strategy implementation is the process whereby operational strategies, functional and organizational-wide, are effected. Successful implementation of operational strategies will be critical to achieving the goal of increasing minority student’ representation in nursing programs. Therefore, efforts directed toward goal achievement will require the coordination of functional operational strategies such as marketing, information systems, human resources and finance (Duncan, 1995). Underlying the functional operational strategies, however, would be organizational wide strategies – organizational culture, organizational structure, facilities and equipment, and ethics and social responsibility that provide the backdrop for the school of nursing.

The organizational culture of a nursing program may be supportive of effecting strategies to increase minority students or the culture of an organization may resist and changes that alter the accepted way of doing things (Duncan, 1995). When the latter happens, the organization must implement measures to modify the culture.

For an organization to achieve a goal of increasing minority representation, there must be support and genuine commitment of top management (Cox, 1994). Initially there needs to be confirmation of nursing education administration and faculty’s commitment to minority education (Tucker-Allen, 1989). Nursing education programs that have been successful in recruiting, admitting and graduating minority students have demonstrated commitment by faculty to minority education. Once commitment by the administrator and faculty has been established, discussion groups should be held for the purpose of allowing faculty to ventilate their feelings regarding minorities in general and students specifically. Discussion groups should be facilitated by an individual with expertise in organizational development and behavior with emphasis on cultural diversity in organizations. Also, the climate in the organization may need to change in order to ensure that the environment is conducive to success.

Cultural diversity should be incorporated as a core concept within the curriculum and receive the same consideration as other concepts such as safety, integrity, caring, etc. Measures should be undertaken to ensure that those presenting cultural concepts are grounded in theory about the culture. In addition, the presence of individuals with different group identities impacts organizational culture. Minority leaders, locally and nationally, in nursing should have increased visibility by being incorporated them into program activities through such appropriate roles, such as being guest speakers. Also, increased visibility of minorities can occur through the employment of more minority faculty and staff. In recognizing the need for minority faculty, Mirando (1998) states “ninety percent of health care givers are Caucasian. I think that’s a critical problem, especially when considering the “browning” of America. You need to make an effort to recruit culturally diverse faculty, and nursing hasn’t made that effort” (Trossman, p. 24).

A nursing program located in an urban area could easily identify target segments of the population in secondary schools, two-and four-year colleges, particularly if the educational institutions have customers from the minority population. Collaborative efforts with the administration of secondary and post secondary educational institutions could lead to joint ventures such as the establishment of a formal mentor program for minority students interested in pursuing nursing as a career. Through the development of a mentorship program, potential students will be afforded the opportunities for: (a) early advisement regarding the admission requirements for entering nursing and the kinds of courses that should be taken to acquire a strong background in the basic sciences; (b) further academic preparation by attending tutoring in the basic sciences department at academic health centers or at other post secondary schools; and (c) provision for attending forums with minority nursing faculty and leaders in the nursing community. Consequently joint ventures of this nature would facilitate minority students; recruitment, admission, and retention in a nursing program and NCLEX-RN, licensing exam, success.

Another area for marketing strategy implementation related to product development would be the enhancement of the qualities of graduates from a particular nursing program. As a service profession, nursing needs to ensure that its product, the graduate, acquires the knowledge and skills to meet the health care needs of a culturally diverse population in a revolutionized health care delivery system. Therefore, the curriculum must include culturally relevant course content. To achieve this end, measures must be taken to ensure that faculty development through formal course work or staff development programs, with a focus on transcultural nursing care and research are implemented (DeSantis, 1991). Nursing students that complete a program that has courses grounded in theory about culture, rather than cultural stereotypes, coupled with clinical experiences in practice settings that primarily serve minorities, will positively impact the quality of their practice. As a result of their learning experiences they will be prepared to implement culturally sensitive care which, consequently, would contribute to a decrease in the disparity in health problems between the majority and minority populations.

Strategic Control

Strategic control will be the process by which nursing faculty will assess how well the nursing school is progressing toward accomplishing objectives for increasing cultural diversity. Standards of performance in relation to the objectives should be identified. Also, there needs to be ongoing monitoring, evaluation, and adjusting of strategies throughout the strategic management process in order to identify the reason for, and correct, ineffective or inefficient strategies.


As nursing prepares to enter the 21st century, diversity will impact the profession through its workforce and patients. Therefore, one of the greatest challenges that nursing will face in the next century is managing diversity and its effectiveness in this area will be evidenced by the health care outcomes of the population served.


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Mary H. Hill, RN, MS, Assistant Professor, University of Mississippi School of Nursing, Jackson, Mississippi.

Copyright Riley Publications, Inc. Center for the Study of Multiculturalism and Health Fall 1998

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