The crisis of unequal health outcomes between Americans of color and the Caucasian majority has risen to the forefront of today’s national health care agenda. Sweeping federal initiatives like former President Bill Clinton’s Initiative to Eliminate Racial and Ethnic Disparities in Health have spawned literally hundreds of intervention programs and research studies that focus aggressively on “closing the gap.” But, some minority nurse educators wonder, just how much of this activity is trickling down to nursing school classrooms, where tomorrow’s health care providers are being trained?

Sandra Millon Underwood, RN, PhD, FAANSandra Millon Underwood, RN, PhD, FAAN

Sandra Millon Underwood, RN, PhD, FAAN, is trying to address this issue by holding workshops that train nurse educators to teach their students about the importance of eliminating minority health disparities. These workshops focus on disparities in cancer prevention and early detection and are funded by the National Cancer Institute.

Underwood, the American Cancer Society Harley Davidson Oncology Nursing Professor at the University of Wisconsin-Milwaukee School of Nursing, has some doubts about how seriously the issue of health disparities is being taken. “It’s certainly a buzzword of the 21st century, but I don’t see us as educators addressing it,” she argues. “I would like to believe the situation is improving, but I don’t think it is.

“Engaging nursing students in this issue is the most powerful way we can effect a change in the future,” Underwood continues. “We’re teaching the next generation so they can engage in practices that may reduce health disparities. If we would truly commit to doing what we can about this, we would see a change.”

While you might expect the problem of racial and ethnic health disparities to be news to many white students, you may be surprised to find out how little minority nursing students may know about the issue. “I don’t even think many of my students think about it until it is brought to their attention,” says Edith Ramsay-Johnson, RN, EdD, professor of nursing at the University of the U.S. Virgin Islands in St. Thomas, a historically black university.

As director of the Collaborative Minority Institutions in Alcohol Research Development project at historically black North Carolina Central University, the students taught by E. Joyce Roland, RN, PhD, are 85% African American. Yet she says she’s still met with surprised looks when she shares data showing higher mortality rates for black Americans compared to the white population.

“Students hear about this on the news and they know what’s happening in their own family, but when the statistics are put in front of them and they’re staring at health disparity face-to-face, it can be shocking for them,” Roland explains. “Many of them were drawn into nursing because of health problems their family members have, but they often have no idea how widespread these problems are.”

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Give Them the Facts

“The biggest mistake [nursing professors] make in teaching health disparity issues is not sharing scientific data with students,” Underwood believes. She recommends sharing national, state or regional, and local data. By doing so in her classes, she shows students that the gap of unequal health outcomes is not someone else’s problem. Students are able to see the impact the uneven playing field has in their own communities.

Edith Ramsay-Johnson, RN, EdDEdith Ramsay-Johnson, RN, EdD

“I try to share the information in such a way that students can see what the challenges are within their own area of influence,” Underwood adds. “I often ask them if they can identify persons from their community who are representative of the data. I ask them to comment on factors that may have influenced [these persons’] states of health. Then I ask them to identify reasons they believe the disparities exist and what nurses can do to effect a change.”

This type of data and discussion can be worked seamlessly into lesson plans. Simply share the appropriate health disparity statistics as you go through planned coursework.

“In my courses, I try to be more explicit with health disparity information,” says Ramsay-Johnson. She adds that she brought back a great deal of information from Underwood’s workshops that is now incorporated into her lectures.

Ramsay-Johnson merges minority health statistics into her third-year medical/surgical nursing courses so that students end the year with an in-depth awareness of the race-based gaps that need to be closed. The course is broken down into two semesters: Fall concentrates on treating young patients while spring focuses on middle-aged and older patients. Discussion about health disparity issues falls into those categories, as well.

“I use the statistics relevant to [the types of patients being studied],” Ramsay-Johnson explains. “We might discuss HIV/AIDS and its growing effect on young black women during the first half of the course. High death rates from heart disease and cancer are studied in the second semester.”

While you should share data liberally, don’t assume that students are able to fully digest it alone. Underwood says she does occasionally come across students who are unable to interpret statistics, even at the upper-class levels. When introducing your first set of statistics, offer a primer on statistical interpretation and consider making yourself or other resources available for students having problems with data.

Fill Your Information Arsenal

Of course, to teach data, you must first have it. Chances are, you’ll need to look outside the standard nursing textbooks to find the most current and relevant research on minority health disparities.

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Teaching Nursing Students About Minority Health Disparities

“It does show up in most curricula, but we need to have more,” says Roland. “We [nursing educators] do have to become more aware of the issue in order to teach it.” In her classes, she combines the latest data from nursing journals with the information available in texts.

The Department of Health and Human Services’ Healthy People 2010 reports (available online at are considered a primer on health disparity issues. Another recommended resource is Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, a landmark 2002 study by the Institute of Medicine (IOM), one of the four National Academies. This exhaustive, 600-page report can be purchased from the National Academies Press at (800) 624-6242 or


Underwood calls the IOM study a resource that every nursing instructor should have. “It’s an analysis of a large body of research that looks at health across a spectrum and summarizes the research,” she says. “It shows clearly that even when education and income are the same, the care that is provided to minority patients is not the same.”

Educators will also be able to find more information in Eliminating Health Disparities Among Racial and Ethnic Minorities in the United States, a monograph from the Annual Review of Nursing Research that will be published in June. This work is edited by two distinguished minority nursing leaders, Antonia M. Villarruel, RN, PhD, FAAN, and Cornelia P. Porter, RN, PhD, FAAN. It can be advance ordered from the publisher at (877) 687-7476 or

“The monograph is a compilation of reports prepared by minority nurse researchers which examine the state of the nursing science related to the prevention of health disparities,” Underwood declares. “It should be considered a ‘must read’ for students, clinicians, educators and researchers alike.”

Web sites are also a vital resource for information and links to the latest research on minority health. Just a few examples of recommended sites include:

• Institute of Medicine,

• Centers for Disease Control and Prevention (CDC) Office of Minority Health,

• Office of Minority Health Resource Center,

• National Center on Minority Health and Health Disparities,

• National Institutes of Health,

Go Beyond the Numbers

While statistical data show the science behind minority health disparities, students must also know the reasons for unequal health outcomes and how to work within the health care framework to end them.

“We expect our students to be able to function in a variety of settings, not just hospitals,” says Ramsay-Johnson. “We want them to come out [of the nursing program] ready to develop into leaders. We expect them to be engaged in prevention and teaching as well as treatment. They need to develop those skills now.”

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The first step in doing so is to make sure your students understand the possible causes of health disparities. Talk about socioeconomic issues, health and lifestyle choices, lack of access to health care services, lack of insurance and financial resources, etc. Discuss any local contributing factors, like the environment or industrial settings, as well. Then, show them how and when they can change things.

Roland trains students to keep populations victimized by health disparities in mind and to constantly look for those “teachable moments” with future patients when a disparity might be equalized. For instance, her students know that HIV/AIDS cases are rising in the African-American community, but she also wants students to be able to recognize the precursors where a nurse may intervene.

“When we see an increase in sexually transmitted diseases, that’s a teachable moment,” she says. “We know that people who have STDs are at higher risk for other diseases, so that’s when we need to talk about preventing HIV infection. I tell my students not to just focus on one thing but to see how one thing may lead to another if there is no intervention.”

Many professors are also mixing some lessons in social work with their traditional nursing curriculum. “Students need to know how to develop a network of health care providers,” Roland points out. “They need to know where [minority patients] can get into the health care system. It’s so important that nurses be able to inform people as to what a particular community has to offer.”

To accomplish that goal, teach students where and how to find resources available in a community. “If you’re sick and you don’t go to a health care provider, you’re going to get worse,” says Roland. “If you have no insurance or money, you’re going to put off that visit. You may not know that there’s a community health center with a sliding scale or other resources available to help you.”

Underwood uses case studies to prepare her students to track down resources. “In one of my exercises, students are given a client with social and economic constraints. I ask them, ‘where can this person go for care?’”

She also uses the opportunity to share information about national organizations that can point students toward additional resources. “Students can go to the National Cancer Institute Web site,” Underwood explains, “and identify what are considered to be the most appropriate options for treating cancer at a specific stage. Then they can identify where appropriate treatment is available locally or regionally. I also have students identify places for clinical trials. They get actively involved in the process and look for ways and methods of treatment that can reduce the disparity.”

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Make It Real

Out-of-classroom learning activities are another way to give nursing students hands-on experience in addressing the health care quality divide. Look for opportunities to expose your classes to specific minority health disparities and affected communities through both student projects and clinicals.

Ramsay-Johnson works to make sure all of her students are exposed to different populations, even in the seemingly homogenous Virgin Islands. “Look for ways to enrich the experience of your students,” she advises. “Find a variety of experiences to help them see what other groups go through.” For example, she has used films and other class projects as one way to bring a different perspective to her students.

“I have them do a couple of activities that require them to interact with older people,” Ramsay-Johnson continues. “I want them to have that experience, to know someone living with multiple chronic illnesses. Each student selects someone at least 65 years old and shares his or her life history. A group of students may go to the senior citizen center and do a program on medication. This is a chance to actually see what they’re reading about in the textbook. It becomes real.”

Make sure your majority students are included in these activities–and that doesn’t just mean including white students. In actuality, it can mean much more. It may mean male students learn about the problems faced by a poor, single mom. It may mean students from affluent backgrounds spend a day at a homeless shelter learning how difficult it is to find health care without insurance or cash.

Sometimes, unfortunately, you may find majority students who don’t react with enthusiasm or who even doubt the science or causes of health disparities. Such resistance may not always be obvious, but it must be addressed.

“Most majority students do understand minority health disparities. Some become excited. Some become angry,” says Jean Goeppinger, RN, PhD. With Roland, Goeppinger serves as co-director of the Research Enrichment and Apprenticeship Program (REAP) at the Center for Innovation in Health Disparities Research, a partnership between the nursing departments at Winston-Salem State University, North Carolina Central University and the University of North Carolina at Chapel Hill. This project seeks to increase the capacity for culturally competent nursing research and is funded by the National Institute of Nursing Research and the National Center for Minority Health and Health Disparities.

For those students who seem indifferent to the problem, Goeppinger recommends guided experiences. The need for guidance often becomes apparent during small group discussions. When that happens, other students may become the best educators.

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Goeppinger recalls a class a few years ago where several students expressed the opinion that minority health disparities would disappear if the affected populations simply took better care of their health. She brought in scientific information showing otherwise and encouraged other students to share their thoughts on the issue. “Faculty members were then able to support students who challenged those [opinions],” she remembers.

When presenting data on health disparities, Underwood recommends seeking input from the affected populations. “[It’s important] to engage people who represent the populations,” she emphasizes. “When you do that, students not only get the data, but they also get real-life stories. Students don’t just need to observe. They need to be actively engaged. That’s when they gain a better understanding of the issue.”

Underwood accomplishes this by engaging representatives of groups that bear an undue burden of disparities to share input where appropriate. She also works to enhance cultural competency by bringing in racially and ethnically diverse speakers from minority and faith communities to share their insights.

Find Your Protégés

Of course, one way to add to the body of knowledge on minority health issues is to increase the number of minority nurses involved in research. Educators should always be on the lookout for curious, bright nursing students who could become research stars. When those students show up, it’s vitally important to take the time to offer information, encouragement and mentoring.


For Roland, one of the most effective ways of accomplishing this is to provide information about careers in nursing research and explain why it is so important for more nurses of color to become involved. She shares tangible information on how research works, including the funding process. She also encourages students to compete for research opportunities and, if graduate school is not in a student’s plans, to consider jobs related to research that might not require an advanced degree.

“A lot of students are coming into nursing looking for a career and aren’t thinking much beyond their BSN,” she says. “Let them know that if they are really interested [in closing the health disparities gap], they can go into research and make a difference.”

Note: For information on Dr. Sandra Underwood’s cancer prevention and early detection workshops for nursing educators, contact her at [email protected].


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