Increasing diversity in the nursing workforce: a social determinants of learning framework

Creating a more diverse and inclusive nursing pipeline is a public health priority, and one that requires leadership from schools of nursing. Increasingly, research findings indicate that when healthcare workers are more representative of their patient demographics, communication, access to care and patient satisfaction improves. However, just 1 in 5 nurses come from a racial or ethnic minority group, even as the Census Bureau projects that by 2045 more than half the country will shift in that direction.

This is an industry-wide concern, and one being voiced by the nation’s largest nursing organizations, as outlined in the National Academy of Medicine’s Future of Nursing 2020-30 report, as well as healthcare systems. With so much at stake, schools of nursing must do more to positively impact both public health and education—starting with the pipeline of more than 360,000 baccalaureate nursing students. According to the annual survey of the American Association of Colleges of Nursing, the 793 participating schools reported an average of just 36% of students from diverse backgrounds.

To increase diversity of the student pipeline, schools of nursing must incorporate evidence-based approaches that address each student’s distinct set of circumstances. Through our research into admissions and student supports at schools of nursing, we were inspired to create an actionable framework to encourage greater diversity at the schools: social determinants of learning. We are actively sharing this framework with healthcare and nursing focused organizations that recognize the need to make systemic changes.

The SDOL framework, which is detailed in a case study co-authored by Carla Sanderson and Linda Hollinger-Smith, fills a void in current research specific to nursing students by first identifying social determinants that can create barriers to student success: self-motivation, psychological and physical health, economic stability, and physical and social environment. In fact, research has found that just a small percentage of the variance driving NCLEX-RN nursing licensure results may be explained by academic factors alone—which means many other factors, such as social determinants, are at play, and can be addressed more effectively when identified.

As part of the development of our framework, we looked at a range of practices being used by other schools of nursing, including a comprehensive study into holistic admissions processes by the American Association of Colleges of Nursing. At Chamberlain University, which has the largest nursing school in the country, 63% of the university’s more than 11,000 pre-licensure nursing students identify as coming from racially or ethnically diverse backgrounds (summer 2020), so we also have a unique opportunity to explore and assess initiatives internally.

For example, in addition to using a holistic student admissions process, the university incorporates a personalized learning plan, access to workshops, coaching and other resources that support students’ academic journeys. According to an initial analysis, Chamberlain pre-licensure bachelor of science in nursing graduates experienced nearly a 13% increase in NCLEX pass rates from 2016 to 2020, and in 2020 the rates were above the national average.

Another area for targeted research is in addressing students’ social-emotional well-being, which can impact their ability to focus, retain information and perform well on tests.

Ensuring a more diverse nursing staff requires a more diligent approach at the educational institution level, and such efforts build on the pivotal 2004 report on diversity in the healthcare workforce by the Sullivan Commission and more recent efforts such as the 2020 recommendations from the Josiah Macy Jr. Foundation. Doing so ensures that we are supporting the needs of healthcare systems through the development of a workforce that better represents the communities they serve.


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