Using Evidence-Based Practice to Improve Minority Health Outcomes

Using evidence-based practice (EBP) to give patients the best possible care is one of the hottest topics in nursing today. Yet evidence-based nursing is not a new model of care. In fact, says Linda Burnes Bolton, DrPH, RN, FAAN, vice president and chief nursing officer at Cedars-Sinai Medical Center in Los Angeles, it is simply another way of looking at the traditional theme of nurses living up to their sacred trust with society.

“The sacred trust is based on the belief that nursing professionals will always act in the best interest of the patient,” Burnes Bolton explains. “We cannot do that without knowing what would best benefit and assist the patient. Part of that trust and commitment to patients is to give the very best care for each individual. We cannot be lulled into a false sense [of security] that it is OK to do something just because ‘this is the way we have always done it.'”

These days, it’s hard to open up a nursing magazine and not see an article about evidence-based practice. But because it’s a complex concept, many nurses still don’t completely understand what EBP is all about.

One of the best explanations of what EBP is and is not comes from Bernadette Melnyk, PhD, RN, PNP/NPP, FAAN, FNAP, dean of Arizona State University (ASU) College of Nursing & Healthcare Innovation in Phoenix. Three years ago, Melnyk founded the nursing school’s Center for the Advancement of Evidence-Based Practice (CAEP), one of a handful of university-based centers across the country dedicated to this paradigm of care.

Speaking at the 2006 National Black Nurses Association annual conference, Melnyk noted that “improving health care through EBP is a problem-solving approach that integrates the best research data with the nurse’s clinical expertise and the patient’s individual needs and preferences. It is not just research utilization or translating research into practice. It’s the process of synthesizing the best evidence across multiple studies to come up with what’s best for [that particular patient in that particular situation].”

With its emphasis on developing interventions based on sound clinical evidence and proven best practices, evidence-based practice is an ideal tool for nurses to use in their efforts to eliminate racial and ethnic health disparities. Yet using EBP in the specific context of improving minority health outcomes poses unique challenges—from where to find research data that is inclusive of minority populations to understanding how culture and language may influence a patient’s preferences.

Defining EBP: A Closer Look

David Sackett, MD, a Canadian physician, is considered the father of evidence-based practice, according to Cheryl Fisher, MSN, RN, program manager for professional practice development of nursing and patient care services at the National Institutes of Health (NIH) Clinical Center. Located in Bethesda, Md., the center is the nation’s largest hospital devoted entirely to clinical research.

Fisher has adopted Sackett’s definition of EBP. “He states that evidence-based practice is ‘the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients. . .[by] integrating individual clinical expertise with the best available external clinical evidence from systematic research.’ In our hospital setting, we also take into consideration the patient’s preference since our care is patient-centered.”

Searching the literature to find the best evidence doesn’t have to be an overwhelming or time-consuming process. To target their search and quickly find the relevant research, says Melnyk, nurses should formulate a clinical question using the PICO framework:

P = Patient, Population, Problem
I = Intervention
C = Comparison
O = Outcome

“When you phrase questions in that way [with these criteria in mind], you will not spend days and days searching for the evidence to answer your question,” she says. “You will know how to put key words from PICO into a database search and rebuild your answer in a short period of time.”

Once you have come up with the key words to focus your inquiry, the next steps in the EBP process are to:

1. Search for the best research studies relating to your question;
2. Do a rapid critical appraisal of the research findings;
3. Integrate the evidence with your clinical expertise as well as the patient’s circumstances and preferences; and
4. Evaluate the outcome in the context of your own practice setting and, if necessary, make changes to current practices to give the patient better care.

A rapid critical appraisal helps clinicians establish the validity, reliability and patient applicability of a study or group of studies and find the most important nuggets of evidence to use in their practice. “And then you have to make the decision as to whether or not you are going make a practice change and integrate Step 4,” Melnyk says.

For Adelita G. Cantu, PhD, RN, a clinical instructor in the Department of Family Nursing Care at the University of Texas Health Science Center at San Antonio School of Nursing and a researcher who focuses on Hispanic health disparities, EBP means looking at what clinicians are doing on a daily basis, looking at patient care and knowing it is based on research. “You need to know there is some evidence that says this is the way you should do it and why you are doing it,” she emphasizes. “[As nurses], we need to explain to the patient why something is being done and that there is a reason it is being done a particular way. That should translate into better patient compliance.”

Sandra Millon Underwood, PhD, RN, FAAN, American Cancer Society Oncology Nursing Professor at the University of Wisconsin-Milwaukee College of Nursing, is a researcher who has devoted much of her work to cancer prevention and early detection among medically underserved minority populations. She cautions against taking too narrow a view of what EBP can accomplish. All too often, Underwood says, when clinicians think about evidence-based practice they focus solely on using the data from research to guide decisions.

“I think in many ways that is short-sighted, because most evidence-based practice models expand that vision,” she explains. “The evidence and research is critical but so are the other domains of EBP in making decisions for individuals, for communities and for population groups at risk.”

Underwood believes there are six domains that come into play when using EBP: scientific evidence, clinical experiences, the resources that are available within the academic arena or clinical environment, patient preferences, patient condition and patient characteristics.

The Importance of Inclusive Research

One of the biggest challenges nurses face in using evidence-based practice to address minority health disparities is finding enough evidence that is relevant to the needs of minority patients. There are many areas of medical research where people of color are underrepresented in clinical studies, or not included at all.

Burnes Bolton stresses the need to use research that is based on minorities to treat these populations. She points to skin cancer as an example. Skin assessments for people with dark skin will be vastly different than those done on Caucasians. “Generally, you look for changes in a [mole or spot on the body] where the skin is a different color,” Burnes Bolton explains. “With African Americans, they may not be able to see that.”

To share resources in support of evidence-based projects for reducing Native American health disparities, nursing leaders from the National Institutes of Health, the Indian Health Service and the National Alaska Native American Indian Nurses Association teamed up to create a collaborative online community

The end result can be deadly. According to the American Academy of Dermatology, failure to recognize skin cancer in people of color can lead to late diagnosis and lower long-term survival rates—only 58.8% compared to 84.8% for Caucasians. Furthermore, many people are under the misconception that melanoma is not a threat for individuals with darker skin. And studies of African Americans who are diagnosed with melanoma highlight another relatively unknown fact: In African Americans the condition most often develops on areas of the body that are not exposed to the sun.

“You can’t only use skin texture as a factor,” Burnes Bolton says. “You have to ask patients questions in a culturally appropriate manner.”

Another example, she continues, is the effects medications may have on different populations. “Many of the research studies [of medications] have been conducted [only] on white males,” Burnes Bolton points out. “It is very important when someone is prescribing a medication to know if that drug was tested on diverse populations. When reviewing the research, you must make sure you know what is the best evidence [about the drug’s effect on different populations].”
What Underwood finds disheartening is that even when a research study does include racially diverse participants, often the results are not analyzed by subgroups. “Inclusion [of minorities in a study] is not sufficient if one is not looking carefully at the outcomes of the research to determine whether or not there are similarities or differences for minorities, or nuances that need to be addressed in nursing practice,” she says.

Another factor that must be taken into account is the diversity that exists within a particular racial or ethnic group, Cantu advises. She says it’s critical for nurses to analyze the data and make sure there was a good research design in place. “Hispanics living on the U.S./Mexican border are going to be different than those living in an upscale suburban setting. You have to ask yourself: Is the population [in the study] similar to the one you treat? Where do they live? Do they have a high economic status? Do they have a low economic status? Make sure you are looking at evidence that pertains to your population.”

Where to Find Data

There are a number of ways to gather research data. Searching Internet databases is one of the fastest. Some of the best evidence-based health care databases include:

• The Cochrane Collaboration
• Cinahl Information Systems
• PubMed
• Agency for Healthcare Research and Quality (AHRQ)

There are also some databases and EBP online communities that focus specifically on minority health and health disparities, such as:

• American Public Health Association (APHA) Health Disparities Community Solutions Database
• National Minority Quality Forum
• Health Disparities Collaboratives
The Office of Minority Health Resource Center (OMHRC), the nation’s largest repository of information on minority health issues, provides free customized database searches on request. This service can be obtained by calling (800) 444-6472 or emailing the center at [email protected].

Another valuable source of data and best practices is other nurses—both researchers and clinicians. Burnes Bolton suggests tapping into the resources of professional nursing organizations, such as the American Academy of Nursing, for information. AAN initiatives such as Raise the Voice, which showcases the work of nurse “Edge Runners” who have created successful interventions and care models, may offer insights, she says.

Cantu suggests tapping into national and regional minority nursing associations. In addition, she says, many hospitals have clinical nurse specialists and nurse educators on their units. “They are a resource to go to. Schools of nursing are another place to use as an information resource. Maybe you can partner with them. Using these community resources is very appropriate and saves time for the bedside nurse.”

Sharing EBP Resources Online

Fisher has been working with the National Alaska Native American Indian Nurses Association (NANAINA), the Indian Health Service (IHS) and the NIH to create an online virtual community that helps promote the use of EBP to advance the agenda for reducing American Indian/Alaska Native health disparities. The online community links NANAINA faculty mentors with nurse clinicians at remote IHS sites and research staff from the NIH Clinical Center to collaborate and share resources in support of evidence-based projects.

According to Fisher, the virtual community grew out of a series of face-to-face meetings held in 2006-07 to establish relationships between the three collaborating organizations and to define evidence-based projects the nurses would work on. She says the Web-based community was launched last fall to provide technical support for the project’s mission and to enable the mentors and mentees to collaborate in an online environment.

“The virtual community provides a way to communicate and collaborate with the Indian Health Service nurses to promote evidence-based practice in their work settings,” Fisher explains. “The goal of the community was to provide a way for us to stay in touch following face-to-face meetings in order to continue our work.”

The online community includes such features as a discussion board, a resource center, a links section to help members quickly find Web-based information that will support their work, and opportunities for live chat or real-time meetings between two or more members.

Although the community is less than a year old, it has already accomplished a great deal, Fisher reports. “We were able to develop a list of members with contact information, share resources and develop posters for national presentation utilizing the virtual community—which would have otherwise been very difficult, since we [are all physically located in different parts] of the country. The virtual community has provided us with a means for staying connected.”

Filling Evidence Gaps

Another challenge that can arise when using EBP as a model of nursing care is: What do you do if the specific research data you need to answer your clinical question just isn’t out there—or at least not yet? Finding enough minority-inclusive research is just one part of the problem. Another obstacle, says Melnyk, is that it currently takes an average of 17 years for the findings of a study to become a valid, accepted part of the nursing literature.

“That [time lag] is a huge issue,” she emphasizes. “There are many areas in nursing where we do not yet have good evidence-based interventions to improve health outcomes. There are a lot of gaps in the evidence. That is why we need outstanding nurse researchers to generate evidence where we do not have it. Then we need outstanding clinicians to take the evidence that is generated and [apply evidence-based nursing skills] to translate it into clinical practice.”

One strategy for filling evidence gaps, Melnyk adds, is for nurses to generate practice-based evidence in their own clinical site by using outcome management. “Collect data through your chart records, do a certain practice and then look at outcomes and look at the data you have available,” she says. “The message I want to get out is that you do not have to be a rigorous researcher to be able to do outcome management and generate some evidence to guide your own practice in your [clinical] setting.”

This do-it-yourself approach to evidence generation can also be extremely helpful for busy nurses who might otherwise not have time to sit down at a computer and search for research data. “I think that many nurses, particularly bedside nurses, are so involved in patient care that they do not have the time to review on their own or attend meetings, workshops or seminars where evidence-based practice is discussed,” says Cantu.

Using EBP Effectively

Ellen Fineout-Overholt, PhD, RN, FNAP, director of the Center for the Advancement of Evidence-Based Practice at ASU College of Nursing, believes that having open communication with patients and colleagues plays a key role in providing evidence-based care.

“If I am taking care of a patient of color and do not know anything about that [person’s] culture, it is incumbent upon me to find out, to ask some questions,” she says. “Then it is incumbent on the patient to tell me, to talk to me. We need to have a dialogue so we can come to understand and know one another better to get the best outcome. Nurses need to [look at patients’ cultural beliefs and values] to see what they want and what they may need [in terms of care].”

That isn’t to say every outcome will be positive. Sometimes patients may not be willing to make a change in their behavior, especially if it goes against their belief system. “Then you need to tell them, ‘This is what the evidence says might happen. If you still want to go ahead [with that behavior], be informed of what your outcome may be,” Fineout-Overholt explains.

To use EBP effectively, she continues, nurses must always keep two things in mind: Why are we doing this and what outcome are we trying to achieve? “[Whatever you’re doing, whether it’s] inserting a Foley catheter into a bladder or holding a dying patient’s hand during a procedure, if you can keep those [two questions] as your focus it will really help you to understand what aspects [of the evidence] to put into practice. With hand-holding, culture . What does it mean to comfort someone in certain situations? With putting in a catheter, what you are trying to accomplish depends on what kind of circumstances there are. Keeping patient care front and center is imperative.”

Nurses should question the research data if it does not seem to fit in with their own clinical experiences, Cantu says. “We teach critical thinking [at our university]. In your experience, if you have seen something different, you cannot discount that. Then you may need to ask, ‘How do I get [these two pieces] to fit together?'”

Melnyk stresses that nurses need to work in a culture that supports EBP. “[Buy-in from] upper management is critical. Nurse managers and nurse executives need to understand EBP, practice it and create a culture that [encourages their nursing staff] to implement it. Part of that culture is having a cadre of It is critically important for nurses of color to be in the forefront of the evidence-based practice movement, Fisher emphasizes. “Minority nurses can help pave the way through modeling and dissemination of their EBP projects, which was the goal of our work with NANAINA and the Indian Health Service. It is exciting to see the nurses get involved with EBP and use their creativity to improve patient care. Once EBP becomes [more widely accepted] as a new way of practicing and providing care on a daily basis, both nurses and patients will benefit.”

Want to Learn More About EBP?

Join the (Journal) Club!

Two years ago, Pattie Soltero, BSN, RN, MAOM, operations manager for 6 North, a pediatric rehab and med-surg unit at Childrens Hospital Los Angeles, was looking for a way to help introduce the unit’s nursing staff to evidence-based practice (EBP). So she started a journal club. Journal clubs—also known as research clubs—are so called because they involve reading and discussing research studies published in clinical journals.

Soltero was introduced to the concept of EBP when she went to a professional conference. There was a group of critical care nurses from a hospital here in L.A. who wanted to develop [a procedure for] providing their intubated patients with the best oral care possible,” she says. “So they went and researched the best mouthwash, the best toothbrush or utensil, and all the things related to providing the best oral care for intubated patients. Then they went to their manager and said, ‘These are the items we need.’ It turned out that the hospital already had a contract with a supplier that had every single item they needed. Based on that, they were able to develop a package for every single intubated patient in the ICU based on the evidence and their practice. Now [this hospital system] uses it in all of their facilities.”

The nursing staff on 6 North have varying levels of education, which is another reason Soltero started the journal club. “We have nurses with advanced degrees who are nurse practitioners and we have other nurses who have two-year associate’s degrees,” she explains. “Nurses with a two-year degree have had [little or no exposure to nursing research]. So we have taught them how to read a research article. We have taught them that nursing research is not something to be afraid of: It is done by nurses, it is not in a foreign language and it is applicable to our practice.”

When the club first started, Soltero picked a research article once a month, posted it for everyone to read and then scheduled a meeting to discuss the study. “Little by little, after about six or seven months, some nurses started to really enjoy the journal club, so the staff [eventually took it over themselves],” she says. “Now it is just positive peer pressure [that motivates them to participate], so they meet on the weekend to do the journal club. I am not involved in it.”

While approximately 75% of the children the hospital treats are Hispanic, the facility also serves a variety of other ethnic communities. “We have an Armenian community close by and a Chinese community close by. And the rest of [our patient population] is a very diverse mix,” Soltero says.
She feels the journal club has been an excellent vehicle for implementing evidence-based practice to better meet the nursing needs of children of color. “For example, we looked at the spiritual care of our kids and how we are meeting those needs [given] the diversity of our population. People think because you are Hispanic you are Catholic, but that is not always true,” she notes. “We found a research article that focused on the spiritual care that was delivered to pediatric patients. Based on that, we were able to talk about how important that aspect is to their care.”


Careers in Rural Minority Health

Besides performing his regular duties as a public health nurse at Creek Nation Community Hospital in the town of Okemah, Okla., Jim Schmidlkofer, BSN, RN, might on any given day start an IV in the surgery and recovery unit, assist in the radiology lab or help treat patients in the emergency room. The hospital is part of a health care system that provides services to American Indians living within the boundaries of the Muscogee (Creek) Nation.

“All of the hospital’s different departments work together,” he says. “We’re like one big family. So many patients and people I work with [are people] I see in the community. We’ve become more like friends.”

This small-town camaraderie is just one of the rewards of working in rural health. The pace may be slower than in a big city, but the variety of the workday and the opportunities to make a significant difference in patients’ lives can’t be beat.

“When I worked in the city, there was a lot of focus on the technical aspects of health care,” Schmidlkofer says. “Here you have time to hold a patient’s hand.”

More minority nurses like Schmidlkofer, who is affiliated with the Potawatomi Nation, are urgently needed in rural areas, where they can play important roles in narrowing health care disparities and improving health outcomes in some of the nation’s most severely medically underserved communities of color.

Troubling Disparities

Health disparities in rural America are so pervasive and troubling that it’s hard to know where to begin talking about them.

“Compared to the general population, rural residents are poorer and older, and these two factors make up the greatest predictors for health status,” says Brock Slabach, senior vice president of the National Rural Health Association in Kansas City, Mo., and a former rural hospital administrator in Mississippi.

People living in rural areas are less likely to have employer-sponsored health insurance or prescription drug coverage, and the rural poor are less likely to be covered by Medicaid benefits. Rural residents are also more likely to lack access to health care providers than urban residents. Many rural areas suffer from a shortage of primary care physicians, specialists, mental health services and nurses. It’s not surprising, therefore, that rural dwellers have higher rates of chronic diseases and poorer overall health than people in big cities.

Diabetes and hypertension, for instance, are rampant in east and central Oklahoma, where the Muscogee Nation Health System operates. Educating patients about disease prevention is a continual challenge for the system’s nurses.

“A lot of people have the [fatalistic] mindset that they’re just going to have diabetes,” says Sheryl Sharber, RN, director of nursing at the Creek Nation Community Hospital. “They figure, ‘Mom had diabetes, Grandma had diabetes–that’s just the way it is.’”

Disparities in health and socioeconomic status between rural and urban residents are especially pronounced among minorities. Although the term “rural poor” tends to invoke images of white Americans living in areas like Appalachia, the reality is that African Americans, Hispanics and Native Americans in rural areas are more likely to be poor than rural whites, according to Minorities in Rural America: An Overview of Population Characteristics, a 2002 report by the South Carolina Rural Health Research Center. And a greater percentage of rural minorities than rural whites live in federally designated Health Professional Shortage Areas.

Geographic isolation and lack of transportation are major barriers to health care for low-income rural residents, says Gloria N. Santos, RN, MS, vice president of patient care services at the 101-bed Feather River Hospital in Paradise, Calif., a small community in the Sierra Nevada foothills 85 miles north of Sacramento. Public transportation is sparse, and there are no sidewalks along main roads. Once a ride becomes available, patients show up at the hospital’s emergency room for treatment.

“Lack of transportation is sometimes the reason our emergency department patients give for not going to their regular doctors’ appointments,” Santos says.
To help improve access to care, the hospital plans to open a new outpatient clinic in Paradise which will be located right across the street from a bus stop.

Rural Cultural Competence

Although careers in rural health care might seem less “glamorous” than working in a large metropolitan area, this field offers tremendous opportunities for minority nurses to make a difference in communities where they are needed most. Demand is especially strong for nurse practitioners, health educators, emergency nurses and nurse managers.

The shortage of minority nurses is more acute in many rural settings because nurses of color are heavily recruited in urban areas, where pay and advancement opportunities are greater. Yet a racially and culturally diverse nursing workforce is just as important in rural areas as it is in urban locations. “It’s vital that the health care professionals mirror the community,” Slabach says.

Minority nurses working in rural health can serve as role models and play a major part in increasing cultural awareness and delivering culturally sensitive care.

“[When you come from the same culture as your patients], you have a better understanding of what they go through and how they were raised,” says Arlene Isham, RN, who works in the family clinic of the Creek Nation’s Okmulgee Indian Health Center in Okmulgee, Oklahoma. “[Because I myself am a member of the Creek tribe], it makes a difference with patients. They’re more at ease. If a patient tells me he was playing stickball and fell and hurt his leg, I know what he’s talking about.”

Isham recalls one day when a patient brought her husband to the clinic because he was delirious. His blood sugar level turned out to be low as a reaction to taking medication on an empty stomach. The man had been on a one-day ceremonial fast, and Isham educated the patient about how to handle his medication when fasting. As a tribal member who also participates in ceremonial fasts, she knew the importance of the ritual from personal experience, which provided a deep understanding of the patient’s need for culturally appropriate care.

“I enjoy working with my own people and trying to raise awareness of their health issues,” she says. “I could go to Tulsa and make more money, but I really like working with my tribe.”

Isham also continues to deepen her knowledge of her cultural heritage. She is learning more of the Creek language, which she did not learn when growing up but is still exclusively spoken by some of the tribe’s elders.

Schmidlkofer says his affiliation with the Potawatomi Nation does not necessarily put him ahead of the learning curve when working with his Creek patients. “Each tribe is unique and a nation unto itself,” he explains. “The most important thing to learn is to be very patient and very respectful when giving information or receiving it.”

Rural Health Research

Rural patients tend to trust health care providers who look like them or whom they’ve known for a long time, says Randy Jones, PhD, MSN, APRN, an assistant professor of nursing at the University of Virginia in Charlottesville. Jones’ research focus is on health disparities in rural minority and vulnerable populations, and he is particularly interested in addressing prostate cancer disparities in African American men, who are 1.5 to two times more likely to develop the disease than white men.

Jones was principal investigator in a study by the university’s Rural Health Care Research Center that found that female family members–wives, sisters or daughters–influenced whether black men decided to get screened for prostate cancer. Trust of the health care system also played an important role. Study participants said they trusted doctors and nurse practitioners with whom they had long relationships.

Jones, who has also published research about diabetes among rural African Americans, says health care facilities need to create a welcoming, non-judgmental environment and educate people every time they come through the door about any health issues for which they are at risk.

Establishing trust is also critical for recruiting rural people of color to participate in health care research. Jones points out that many older African Americans remember the infamous Tuskegee syphilis experiment, in which the U.S. Public Health Service conducted research on 399 black men with syphilis from 1932 to 1972. The men were mostly sharecroppers with limited education and were told they were being treated for “bad blood.” In reality, they were given no treatment at all. The scientists planned to study data from the autopsies of the men and essentially left them to deteriorate from the disease. When the media exposed the story in 1972, the experiment finally ended and the men received treatment. By then, 128 of them had died of syphilis or related complications.

Jones, who is African American, says he thinks in some cases his race has helped him establish the trust needed to recruit African American participants into research studies. But most important was his openness and the time he took to explain the intentions of the research. He immersed himself in the community and became acquainted with “gatekeepers,” such as pastors, owners of barbershops and other small businesses, and members of city boards, town councils and the local NAACP.

Filling the Need for Nurses

Increasingly, rural communities are beginning to address the nursing shortage by growing their own RN workforce. Santos, for example, recruits recent nursing graduates from a nearby community college and from a BSN program at nearby California State University, Chico.

Recruiting seasoned nurses is more challenging, she says. Therefore, her hospital is looking at sending newly hired RN graduates to a hospital in Sacramento for a week or two to immerse them in a large-scale critical care setting. This would enable them to see a wider variety of patients and strengthen their skills and confidence in less time than it would take at the rural 12-bed critical care unit.

Santos also participates in a program at CSU Chico that matches minority nursing students with mentors to improve retention. She meets regularly with a Hispanic nursing student to offer encouragement, and she and her mentee have become friends.

Nurses who have found rewarding careers in rural health care say this field offers many advantages, from both professional and personal perspectives. “I think every nurse should work in a rural hospital in the early part of their career, because you have to do a little bit of everything,” says Sharber. “You get a broad exposure.” Although the Creek Nation Community Hospital doesn’t have specialty departments, such as obstetrics or pediatrics, it sees patients of all ages and all disease processes, she adds.

In a rural hospital, emergency nurses are often the first line in caring for patients. “Many times the physicians may not be in house or may be a few miles away,” Slabach says. He also notes that a rural hospital is a more personalized work environment. Nurses and administrators know each other well, and this can lead to greater understanding and flexibility.

Santos grew up in New York and worked in various Adventist Health System hospitals in large cities before moving to her current job at the system’s hospital in Paradise. Her position as vice president of patient care services is equivalent to a chief nursing officer at a larger hospital. But she also oversees other departments besides nursing, including respiratory and cardiology services.

“You’re never at a loss for learning,” she declares. “I just enjoy my work here. I like patient care and I enjoy being able to remove barriers to quality health care.”

Nursing School Diversity Directors: What Do They Do and What Difference Are They Making?

Diversity directors appear to be a small but dedicated niche among nursing schools that are making an effort to better include and serve people of varying racial, ethnic and cultural backgrounds. While campus-wide diversity and multicultural affairs offices are fairly common at major U.S. universities, it’s rarer for nursing schools—or other individual colleges and professional schools, for that matter—to have a diversity department of their own.

“There have been pockets, but it hasn’t been done consistently, and there hasn’t been a big vision ,” says Mary Lou de Leon Siantz, PhD, RN, FAAN, assistant dean for diversity and cultural affairs at the University of Pennsylvania School of Nursing in Philadelphia.

There’s at least one reason, however, why the idea of establishing an office dedicated to enhancing the recruitment, retention and teaching of a diverse population may soon catch on at more nursing schools. “Now more than ever, because of the changing demographics of the United States, [a greater focus on multiculturalism in nursing education and practice] is very badly needed,” notes Siantz, who is a past president of the National Association of Hispanic Nurses.

By having their own formalized diversity departments and appointing diversity directors, nursing schools are in a position not only to create a more inclusive profession but also to prepare future nurses to meet the health care needs of an increasingly multicultural patient population. But what exactly do diversity directors do? And is this an emerging career opportunity that more minority nurses should consider pursuing?

The Mission and the Vision

One of the first tasks that Lillian Stokes, PhD, RN, FAAN, took on when she took the helm of the Office of Diversity and Enrichment at Indiana University School of Nursing in Indianapolis was to help fashion a diversity mission statement. Today, she sees that message displayed on a bronze plaque each time she walks through the front entrance of the school.

“Our overall vision is to try to promote an environment that values respect and reflects a global view of diversity,” says Stokes, who is also an associate professor at Indiana and the national president of Chi Eta Phi, a sorority for minority nurses.


Clarifying the vision of a diversity department usually starts with determining what diversity means. “We define diversity here as ‘holding multiple perspectives without judgment,’” says G. Rumay Alexander, EdD, RN, director of the Office of Multicultural Affairs and associate clinical professor at the University of North Carolina-Chapel Hill School of Nursing.

Nursing school diversity directors say they want to expand the definition of diversity beyond the familiar parameters of race, ethnicity and gender. “One of the things I always talk to our first-year students about is the need to think about diversity in broader terms, not just [in terms of] ethnicity,” says Jana Lauderdale, PhD, RN, assistant dean for cultural diversity at Vanderbilt University School of Nursing in Nashville. “That’s something I kind of preach all the way through the program.”

The term can apply to any subculture or underrepresented group, she explains–for example, homeless persons, people with disabilities or people with chronic illnesses.
In Alexander’s view, achieving diversity means more than simply admitting more students from diverse backgrounds. These students need to find a supportive environment that will help them succeed.

“If you’re inviting people into an environment that for whatever reasons does not feel welcoming to them, or treats some [members] of its community in an inequitable way, then you may be bringing in many people through the door, and your numbers may be going up in terms of admissions,” she says. “But if these students are not successful in matriculating through the program and graduating, then it’s kind of like coming in the front door of a house and going out the back door.”

At Penn, Siantz says a key element of the school’s vision is that the commitment to diversity must be top-down. “That means that at the top there is recognition of the need to diversify the administration and the faculty, as well as the student body, to better promote the mission of the school,” she explains. “Diversity is the number one strategic goal of the School of Nursing. Globalization is the second.”

The Scope of the Job

A common thread in the job descriptions of nursing school diversity directors is a major focus on assisting students. Some are also involved in faculty programs and curriculum development.

At Indiana University School of Nursing, Stokes’ Office of Diversity and Enrichment is part of the Center for Academic Affairs. The enrichment part of her job title is broad in scope.

“This position calls for working with all students, not just minority students or underrepresented students,” she says. “Although the faculty and my office are committed to supporting underrepresented students as much as possible, I probably see just as many or more majority students.”

Diversity-related programs at Indiana’s nursing school include “empowerment sessions” to aid students with test taking, stress management, time management, organization and other skills; peer-led tutorial reviews of specific classroom subjects; a Diversity Forum series featuring presentations by faculty members and local and national leaders; and workshops for faculty on teaching students from diverse cultures.
Recruitment of minority and international students is another aspect of Stokes’ job, although she says it’s not her primary role. “We have a marketing and recruitment person [who is in charge of that],” she explains. “I work very closely with that office, and also with our graduate offices.”

Stokes and some of the senior nurse researchers on the faculty have established a program called Connections that targets students who might be good candidates for the PhD program in nursing. “We meet with students—it may be one student or ten—who express an interest or who I see have potential,” she says. “We take them through the admissions process [and] get them to start thinking about their research area, so we can think about a faculty member who might work with them.”

Two students–one African American and one Nigerian–who participated in Connections have since begun their doctoral studies in the School of Nursing. “They are doing very well,” Stokes reports.

She is also a founding member of the nursing school’s Minority Advisory Council, now called the Diversity and Enrichment Council. The group includes faculty, students, staff and community partners, such as practicing nurses, politicians and leaders of local organizations.

Lauderdale, who is president-elect of the Transcultural Nursing Society, says the range of her job at Vanderbilt “seems to be a moving target. Almost every day, there seems to be another layer added to it, which tells you something about the scope of the need for a position of this type.”

Lauderdale’s initial focus was on ensuring a “cultural diversity content thread” throughout the curriculum, “so that by the time students graduate, they feel comfortable working with patients from different cultures and are able to provide culturally competent care.”

Today, in its expanded role, the cultural diversity office at the School of Nursing offers an Academic Enrichment Program in which a group of students meet about once a month for brown bag lunch discussions on a wide range of topics–from critical thinking skills and time management to working with culturally diverse patients. Lauderdale also coordinates a Pre-Nursing Society for freshmen and sophomores who are considering nursing as a career.

For faculty, the nursing school’s summer institute on teaching strategies includes discussions of how to celebrate cultural diversity in the classroom. In addition, Lauderdale works closely with the faculty member who directs the cultural diversity program in the School of Medicine.

Diversity Is a Full-Time Job

When Alexander came aboard at UNC, she turned what had previously been a part-time role into a full-time focus. “Prior to my [being hired], the issues relating to diversity and inclusion were part of an assignment [given to] someone else on the faculty,” she explains. For her predecessors, this function took up a relatively small percentage of their responsibilities.

“I came into the interview with a clear understanding, because of [my] past work experience in diversity, that if it wasn’t getting the full attention of someone and it was kind of the job of ‘everybody,’ it was not going to get the traction that it needed to get,” Alexander says.

Specific diversity enhancement strategies at her school include a continuing education requirement for faculty and staff that is linked to their performance evaluations and compensation; the Kindred Spirits Award for Excellence in Multicultural Scholarship, given each year at commencement to a student who exemplifies respect for diversity; and an Ethnic Minority Visiting Scholars Program.

All of these elements, Alexander says, make her days on the job “unpredictable and lots of fun.”

At Penn, Siantz works closely with the nursing school’s Master’s Curriculum Committee and Diversity Committee. She also partners with other groups within the school and throughout the campus that are interested in promoting diversity.

For example, Siantz has partnered with the university’s medical school to develop a Leadership Education and Policy Development program to promote leadership skills among nurses and physicians of color. Supported by the university vice provost’s Office for Diversity, this program also teaches them how to use their research and clinical practice to help shape public health policies to eliminate disparities.

Another key strategy for Siantz has been to become a faculty member of minority nursing student organizations on campus, holding leadership retreats with the groups’ outgoing and incoming boards.

Challenges and Rewards

All of the nursing school diversity directors interviewed for this article admit that the work they do has its share of challenges. Yet they also find it extremely rewarding, especially when they see that their efforts to promote diversity and inclusiveness are producing measurable results and making a real difference at their institutions.

Siantz says one of the biggest challenges in diversifying the nursing profession is that nursing schools need to extend their outreach beyond the college campus.

“We need to partner with the [elementary and secondary] school systems, because despite the fact that the numbers [of people of color] are growing, they’re not going to college,” she emphasizes. “That’s something that the schools in individual communities need to wrestle with in terms of how they’re going to change that picture over time.”

Stokes sums up the main barrier multicultural students face in advancing their nursing studies with one word: “Money.” For example, she says, “I’ve been in communication [recently] with a young lady who graduated from another university here in [Indianapolis]. She has attended several of [our] Connections programs, but right now it’s [the lack of] money that’s keeping her away [from pursuing doctoral studies here].”

On the plus side, the school has been successful in obtaining a National Institutes of Health grant that provides some scholarships and stipends for qualified nursing students. About 36 nursing students at Indiana have participated in the university-wide Summer Research Opportunities Program, and several have gone on to pursue graduate studies. “I think we have had more students in the program than any other unit [of the university],” Stokes comments.

Another success story for Stokes has been seeing the nursing school’s learning environment change for the better when it comes to faculty interaction with students from diverse backgrounds. “They just have a better understanding of students who are different from them,” she says.

At UNC, one of Alexander’s proudest accomplishments has been to have the School of Nursing become a national role model for promoting and achieving diversity.
“We are called on frequently to consult with other schools about how to walk the talk of inclusion,” she says.

Is This a Career for You?

Because nursing school diversity directors represent a newly emerging specialty, there is little data available about their current employment statistics, salary levels or the career outlook for the field. However, the U.S. Bureau of Labor Statistics reports that the mean annual wage for all education administrators in colleges, universities and professional schools was $86,480 in 2006.

What kind of background and experience would be prerequisites for this career? The BLS notes that top student affairs positions usually require an EdD or PhD, along with good interpersonal, leadership and decision-making skills.

The directors interviewed for this article all have credentials that fit that profile. Alexander has an MSN from Vanderbilt University, training as a family nurse practitioner and an EdD in educational administration and supervision from Tennessee State University. She also has work experience in both hospital and corporate settings. Just prior to arriving at UNC, she was the head of her own diversity consulting business in Nashville.

Lauderdale has an MSN with a major in maternal-child health from Texas Women’s University and a PhD in transcultural nursing from the University of Utah.

Stokes has an MSN from Indiana University School of Nursing and a PhD in instructional psychology with a minor in gerontology from Indiana University-Bloomington. She says her instructional psychology background, with its focus on teaching behaviors, is an asset in her current job.

Siantz has a master’s in child psychiatric nursing and community mental health from UCLA and a PhD in human development from the University of Maryland. Before accepting her position at the University of Pennsylvania, she was an associate dean and director of the Center for Excellence in Hispanic Health at Georgetown University.

Siantz believes the successful nursing school diversity director will be someone who is a visionary leader with excellent communication skills and strong relationship-building skills. “The person who is recruited to this position must be a senior-level person who not only walks the talk but also understands, and has a vision for, how to pull it forward,” she says.