Going the Distance

As nursing schools across the country continue to work aggressively to increase the diversity of their student populations, minority nurses remain less represented in doctoral degree programs than at the bachelor’s and master’s levels. But progress has been made over the last decade, and today universities are continuing to look at ways to not only recruit more nurses of color into doctoral programs but also ensure that they graduate.

According to data from the American Association of Colleges of Nursing (AACN), minority doctoral enrollments are up across the board among all ethnicities. Of the 3,362 nurses enrolled in research-focused PhD programs in 2006, for instance, 670–almost 20%–were nurses of color. That’s almost double the number from just five years earlier, when minority enrollment in those programs totaled 359 (about 14%). Ten years ago, minorities comprised just 11.6% of research-focused doctoral nursing students.

Graduation rates are up, too, AACN reports. Seventy-four minority nurses graduated from doctoral programs in 2006, comprising about 17% of all doctoral nursing graduates, compared with only 47 minority graduates (about 10% of the total) five years ago.

But many nurse educators believe universities need to do more to increase doctoral program enrollment and graduation rates among all students in general, and to continue to increase the representation of minorities.

“I think we still have a ways to go in getting more nurses interested in pursuing doctoral education,” says May Wykle, PhD, RN, FAAN, FGSA, dean of Case Western Reserve University’s Frances Payne Bolton School of Nursing in Cleveland, Ohio.

The need for more doctorally prepared nurses is critical for addressing the nursing faculty shortage. “It’s a big problem,” says Marjorie Isenberg, DNSc, RN, FAAN, professor and dean of the University of Arizona College of Nursing in Tucson. “The average age of a faculty professor is 55, so we have a large cohort of faculty who are preparing to retire.”

This has implications not just for nursing schools but for health care as a whole. If universities can’t recruit enough nursing faculty, they can’t expand their enrollments and programs to meet the nation’s need for more nurses. And nursing schools especially need more minority faculty members to foster a diverse student body.

More Options, Closer Access

Of course, doctoral degrees enable nurses to do more than just teach. More doctorally prepared minority nurses are also needed to conduct research and work in the field, especially in areas relating to the elimination of racial and ethnic health disparities. Wykle says nursing schools need to make sure that potential minority doctoral students know about other, newer options besides the traditional PhD degree, such as clinical doctoral programs for nurse practitioners (Doctor of Nursing Practice degrees).


The ability to work in the community with a doctorate is an important factor that is leading more American Indian and Alaska Native nurses to pursue terminal degrees. One reason Native nurses have been particularly underrepresented in doctoral programs is that many wanted to work in their communities and help their people in more tangible ways than they could through a faculty or research position at a university, says Sue Henly, PhD, RN, professor and project director of the American Indian/Alaska Native MS to PhD Nursing Science Bridge program at the University of Minnesota School of Nursing in Minneapolis.

“When pursuing a doctorate, Native students are doing something that’s less familiar to their families and communities,” she explains. “There’s less certainty about how it will pay off and fit in with their lives. What will come afterwards? They’re really trailblazers.”

Universities are also working on making young nursing students more aware of doctoral education opportunities. At the University of Arizona College of Nursing, faculty and diversity directors identify younger students who have an interest in research and teaching and then encourage them to move toward pursuing advanced degrees sooner rather than later. The university is one of a growing number of nursing schools that now offer BSN-to-doctoral programs, which are designed to put students on the path to the doctorate earlier in their careers than ever before.

“We have this tradition in nursing in which students earn a degree and go out and practice, and then they get another degree and practice again, and then they come back and get their doctoral degree,” Isenberg explains.

But by that time, nurses are in their 40s. They’re often married with children and they may be caring for aging parents. “Then life becomes very complicated,” Isenberg says. “We’re not talking about a 20-year-old who can lay all those things aside and concentrate on [getting a PhD].”

Schools that hope to recruit more minority doctoral students also need to look at making their programs more convenient for students to get to. Picking up and moving one’s family to another city or state to pursue a rigorous course of study is difficult at best. It’s particularly challenging for students from Hispanic, American Indian and other cultures, where the family context is so important, Isenberg says.

To address this issue, the University of Arizona College of Nursing launched a full-time online doctoral program four years ago. The distance-learning program has been well received by students, because they no longer have to leave their families behind to go to class.

“We noticed that some of our students were driving 200 or more miles to go to school,” Isenberg says.

Students and faculty meet face-to-face before the semester begins, and everyone has a camera on their computer to make communicating online more personal. The students get to know each other well: Each cohort has about 10 people, who move through the doctoral program together. “They become a very tight-knit group,” Isenberg adds.

Meeting Financial Needs

Because doctoral education is expensive, nursing schools also must make sure their programs are financially accessible to students of all backgrounds. Financial aid, including stipends as well as assistance with tuition, is critical for doctoral students, Wykle says. “If students don’t have enough scholarships, and they have to work [while trying to pursue their degree], that can be deadly.”

In recent years, the federal government has created more funding opportunities to assist nurses in obtaining advanced degrees. For instance, the Health Resources and Services Administration (HRSA)’s Nurse Faculty Loan Program (NFLP), created by Congress to address the nursing shortage, provides loans to nursing students enrolled full time in master’s or doctoral programs. If the student becomes a full-time nursing faculty member after graduating, the program forgives up to 85% of the loan.

The Graduate Assistance in Areas of National Need (GAANN) program, offered through the U.S. Department of Education, provides grants to academic institutions that enable the schools to offer fellowships for doctoral students in fields considered areas of national need, such as nursing. The Yale University School of Nursing in New Haven, Conn., is among the schools where GAANN fellowships are available. The school launched a new PhD program last fall to replace its Doctor of Nursing Science (DNSc) degree and received the three-year federal grant to support the recruitment and training of doctoral students to counter the nursing faculty shortage.

The school uses the grant funding to provide tuition and a stipend for four students based on financial need. In the first two years of the program, students work closely with faculty to gain graduate research experience. In the third or fourth years, they are mentored as they get experience teaching master’s-level classes. The students also receive support through the university’s Center for Graduate Teaching, which helps them with such practical issues as how to handle difficult students and how to write exams.

“When people graduate from here, they should be pretty set to go into an academic position,” says Marjorie Funk, PhD, RN, FAAN, FAHA, director of the PhD program.

Attention Helps Retention

Having a diverse and culturally sensitive faculty is also an important factor in the recruitment and retention of minority doctoral students. And faculty members must be trained in how to mentor students. “The faculty needs to be able to understand what you do to advise students,” Wykle says. “It goes beyond establishing office hours and returning phone calls.”

Individualized attention from faculty is a key to student retention in the doctoral program at Hampton University School of Nursing in Hampton, Va., the first historically black nursing school to establish a PhD program. Students have access to faculty members’ home phone numbers as well as work numbers and email, and the cohorts are kept fairly small–about 10 people–so everyone gets to know each other well. Classes are offered online and students are encouraged to post their own Web pages on the program’s network. Telephone conferences and computer cameras allow students and faculty to talk to and see one another. And an annual three-day to one-week residency brings faculty and students together for education and socialization.

Far more students apply than the PhD program can accommodate, says Pamela Hammond, PhD, RN, FAAN, professor and director of the program. Ten students so far have graduated, and five more are expected to graduate in the next year. The program receives numerous calls from employers interested in hiring its graduates for faculty and research positions, Hammond adds. “People are looking at our students because they know the program is rigorous and that our students do very well.”

Unfortunately, says Wykle, attitudes still prevail in some parts of the academic world that expanding minority enrollment in doctoral programs will mean letting standards slip. Not only is this completely untrue, she argues, but even students who are accepted on a provisional basis can succeed if they receive assessment of their study and writing skills, a welcoming attitude and enough support so that they have the tools and resources they need. “Schools have to go the extra mile to offer support services,” she emphasizes.

Bridging the Distance

Still another initiative that is not only boosting the number of minority nurses enrolled in doctoral programs but also ensuring that these students receive the cultural, academic and financial support they need to cross the finish line is Bridges to the Doctoral Degree, sponsored by the National Institutes of Health.

Bridges programs, such as the American Indian/Alaska Native MS to PhD Nursing Science Bridge program at the University of Minnesota, pair one or more universities that offer Master of Science as their highest degree with a university that has a doctoral program. The partner schools work together to help minority students successfully bridge the transition between the two programs. Other nursing schools whose doctoral programs are participating in Bridges to the Doctoral Degree include the University of Illinois at Chicago College of Nursing and Rutgers, The State University of New Jersey College of Nursing.

In the last six years, 17 Native nurses have been set on the path toward PhDs through the bridge program at the University of Minnesota, whose partner schools are the University of North Dakota and the University of Oklahoma. That’s a significant number considering that there were only a dozen American Indian/Alaska Native nurses in the country with a PhD when the program started. Of the 17, five have attained their master’s degrees, three have transitioned to the PhD program and one has advanced to candidacy.

While earning their master’s degrees, students in the bridge program receive financial support through paid research assistantships. This also helps them gain hands-on experience while serving as a valuable resource to faculty members. Students learn library research skills, data management and how to compile and critique research literature.

Once they enter the doctoral program at the University of Minnesota, the students receive financial assistance in the form of a research or teaching assistantship for the first year, which includes tuition. They are then encouraged and supported to apply for competitive fellowships through the university.

Recently, the University of North Dakota and the University of Oklahoma both decided to start their own doctoral programs, Henly reports. As a result, the bridge program at the University of Minnesota will end in July 2007. But the addition of the two new programs at the former partner schools will continue to increase Native nurses’ access to doctoral education. And with its history of providing culturally sensitive support, the American Indian/Alaska Native MS to PhD Nursing Science Bridge program leaves a legacy that serves as a successful model.

The program relied on American Indian academic consultants, who guided the faculty and served as role models for students. It also worked closely with Native elders, medicine people and spiritual guides to provide a welcoming environment. A highlight of the program was a project retreat every two years, in which faculty and students gathered with tribal elders and spiritual leaders to learn about and experience Indian culture.

“The program has been a bridge from good intentions to action in supporting Indian students in doctoral education,” Henly says.

Ever Upward: Minority Enrollment and Graduation Rates Continue to Rise

Enrollment in Nursing Doctoral Programs, 2006

Research-Focused Programs:

Ethnicity No. of students % of total
American Indian/Alaska Native 28 0.8
Asian/Native Hawaiian/Pacific Islander 172 5.1
Black/African American         357 10.6
Hispanic/Latino 113 3.4
Caucasian 2,692 80.1
Total minority:          670 19.9%

Doctor of Nursing Practice:

Ethnicity No. of students % of total
American Indian/Alaska Native         5 0.7
Asian/Native Hawaiian/Pacific Islander 17 2.2
Black/African American         56 7.3
Hispanic/Latino 21 2.8
Caucasian 664 87
Total minority:          99 13%
Graduations in Nursing Doctoral Programs, 2006
Research-Focused Programs:
Ethnicity No. of students % of total
American Indian/Alaska Native         0 0
Asian/Native Hawaiian/Pacific Islander 19 5.3
Black/African American         34 9.5
Hispanic/Latino 9 2.5
Caucasian 297 82.7
Total minority:          62 17.3%

Doctor of Nursing Practice:

Ethnicity No. of students % of total
American Indian/Alaska Native         0 0
Asian/Native Hawaiian/Pacific Islander 2 2.8
Black/African American         6 8.5
Hispanic/Latino 4 5.6
Caucasian 59 83.1
Total minority:          12 16.9%
Source: American Association of Colleges of Nursing
Commission on Diversity in Health Workforce

Commission on Diversity in Health Workforce

Louis W. Sullivan, M.D. founding dean of Morehouse School of Medicine Louis W. Sullivan, M.D. founding dean of Morehouse School of Medicine

“Role models are important!” says Louis W. Sullivan, M.D. founding dean of Morehouse School of Medicine and former U.S. Secretary of Health and Human Services. “Too many minority young people have never interacted with any minority health professionals. [This type of interaction] tells the youngster-even if silently or indirectly-that they can be successful, too.

Sullivan urges all minority health care practitioners to become role models for minority youth in their communities by providing information, guidance, and support.

“Minority health professionals can answer questions with greater credibility for these youngsters. We need minority physicians, dentists, nurses and [other health care providers] to play such a role. We need local involvement; this is one of those local activities that can mean so much. It makes it real, rather than abstract, for a youngster to have [a role model] right in the room or right in the community as opposed to on television.”

Shortage of Minority Health Professionals

Role models for future minority health care practitioners is extremely important in a time when African Americans, Hispanics and American Indians combined make up more than 25% of the U.S. population but represent less than nine percent of nurses, six percent of physicians, five percent of dentists, and similar low percentages of other health professions.

In certain regions, the disproportion is worse. For example, in Georgia, the Hispanic population has surged to four percent, but only 0.8% of the state’s nurses are Hispanic.

The American Council on Education reports that fewer than 8,000 minority men and women earned master’s degrees in health professions in 2001 (the most current year data was collected). That’s only 18% of all the health professions master’s degrees awarded that year.

And the shortage may be getting worse-fewer minority students are enrolling in health care education programs. For example, in 2002, of more than 8,000 medical students in the state of New York, there were only 265 minority first-year students. This was 5.4% fewer than in 2001; it was also a ten-year low. “Deans and university officials are saying that they have none or only one new black or Hipanic student in their classrooms for the first time in decades,” Sullivan reports.

“We know that the lack of minority health professionals is adversely affecting critical racial and ethnic health disparities,” Sullivan adds. African Americans, Hispanics, and American Indians and Alaskan Natives on average receive less prenatal care, lower vaccination rates, less cancer screening, and worse control of diabetes and hypertension. In general, non-majority Americans receive less effective health care and are more likely to report poor or fair, rather than good or excellent, health. For many, life expectancy is cut short.

Sullivan Commission Takes to The Road

Louis Sullivan is not accepting deteriorating health outcomes with resignation. Supported by Kellogg Foundation funding, he has organized the Sullivan Commission on Diversity in the Healthcare Workforce in order to create solutions. “This is a problem that can be solved,” he affirms.

Since the fall of 2003, the Commission has held field hearings in Atlanta, Denver, New York, Chicago, Los Angeles and Houston, and a town hall meeting in Boston. At each hearing and meeting, the Commission has collected data and testimony from health experts, community advocates, business leaders and local governmental officials.

In New York, U.S. Representative Charles B. Rangel stated, “Increasing diversity in medicine, dentistry and nursing is one of the key strategies to reduce the alarming health disparities facing our nation. In the last decade, we have seen hardly any increase in the number of minority health professionals despite the growing ethnic diversity of our population. The work of this Commission will provide Congress a needed roadmap on how to solve this health care problem facing our nation’s citizens, including the poor and millions of minorities.”

In Chicago, U.S. Representative Jesse L. Jackson, Jr. stated, “Racial minorities–especially blacks, Hispanics and American Indians–are over-represented when it comes to disease and illness, but underrepresented in the healing professions. Both dimensions-health and healing-must change for the better soon. Increasing diversity in the healing professions is one way to bring about that change. The Sullivan Commission is pointing the way to close these gaps in the health care professions.”

Rupert Evans, president of the American Hospital Association’s Institute for Diversity in Health Management, testified, according to Associated Press reports, that minorities seek out medical care more frequently with providers of the same race. He said that in order to solve the racial disparity issue, the country needs providers that are culturally similar to and sensitive to patients. “It’s all tied together,” Evans concluded. “You can’t have one without the other.”

Take Action Now

“Now is the time to confront the crisis in the nation’s health care system and utilize the tool of diversity in crafting solutions,” Sullivan declares. “Barriers that are blocking the aspirations of minority students to become health professionals must be removed.”

Commission on Diversity in Health Workforce

The Commission emphasizes that all children deserve quality education from kindergarten on up. “We must strengthen educational preparation so that young people don’t have to leap over a chasm to gain entry to health care careers,” Sullivan says.

The Commission calls for better coordination at each level of school-from kindergarten through junior high, high school, college and graduate programs-so each level doesn’t stand alone “like a silo in a field,” as Sullivan puts it.The transition from two-year to four-year institutions of higher education is especially critical. At the hearings in Denver and again in Houston, the Commission heard that many minority youth enter higher education through community colleges. The Commission believes colleges and universities should smooth the way for these transfer students, with coordinated curricula, guaranteed transfer of credits, and even guaranteed admission to four-year programs for successful two-year students.

Another major recommendation is improved financial aid for students in health care programs, with more scholarships and low-interest loans, rather than unsubsidized loans. The prospect of heavy student debt distorts career choices, Sullivan explains. “It’s hard to explain to a young person from a low-income family that with the professional credential they would be earning enough to pay off the loan. That kind of debt can be a barrier. And financial barriers affect majority as well as minority youngsters.

“We have to find easier ways for youngsters to finance their health professions education than we have now,” Sullivan warns. “Our current system is very threatening for a youngster coming from a low-income background.”

For college graduates seeking careers as physician assistants, pharmacists, and other professions requiring graduate education, the Commission recommends short, “brush-up” programs to improve their preparation for professional school. “Students who have the intellectual capacity but find a weakness or deficiency in some area” would thereby be better prepared for admission to, and success in, graduate programs.

The Commission’s hearings also highlighted the often-overlooked fact that many minority people are already working in other jobs when they decide to pursue their dream of a health care career. “This represents a new career shift for them,” Sullivan explains, and the Commission calls for “strategies to help identify and assist those people in the transition to a second career.”

Cultural Competence for a Diverse America

“Years ago, when we talked about minority populations we were talking primarily about the African-American population,” Sullivan relates. “But today the Hispanic population has increased significantly; it is now larger than the African-American population. We also have Vietnamese, Hmong, Cambodian, Eastern European and so many other groups. The concept of diversity now implies a lot more specific cultural backgrounds that those in the health professions have to be aware of and adapt to.

“We need to meet these people more than half way, Sullivan says. “Even if you have a highly competent, technically and scientifically trained group of health professionals with the best facilities, it doesn’t help [patients] if there is no communication. If there is a communication barrier, then all that excellence is frustrated.


“The ideal that we envision in the Commission,” Sullivan adds, “is a health professions community sufficiently multicultural in orientation and understanding so that they know how to communicate with someone from a different background. They can communicate in such a way that patients are comfortable and develop trust. Then you’ll have patient compliance, whether it’s taking medicine, coming in for a follow-up visit, or any of a whole host of things.” Ultimately, patient compliance leads to better health outcomes.

Similarly, institutions of health care education can create environments that are more “user-friendly,” Sullivan suggests, so that “minority students have an experience that is affirming, rather than hostile or indifferent.”

All health care workers should take on these changes, Sullivan believes. “The health issues of minorities are not going to be addressed solely by minorities,” he says, “nor should they be, from an idealistic point of view. We need everyone involved, because, frankly, this is a problem and a challenge for all of us.

“As we find solutions, not only will there be improvements within the minority community in terms of improved access to health care careers, improved health care and improved health status, but also there will be advances in community development, social stability, and economic development. All of these things are intertwined.”

Sullivan gives credit to neighborhood institutions like the Boys’ Club and Girls’ Club that help young people develop self-esteem and become successful. “Youngsters have to view themselves as capable of achieving something,” he points out. “The more confidence they have, the more willing and able they are to take risks” such as pursuing demanding professional careers in health care.

His own Morehouse School of Medicine invites grade school children to a “Saturday Academy” on campus, collaborates with the Explorer Scouts, and even awards a scholarship to Boys’ and Girls’ Club members.

“Advocating for the necessary changes, including greater availability of financial resources, will be essential,” Sullivan concludes. He invites everyone in the health care field to make their views known.

“Individuals who are decision makers in federal government, state governments, the business community and the philanthropic community will have to be convinced that this is a worthwhile investment. The case has to be made that our society will get important and significant returns on this investment.

“Ultimately, there has to be a broad societal understanding of this problem and a belief that by investing the time, effort, and resources, this is a problem that can be solved.”