Although some progress has been made in recent years, the nursing profession generally remains lacking in both representation by nurses of color and in comprehension of the ethnic minority cultural influences that directly impact the human experience, nursing practice and nursing outcomes. In many cases, the traditional patriarchal philosophy and value-laden health care practices adopted from the field of medicine remain the dominant “culture” in nursing practice.1 Despite the many advances in nursing education and research over the last two decades, there is still ample evidence suggesting that in order to gain entrance and acceptance within the nursing profession, one must go through a series of unpublicized, yet commonly practiced rituals.
Like medicine, nursing has a culture of its own with time-honored traditional codes of conduct that have been passed from generation to generation. Unfortunately, although these issues are rarely discussed openly, it is no secret to veteran nurses that some of these traditional behaviors can result in the humiliation, rejection and alienation of newcomers to the profession, especially those who are not part of the Caucasian, female majority. In light of the current severe nursing shortage the question then becomes: “Have these traditions served nursing fruitfully or have they been harmful?”
While it stands to reason that nursing education will continue to address the needs of future generations of nurses entering the profession, one ponders the notion of how professional nurses will prepare themselves for the rapidly changing and culturally diverse populations of the 21st century. When we critically examine the profession of nursing today, we see a very dissimilar demographic landscape when compared to the 2000 U.S. Census data that indicate phenomenal population increases in racial and ethnic minority groups.
Judging purely by the statistics, nursing gives the distinct impression of being a profession that continues to be more mutually exclusive than culturally diverse, inclusive, and representative of the rapidly increasing racial/ethnic minority populations that make up a large portion of today’s patient base. We need only to examine the results of the 2000 National Sample Survey of Registered Nurses, published by the Health Resources and Services Administration (HRSA), Bureau of Health Professions, Division of Nursing. This survey revealed that nearly 90% of the total registered nurse population is white, compared to roughly 72% of the total U.S. population.
Today, the nursing profession is seriously challenged by an aging workforce, a critical staff shortage and insufficient numbers of new nurses entering the field. In light of the evidence, both published and anecdotal, that I will present in this article, it could be strongly argued that the profession’s lack of racial, ethnic and cultural diversity, combined with the retention of the old familiar biomedical cultural values and practices, is not only contributing to the current shortage but possibly even exacerbating it.
Let us examine an unpleasant but familiar nursing cliché that is commonly quoted by the professional community and, more recently, by physicians, that suggests that some professional nurses are cannibalistic and “eat their young.” Reports of behaviors such as experienced nurses being less than supportive to novice nurses–or worse, allowing minority or foreign-born nurses to experience humiliation because of their cultural differences, whether it is the mispronunciation of medical terminology or a spilled bedpan–suggest that nursing is a competitive, even predatory profession. Most disturbing are reports from minority nurses of behaviors they perceived as publicly disrespectful, devaluing and demeaning. These misguided practices could ultimately threaten the future of the nursing profession and the health of the populations we serve.
The Standardized Testing Debate
Recently, a number of distinguished and respected nursing educators have expressed concern that cultural issues in nursing practice and education will undoubtedly impact the number of persons entering the profession. For example, in an article published in 2002, the esteemed Dr. Michael A. Carter, University Distinguished Professor and retired dean of the University of Tennessee Health Science Center, College of Nursing, noted that “standardized testing is a controversial issue” that is unlikely to be resolved soon because the academy is “firmly attached to continuing to do things” as we have done them traditionally, even if they are no longer applicable or appropriate today.2
More importantly, Dr. Carter emphasized a critical point: “There are very important cultural connections in this topic (standardized testing) and we should listen to our students in this matter.” Indeed, this issue demands the attention of faculty, students, the professional nurse workforce, policy makers and the American public. Recently, one of the most commonly used standardized tests, the Scholastic Aptitude Test (SAT), came under scrutiny for allegedly being culturally biased in ways that preclude minority students from achieving high scores.3
Most undergraduate nursing programs and graduate programs require this standardized test as part of their admissions criteria. While this cultural bias debate continues without resolution, the current nursing crisis escalates. On the graduate level, the Graduate Record Exam (GRE) is now undergoing similar debate about potential bias, at a time when ethnic minority nurses with graduate degrees are seriously underrepresented.3
The College Board, owner of the SAT, the GRE and several other popular standardized tests, recently admitted that prejudice is probably responsible in part for the disparity in test scores between majority and minority students.3 Its 1999 report “Reaching the Top: A Report on the National Task Force on Minority High Achievement” concluded that the limited representation of blacks, Hispanics and Native Americans among top students is a product of several forces, including the intense poverty and cultural differences experienced by many minority families and communities. “At virtually all social strata,” the report notes, “underrepresented minority students have not done half as well as their white and Asian American counterparts, particularly as measured by standardized tests.”
The question then becomes, do racial/ethnic disparities exist only in the area of standardized test scores or do similar differences occur in other nursing education measures, such as the subjective grading of classroom tests or written work? According to Dr. Susan Albrecht, associate professor at the University of Pittsburgh School of Nursing, faculty have sometimes told young students that they don’t have what it takes to become a good nurse.4
Albrecht believes that such a sweeping judgment call is difficult to make, whether you’re talking about undergraduates or even graduate students. “Students who appear not to be interested, or seem anxious to get out the door, are frequently the ones who end up becoming the best nurses and nurse educators,” she argued in a recent interview. “Every person who comes to a classroom or clinical setting has their own field of experience and they have so much to offer.”
Thus, it would appear that some educational measures, such as standardized tests and faculty perceptions of students’ abilities, are tenuous indicators of potential academic success in underrepresented minorities. However, how do we explain instances of culturally biased practice behaviors within the profession that may serve to further impede educational and advancement opportunities for ethnic minorities in nursing?
Sending the Wrong Message
Nursing, like other sciences, must now confront issues directly related to integrating the role of culture into education, practice and research to ensure that diverse populations receive culturally competent health care. But, perhaps, we should begin by ensuring that our universities and colleges of nursing have faculties that are both culturally diverse and culturally sensitive. This would mean that faculty have a rich awareness and appreciation of various customs, experiences, interests, needs and expectations, and that regardless of gender, race, ethnicity, sexual orientation or socioeconomic class, faculty would find both respect and regard for the minority individual’s skills and contributions to the profession.
More importantly, faculty members and students who are racial/ethnic minorities should not have to feel that they must tolerate instances of bias or that they must keep silent because their group or individual cultural identity may differ from the majority opinion. For example, Terrance Ito, RN, BSN, CEN, describes in a recent article how, as a male nursing student of Asian descent, he was subjected to intense scrutiny by nursing faculty.5 He recalls white, female faculty members telling him that he “did not belong in the program” and referring to him as a “medical school dropout.” To make matters worse, the faculty member who used the latter term privately threatened that she was determined to fail him.
Unfortunately, such insensitive practices continue, not only in academia but in the nursing workplace as well. For instance, bilingual ethnic minority nurses are sometimes forbidden to speak in their native languages while on duty. Moreover, one African-American nurse was recently quoted in the press as saying, “It is not safe or acceptable for racial/ethnic minorities to express their beliefs or encourage practices that are not universally acceptable to the dominant health care culture.”
Since the evidence suggests that these are not rare, isolated incidents, one wonders whether the nursing profession is sending mixed messages even as it aggressively increases it efforts to convince more young people to enter the field. Could these instances of minority nurses and students being stigmatized or marginalized cause young people to avoid entering professional nursing, or worse, leave the profession? It is disturbing to think that despite having educational preparation and credentials comparable to those of their majority colleagues, nurses who are perceived as “different” –whether in terms of their skin color, gender, national origin or English language skills–may be treated with professional indifference or even outright discrimination.
Being continually bombarded with cultural insensitivities and negative stereotypes can be detrimental to a minority nurse’s success in employment or education. Nurses of color need to receive positive messages and images to enhance and support their employment and learning. A nurturing workplace and educational experience is essential for all nurses, regardless of their race or ethnicity.
Nursing educators and leaders must also show more respect and sensitivity toward each individual’s unique personal characteristics, such as cultural norms and values, level of knowledge and professional expertise. Replacing the old, exclusive professional behaviors with new attitudes that embrace diversity and inclusion will greatly advance nursing science and significantly impact the future of nursing. As we become an increasingly diverse discipline with different perceptions, symbols, meanings, rules, habits, values and patterns of communication, we will contribute significantly to the development of shared meaning and sense of purpose within the nursing profession.
It is also crucial that nursing consider cross-cultural curricula as a required, integrated component of undergraduate, graduate and continuing education. These curricula should aim to:
• Increase awareness of racial and ethnic disparities in health;
• Establish the importance of sociocultural factors in health beliefs and behaviors;
• Identify the impact of race, ethnicity, culture and class on clinical decision- making;
• Develop individual tools for community assessment of health beliefs and behaviors;
• Develop tools and skills for cross-cultural assessment, communication and negotiation.6
These efforts would serve to enhance communication and understanding of individual differences based on racial/ethnic background, family traditions, religion, geographical regions, gender or other cultural values.
Working Toward Solutions
As we begin to ponder solutions to these complex and daunting issues, let us look at some of the monumental tasks that have been accomplished by nurses working together in a spirit of unity and diversity. Hopefully, we will never forget how Congresswoman Lois Capps (D-Calif.), a registered nurse, introduced the Nurse Reinvestment Act, a landmark bill designed to address the national nursing shortage.7 Signed into law by President Bush in August 2002, the Nurse Reinvestment Act will:
• Provide scholarships for nursing students;
• Establish comprehensive geriatric training grants for nurses;
• Offer grants to nursing schools for faculty loan programs;
• Institute career ladder programs;
• Create nurse retention and patient safety enhancement grants;
• Provide for a national public service announcement campaign to promote the nursing profession.
In the current 21st century nursing crisis, there are approximately 130,000 unfilled nursing staff positions nationwide.7 Moreover, at a time when our country’s population is experiencing phenomenal growth, our national security has been violated by terrorist attacks and the public’s health is threatened by the possibility of biochemical warfare, it is easy to agree with Congresswoman Capps’ assertion that “this [legislation] could not have come at a better time.”8
Nurses are, and have always been, the backbone of the U.S. public health system and the support of U.S. military troops in combat. Therefore, the Nurse Reinvestment Act will provide the nation with a notion of reassurance that there will be enough nurses to handle the country’s health care needs and serve in response to unexpected public health emergencies. According to Congresswoman Capps, “having enough nurses is a critical component of that care, and the Nurse Reinvestment Act will play a large role in shoring up our nation’s nurse workforce.”8
As a minority doctoral student, primary care provider and future nursing educator and researcher, I find it difficult to believe that, given the current “nursing crisis,” we can afford to lose a single competent nurse, regardless of gender, race, ethnicity, sexual orientation or socioeconomic class. Additionally, given the anticipated increases in racial/ethnic minority and elderly populations in the coming decades, can the profession really afford to retain this counterproductive “eating our young” mentality and risk losing the many thousands of potential nurses that want to enter the profession?
According to the U.S. Department of Labor, this nation will need an additional one million nurses by 2010 to adequately staff hospitals, clinics, nursing homes and home health care services. Further, today’s ever-increasing shortage of nursing faculty has been shown to be significantly limiting the number of students many nursing schools can enroll, and even causing potential students to be turned away.9
Thus, whether embraced, appreciated or merely accepted, the concept of cross-cultural nursing will inevitably weave its way into every facet of nursing science and education, because nursing is a human science and nurses value human life. In this context, the need for current and future nursing leaders to acknowledge the importance of seeking ways to promote a sense of worth and satisfaction in all nurses through the discovery and recognition of diverse cultural values and beliefs is nothing short of an investment in the future health of our profession.
As nurse consultant Rita H. Losee, RN, ScD, recently wrote, “The truth is, this nation can spend millions of dollars and invest countless resources in the recruitment of nurses, but if the working conditions and attitudes that nurses encounter once they are working are not remedied, the nursing shortage will not go away.”10
As a science, nursing will have to direct its own research and develop measurement tools to ensure cultural competence and sensitivity within its own standards and practices. Furthermore, nursing must come to realize that a philosophy of empowering nurses (and nursing students), regardless of gender, race, ethnicity, sexual orientation or socioeconomic class, will reap enormous benefits for the profession. Empowered nurses can be motivated to organize a potent workforce that will help formulate ways and means to alleviate the overburdened health care system in which we now practice.
Perhaps the greatest challenge for professional nurses and educators is the ability to implement change. To ensure the future growth and survival of this noble and time-honored profession we know as nursing, we must learn to value diversity and difference–not only in our patient populations but also amongst ourselves.
I wish to thank Judy Carbage Martin, PhD, APRN, BC, for her encouragement and professional mentoring in the investigation of minority health and cultural studies that directly impact or influence quality health outcomes and the advancement of nursing science, and for her technical assistance and advisement during the preparation of this manuscript. Additionally, I would like to personally thank Michael A. Carter, DNSc, APRN, BC, FAAN, for being a visionary leader in nursing science and education. Finally, I wish to acknowledge the American Nurses Association’s Ethnic Minority Fellowship Program for its continued support of minority nurses in higher education.
1. Leonard, B. 2001. “Quality Nursing Care Celebrates Diversity.” Online Journal of Issues in Nursing,Vol. 6, No. 2.
2. Carter, M.A. 2002. “A Different Kind of Cultural Connection.” The Cultural Connection, Vol. 3, No. 5.
3. The Leadership Alliance. 2001. “All Things Being Equal: Minorities and the Merits of Standardized Tests.” Alliance Viewpoint, Vol. 3, No.1.
4. Albrecht, S. 2000. “On TEACHING.” University Times, Vol. 34, No. 14.
5. Ito, Terrance. 2002. “The Robert Flores in Us: Thoughts on the Shooting in Tucson, Arizona.” Nurses Forum.
6. Massachusetts General Hospital. 2002. “Cultural Competence in Health Care,” a report sponsored by The Commonwealth Fund.
7. Capps, L. 2002. “Letter Sent to Appropriations on Nurse Reinvestment Act Funding.”
8. Office of Congresswoman Lois Capps. 2002. “Capps Appeals for Substantial Funding for Nurse Reinvestment Act.”
9. National Black Nurses Association. 2002. “Briefing Statement on the Nursing Shortage.”
10. Losee, R.H. 2003. “Interior Rededication.” Nursing Spectrum Career Fitness Online.
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