Unfortunately, racism and gender inequality still exist not only in our country at large, but also in the nursing field. Because she saw this in anesthesia, Wallena Gould, EdD, CRNA, FAAN, founded and is the CEO of Diversity in Nurse Anesthesia Mentorship Program.
Gould took time to answer our questions. What follows is our interview, edited for clarity and length.
Fred Reed, DNP, CRNA, who has mentored many nurses of color interested in Nurse Anesthesia.
The homepage of the Diversity in Nurse Anesthesia Mentorship Program (DNAMP) states that only 11% of nurse anesthetists are people of color. Why is that? Why hasn’t there been more diversity in these positions?
Honestly, it stems back from decades of graduate nurse anesthesia programs accepting all white cohorts with only one or two nurses of color in each cohort. Also, contributing to the lack of diversity in the nurse anesthesia profession is the historical treatment of Black nurses at the turn of the century. In the early 1900s, until late 1940s, professional nursing associations did not include members of color just based on race. The American Association of Nurse Anesthetists (AANA), founded in 1931, included Black CRNAs into the membership in 1944.
In addition, nursing schools including nurse anesthesia programs were segregated until the late 1940s. One of the historical nurse anesthesia programs that consistently accepted diverse cohorts with faculty that mirrored the community since the Jim Crow Era was the Harlem School of Anesthesia founded by Goldie Brangman, CRNA, MEd, MBA. Founded in New York City in 1951, it lasted for 36 years. Brangman would later become the first and only Black Nurse Anesthetists who was elected as President of the AANA in 1973.
The emergence of diverse nurse anesthesia faculty started in the 1990s and has increased in small increments in the 124 graduate programs. In addition, contributing to the 11% of Nurse Anesthetists of color, is the lack of exposure or encouragement for nursing students of color to pursue Nurse Anesthesia at Historical Black Colleges & Universities, Hispanic Serving Institutions, and Tribunal American Indian Nursing Schools.
There is also gender inequality in nurse anesthetists. Does this mean that more nurse anesthetists are male than female? If so, why does this disparity exist? What has caused it?
According to the American Association of Nurse Anesthetists 2018 Profile Survey of Nurse Anesthetists, there were 52,000 CRNAs in the country with 59% of female and 41% male providers. Male nurse anesthetists were accepted into the membership in the 1950s, into what was a predominantly female profession. There was a stigma of male nurses in the profession from 1950s—2000s.
Today, more men are entering the profession, but still have a majority of female nursing school cohorts. Also, men are pursuing more specialized careers such as nurse anesthesia with the addition of military male nurses entering the profession.
Why did you establish DNAMP? What did you want to accomplish?
As a nurse anesthesia student enrolled in La Salle University in Philadelphia, I had an individual class assignment in the form of a poster project. My focus was to find out the racial and ethnic composition of the nurse anesthesia profession. In addition, I noticed that the six nurse anesthesia programs in the Philadelphia area did not have one full-time faculty teaching in the programs and only a few students of color in each program.
I was able to retrieve demographic statistics from the AANA and polled the Philadelphia nurse anesthesia students from each program. The data from the national statistics mirrored the Philadelphia programs, which demonstrated a severe lack of diversity in nurse anesthesia.
I approached one of our faculty members who taught regional anesthesia, the late Dr. Arthur Zwerling, DNP, CRNA, DAAPM, about my poster and my urge to do something about it. Dr. Zwerling encouraged me to attend the American Association of Nurse Anesthetists Annual Conference in Boston. As a senior nurse anesthesia student, I attended the conference as suggested.
On the first day of the conference, I met Goldie Brangman, CRNA, MEd, MBA (retired), spoke with her for a moment, and knew my purpose was going to make attempts to achieve diversity and equity in the profession.
Today, the non-profit organization, Diversity in Nurse Anesthesia Mentorship Program has mentored more than 510 nurses of color to successfully matriculate into 74 graduate nurse anesthesia programs. We are able to extend the pipeline to diversify the nurse anesthesia profession with a second initiative of a Diversity CRNA HBCU and Hispanic Serving Institution School of Nursing Tour. Lastly, we started our newest initiative with a Diversity Advanced Practice Doctorate Symposium with a collaborative effort of doctorate prepared CRNAs, Nurse Practitioners, Nurse Researchers, and Nurse Midwives to encourage nurses of color to pursue a doctorate and build a body of work.
How can the nursing community at large be an ally or offer support to BIPOC nurses who want to get into anesthesia?
Deans of Nursing serving at predominantly white institutions, HBCUs, Hispanic Serving Institutions, and Tribunal American Indian Nursing Schools can intentionally hire CRNAs of color as full-time, part-time or adjunct faculty. They can also invite CRNAs of color to classrooms to speak to nursing students about nurse anesthesia or teach didactic courses. This includes hiring CRNAs in doctorate-prepared nurse anesthesia programs and affording opportunity to be promoted in rank and publish in nursing peer-review journals. This need to be a national effort to make a profound impact in the trajectory of a diverse profession with accountability.
How does mentoring help assist and encourage more BIPOC to get into this facet of nursing?
For many nurses of color, myself included as a first-generation college graduate, we have been motivated, but just need proper direction in career trajectory. I was a registered nurse for eight years before enrolling in a graduate nurse anesthesia program. So, if CRNAs of color can mentor diverse nurses and nursing students prior to their enrollment into a graduate nurse anesthesia program, students will have the support needed to complete the graduate program successfully.
Is there anything else that nurses need to know regarding racism and gender inequality in anesthesia?
In many nurse anesthesia programs, nurse anesthesia students of color experience social isolation, microaggressions, and in some cases, racism as one of the few in their own program in clinical and or in the classrooms. Nurse Anesthesia students need to be very familiar with student policies and in certain cases, should direct any inequities to the Director of Diversity and Equity Officer for any concerns.
Resources
Bankert, M. (1989). Watchful care: A history of America’s nurse anesthetists. New York
Carnegie, M. E. (2000). The path we tread: Blacks in nursing worldwide, 1854-1994. 3rd (eds.). Sudbury, MA: Jones and Bartlett Publishers, and National League for Nursing.
American Association of Nurse Anesthetists (2018). AANA 2018 Member Profile Survey. Park Ridge: IL.
Racially and ethnically diverse populations have grown in the US. The US Census Bureau finds that approximately 37% of the population is made up of minority groups. Nurses currently make up the largest group of health care professionals in the US, and the need for culturally diverse nurses in the workplace has been identified by many nursing leaders. The demand for culturally competent care has brought attention to the need for culturally diverse nurses. Several studies have identified that failure to provide culturally competent care can influence health outcomes. A 2009 study published in Health Affairs found that increasing minority representation in the health care workforce could have a positive effect on curbing the health care disparities found in minority populations.
The need for culturally competent health care highlights the need for a diverse nursing workforce, particularly since patients tend to migrate towards providers that share their ethnic background. Minority nurses and possibly advanced practice nurses are in a position to help these often underserved minority communities receive care that will increase their likelihood of compliance with medical treatment and increased health literacy.
Additionally, implementation of the Affordable Care Act will allow for the expansion of health insurance to historically underserved populations. This expansion will require an increase in the number of health care professionals available to care for these populations.
Of the almost 3 million registered nurses in the US, approximately 133,000 are black and 55,000 are Hispanic. A 2013 study published in Journal of Transcultural Nursing reveals that minority students account for about 27% of the students in undergraduate schools of nursing. The low number of minority students represented in the undergraduate nursing school enrollment numbers highlights the difficulty noted by graduate schools when it comes to attracting and enrolling minority registered nurses.
Federal initiatives like the Promoting Postbaccalaureate Opportunities for Hispanic Americans program authorized under Title V of the Higher Education Act of 1965 are designed to expand postbaccalaureate opportunities and academic offerings for universities that are educating the majority of postsecondary Hispanic students. According to a 2010 brief published by Excelencia in Education, there were 176 emerging Hispanic-Serving Institutions (HSIs) in 2007. Federal law requires that in order to receive a designation as a HSI, an institution must have at least 25% Hispanic undergraduate enrollment. Emerging HSIs are those with Hispanic enrollment within the range of 12% to 24% and have the potential to become HSIs over the next few years. The HSI designation allows an institution to qualify for grants and other modes of funding. A 2010 study published in Journal of Latinos and Education found that, behind funding, the most important issue facing the presidents of HSIs was the lack of academic preparedness of the students.
Challenges are faced by Hispanic nurses desiring to pursue advanced nursing degrees. Like undergraduate enrollment, the number of registered nurses with baccalaureate degrees applying for advanced practice nursing tracts is low. There are four HSI institutions that offer nurse anesthesia in these fine programs: University of Miami, Kaiser Permanente / California State University, Inter-American University of Puerto Rico, and the University of Puerto Rico. A relatively large Hispanic applicant cohort of prospective students submit to these diverse nurse anesthesia programs along with other urban located institutions within the US. A barrier that some underrepresented students encounter is the lack of academic preparedness and/or lackluster graduate exam scores. This lack of academic preparedness equals fewer applicants who are adequately prepared for undergraduate and graduate education. In the event that a student is successful in an undergraduate program, lack of preparedness could lead to the preparation of a graduate application packet that is not representative of the candidate’s true potential.
Optimization of the nurse anesthesia program application packet can mean the difference between acceptance and rejection. The graduate application for nurse anesthesia school normally contains many components. The application is the first glimpse of the candidate presented to the admission committee. One crucial component of the process is the essay. The essay should contain information that the candidate wants to express describing his or her participation in leadership and extracurricular activities. Admission committee members take note of well-rounded candidates. Candidates should include evidence of involvement in professional nursing organizations and hospital committees. These types of activities highlight the candidate’s desire for professional development. The essay should be edited for grammar, spelling, and content before the packet is submitted to ensure that the candidate appreciates attention to detail.
The construction of a comprehensive application will most likely yield an interview, but the interview process can be intimidating. Most admission committees attempt to evaluate the student’s preparedness for the rigors of the program. The types of questions revolve around principles of physiology, pathophysiology, and pharmacology. Candidates who recognize their deficiency in interviewing should seek out opportunities to practice these techniques. Career centers may offer opportunities to hone interviewing skills.
Prospective students tend to focus on securing a seat in a nurse anesthesia program, but it is unclear how many actually consider the rigorous nature of the program. The amount of preparation that goes into the admission to a nurse anesthesia program is only minimized by the challenges of the didactic and clinical experiences for a new student. These challenges should be considered in conjunction with other stressors that can include financial obligations, reduction of income, and family responsibilities.
How to Strengthen your Application and Secure an Interview
According to the American Association of Nurse Anesthetists (AANA)’s 2012 demographics of nurse anesthetists in the United States and Puerto Rico, as an aggregate number, there is less than 10% of underrepresented minority nurse anesthetists from the 44,000 advanced practice nurses practicing in hospitals, surgery and endoscopy centers, and dental and pain management offices. Less than 3%, 3.2%, and 0.5% are from Hispanic, African American, and American Indian groups, respectively. To learn more about becoming a certified registered nurse anesthetist (CRNA), visit www.aana.com/ceandeducation/becomeacrna. Here, students will find information about the requirements of becoming a CRNA as well as a list of accredited nurse anesthesia programs, frequently asked questions, and a list of related published articles. It is imperative that prospective applicants into a nurse anesthesia program peruse not only the nurse anesthesia program of interest website, but also our national nurse anesthesia association website.
It is vitally important that underrepresented minority nurses learn more about the history of nurse anesthesia and national implications of advocacy. The book Watchful Care by Marianne Bankert is a great resource. It will expand your knowledge about nurse anesthetists and prepare you adequately for the interview, if the admission committee members ask any questions about this well-read topic. The top candidates definitely shine during the interview if they have read this material.
Another way to strengthen your application is to include your shadowing experience with a CRNA in the operating room. You should contact the CRNA and ask to meet him or her in the operating room on an agreed time. Be prepared to witness the CRNA prepare the room by checking the anesthesia machine and related equipment as well as prepare medications for the planned anesthetic prior to a patient’s arrival in the operating room. In addition, you will witness the CRNA interview the patient extensively about his or her medical and surgical history, review and secure the anesthesia consent, and perform an oral exam to assess a Mallampati score (I – IV) to anticipate an easy or difficult intubation prior to entering the operating room. During the shadowing experience, ask plenty of questions about what type of anesthetic is being administered (such as general, regional, or sedation), fluid management, positioning considerations, and more.
Along with learning the history of nurse anesthesia, as a critical care nurse with a baccalaureate degree, you should study and schedule the critical care registered nurse (CCRN) exam offered by the American Academy of Critical Care Nurses (AACN). Information regarding this exam can be found on the AACN website (www.aacn.org). This test demonstrates aptitude in critical care nursing and professional commitment towards excellence. A significant number of nurse anesthesia programs require applicants to earn critical care experience and sit for and pass the CCRN exam prior to actual submission of the essay for a nurse anesthesia program.
Another viable option for underrepresented minority nurses to improve the application process, handle the stressful interview, comply with the rigor of a nurse anesthesia program, excel for clinical preparedness, and learn about doctoral programs in nurse anesthesia programs is to register and attend Diversity CRNA Information Sessions & Airway Simulation Labs scheduled in 2014. This event, sponsored by the Diversity in Nurse Anesthesia Program (www.diversitycrna.org), offers an opportunity to those interested in nurse anesthesia education to fully engage oneself and learn comprehensive information about the process, network, and participate in a hands-on simulation experience in the lab. You will also have the opportunity and access to meet four nurse anesthesia program directors, AANA senior leadership, minority CRNAs, and nurse anesthesia students from across the country. As a result, you will have the ability to include details about your experience in your eventual essay and articulate it during your interview.
An additional application requirement of some anesthesia programs is the Graduate Record Examination (GRE). It is incumbent of any prospective applicant to visit the GRE website (http://www.ets.org/gre) to learn about the comprehensive information about the scores and the actual make-up of the exam (verbal reasoning, quantitative reasoning, and analytical writing).
So, now it is up to you. Will you peruse through the suggested websites to broaden your knowledge base about proper preparation for entry into nurse anesthesia? Do you want to be a competitive applicant for a nurse anesthesia program? Do you want to be academically and clinically prepared for such a program? If you answered yes to these questions, be proactive in your educational goals to advance your professional development in a nurse anesthesia program. You can do it!
Wallena Gould, CRNA, EdD, is the founder and chair of the Diversity in Nurse Anesthesia Mentorship Program (www.diversitycrna.org) and chief nurse anesthetist at Mainline Endoscopy Centers.
Martina Steed is a CRNA and Associate professor and Assistant director in the Department of Nurse Anesthesia at Webster University in St Louis, Missouri. She is also a small business owner and PhD candidate in the College of Health Sciences at Walden University.
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