New Blood
Recruiters, clinics and schools - in an effort to reflect the populations they serve and draw more minorities into nursing - fine-tune programs to support students' cultural priorities

By Cathryn Domrose
March 12, 2003

When Christopher Lee Navarrette, a nursing student at the University of Texas Health Science Center at San Antonio, missed his grandmother's funeral because he had exams and a huge paper due, members of his large, close family were hurt and appalled.

"I tried ad nauseam to explain it, but some of them just could not understand," said Navarrette, president of the student chapter of the National Association of Hispanic Nurses. "Family is a wonderful thing, but when they don't understand what's going on, it can be a problem."

Navarrette has used his experience to support and encourage fellow Hispanic nursing students as a mentor in UT's "Juntos Podemos" (Together We Can) program. The program, which pairs experienced and beginning students of similar backgrounds, helps students feel that they are not isolated, that they have support from people who understand what they're going through.

For the Hispanic students he mentored, the most difficult part of school "was their interpersonal relationships with their families," Navarrette said. "Half of them had their own children. They felt guilty about being away for so long from their families. It's a big challenge for Latino nursing students coming in."

Although the number of racial and ethnic minority nurses is growing, they are still underrepresented in the profession as a whole. Nurse recruiters, community clinics and nursing schools are crying out for more minority nurses-especially bilingual nurses-in an attempt to reflect the populations they serve.

But if the profession wants to attract and keep more Hispanic, American Indian, Asian-American and African-American nurses, it needs to offer support and a welcoming attitude, say those who work to promote greater inclusion of minorities in nursing. This includes recognizing the importance of family support, the need for a social life and a sense of belonging and the value of speaking a second language.

Student aid

Programs like Juntos Podemos and RAIN (Recruitment and Retention of American Indian Nurses) that aim to support minority students in all aspects of their lives have become models for not only attracting minorities to nursing but for getting them through school, into the workforce and, in many cases, back to school for advanced degrees.

Ethnic minorities make up about 30 percent of the U.S. population, according to census figures, and this percentage is expected to increase to nearly 40 percent in 2025. But 12 percent of nurses identified themselves as belonging to one or more ethnic minority groups in 2000, according to the National Sample Survey of Registered Nurses.

As the nursing shortage intensifies, nurse leaders talk of the importance of bringing in new blood, of appealing to all sectors of the population, of looking beyond Caucasian women, who have made up the vast majority of nurses for years.

The message seems to be getting through.

The number of male and racial and ethnic minority RNs has increased rapidly in the last 20 years. The number of nurses identifying their background as one or more racial minority groups or as Hispanic/Latino has tripled between 1980 and 2000, and the representation of minority nurses has increased from 7 percent in 1980 to 12 percent in 2000, according to the nursing sample survey.

But most racial and ethnic minorities are still underrepresented in nursing when compared with the general U.S. population. About 5 percent of nurses are African American, compared with 12.2 percent of the population, according to the sample survey.

About 3.5 percent are of Asian or Pacific Islander descent, compared with about 4 percent of the general population. Hispanic nurses, although the fastest-growing group between 1996 and 2000, are the most underrepresented in nursing. Two percent of all nurses in 2000 came from a Hispanic background, compared with 11.4 percent of the general population.

"We're seeing some" minority applicants for nursing jobs, said Karen DeLevan, senior recruiting consultant for Texas Health Resources in Dallas. "But not as many as we'd like.

"The diversity recruitment program is a very high priority issue. We want to mirror the community that we serve so that there's a comfort level and a support system."

The prevalence of certain diseases such as diabetes and hypertension among certain ethnic groups is a strong reason to recruit more minority nurses, said Willa Doswell, Ph.D., RN, FAAN, assistant professor at the University of Pittsburgh School of Nursing and a member of the advisory committee for the American Nurses Association's Ethnic and Minority Fellowship program. "Given the health disparities in the country with African Americans and other minorities, yes, we do need more minorities in nursing," she said.

Clinics and hospitals that serve specific populations find themselves in a double bind during a nursing shortage, competing with other health care facilities for nurses from certain backgrounds or with certain language skills.

The Indian Health Service, which serves American Indians on reservations, now has more than 400 openings for nurses, said Deb Wilson, program coordinator for the RAIN program at the University of North Dakota in Grand Forks. "They're really in dire straits in terms of needed nurses out there," she said.

Genny Rosario, RN, clinic head nurse at Asian Health Services in Oakland, Calif., said she has been advertising for a year without success for Cantonese-speaking nurses. About 75 percent of the clinic's clients speak Cantonese and all the nurses there speak at least one Asian language besides English, she said. She is Filipina and can speak to patients from the Philippines, but needs a translator to speak to patients in other languages.

"It's very difficult," she said, first to find qualified RNs, then to find qualified RNs who speak Cantonese. "It's double jeopardy for us."

Dirty business

Many Asian families consider nursing a good job, Rosario said. Asian youth understand nursing pays decent salaries and is a respected profession. "But somehow that's not enough to attract them," she said. Asian high school students she talks to say they would rather go into physical or occupational therapy or become pharmacists. "They're in another frame of mind," she said.

Until her niece graduated from high school, she wanted to be a nurse, Rosario said. "She always said, 'I want to be like you, Auntie.' But then she graduated and she told me, 'I want to be sitting in an office and looking at a computer and wearing a lab coat, not dealing with a patient.' She didn't want to be dealing with the blood, the patient injections. She saw the work as dirty."

Viola Benavente, MSN, CNS, RN, has three children, none of whom want to follow in her footsteps. "They said they would never even consider entering the profession because they saw me work so hard," said Benavente, assistant professor in the department of acute care nursing at UTHSC and a member of the board of directors of the National Association of Hispanic Nurses.

They remembered how she worked double shifts and spent weekends and holidays at the hospital. "They didn't want that kind of job. Those holidays are important. [That is] family time. They see nursing as hard work that takes you away from your family."

Family matters

Recognizing the importance of family is important both in recruiting students to a nursing school and in retaining them, Benavente said. Many Hispanic families are reluctant to let their children go away to school, even if the school is only 50 miles away. Once in school, many families do not understand why the student must spend so much time studying instead of taking care of family responsibilities.

She recalled one student in the Juntos Podemos program who was having a hard time taking tests. It turned out that the student's husband was picking a fight with her before each exam because he didn't understand why she needed time to study. With help from her mentor and faculty, the student arranged for a part-time, less strenuous schedule that gave her more time for her family. She and her husband had a long talk, and he agreed to take on more household and child care responsibilities so that she could study, Benavente said.

Winning over the family is important in many Asian communities, as well, said Kem Louie, Ph.D., CS, RN, FAAN, past president of the Asian American/Pacific Islanders Nurses Association, which means nursing schools must adopt a more personal approach. "You've got to go out to the families. You've got to meet them in the schools. It takes a little bit more effort to make that part of your marketing."

Location plays an important part in where African Americans decide to go to school, Doswell said.

Nursing schools in Atlanta and Baltimore, for example, may have an easier time attracting African Americans because they have large African-American communities and can offer students a social life as well as an academic one, she said.

Less than 5 percent of students are African American in the graduate program at the University of Pittsburgh, where Doswell teaches. "They think the program is good," she said. "But they would like a more socially relevant background."

Asian students also want to go to schools where they see Asian students and faculty, Louie said. "Nobody wants to be the only one," she said. "You want to go on campus and see someone who looks like you."

Cornelia Porter, Ph.D., RN, FAAN, associate professor at the University of Michigan School of Nursing and former director of the American Nurses Association's Ethnic and Minority Fellowship program, suggested attracting non-Caucasian nursing students with a "critical mass" approach-bringing in a group of students from racial and ethnic backgrounds who would be able to support each other as they progressed through the program.

It is unethical to bring members of underrepresented groups into a school or college of nursing that is not "minority friendly," she said.

The extra mile

Before the RAIN program started in 1990, the University of North Dakota had graduated 18 American Indians from its bachelor's degree in nursing program since 1973, Wilson said. Between 1999 and spring 2003, the university will have graduated 104 American Indians from its bachelor's degree program and 20 from its master's program, she said.

RAIN offers financial and personal assistance to American Indian nursing students who agree to work for the Indian Health Service after they earn their degrees. This assistance includes paying rent or car insurance, baby-sitting and helping with writing papers or studying for tests.

"It takes everything to get them through," Wilson said. "You're not just dealing with the student, you're dealing with students and their families," which for many American Indians includes children, spouses, aunts and uncles, grandparents and parents. Family responsibility and the crises that go with it "always come into play," she said.

For many students, just coming to a big university campus from a reservation or small town can be a frightening and overwhelming experience, said Marlene Buchner, MS, RN, nursing tutor and mentor for the RAIN program. She remembers her own experience as a student coming to the university from a town of 318 people in Minnesota. She felt lost and didn't know where anything was.

The RAIN staff "took me under their wing," she said. "We are the most important support for the students. We're here and we're like their family away from home."

RAIN also helps bridge the cultural gap between the "circular" way of thinking on the reservation and the "linear" expectations of many Caucasian university professors, Buchner said. "Learning in the circular way is having everything connected. It's like telling a story, not just the facts but how everything intersects. But sometimes the teachers just want the facts."

RAIN staffers stay in touch with the students even after they leave school, Wilson said. "We've found that our students are our best recruiters."

In turn, she feels comfortable sending graduates to work for nursing directors and supervisors who have graduated from the program. When she goes out to reservation health centers on recruiting missions, the graduates welcome her warmly. Others send letters asking for information on the program for colleagues who want to return to school.

Many entered nursing specifically to work in their communities, but Wilson lets them know they can always further their education and return at a new level. She tells them, "I want to see you back for your master's."

Equal opportunities

Hospitals and clinics that want to attract and especially retain minority nurses must look at their environments to see how welcoming and supportive they are, including how many minorities they have already hired and what positions they hold.

"It's not just about money, it's about how they treat their employees," said Benavente, noting that Magnet hospitals have been praised for how they recruit and retain minority nurses. "We want to be made to feel important and that we matter to the institution."

If she were looking for a job in a hospital, Doswell said, "I would like to see how many African Americans are on staff and what positions they hold. If they are all nurses aides, that's not a place I want to work."

Despite the difficulty in recruiting bilingual nurses, Rosario said her clinic has no problems retaining them partly because they are comfortable working among people who speak the same language and come from similar backgrounds.

"Because they are serving their community, they feel the loyalty and dedication to stay here," she said.

The hospital where Benavente worked for many years has Hispanic physicians, nurses and support staff, as well as patients, and she always felt comfortable there. But when she went to a predominantly Caucasian hospital across town, no one talked to her while she was wearing her nursing scrubs, she said. People there became friendlier only when she wore her lab coat and university identification.

Such attitudes, whether conscious or not, have a huge effect on minority nurses. "Why would I stay in a place where I know that I'm just being tolerated and I'm not wanted?" Porter asked.

Rather than look for a simple solution, nursing needs to examine its history and ask difficult questions, Doswell said. Until the 1950s, many hospitals were segregated and the American Nurses Association did not accept African-American nurses as members.

Rhonda Flenoy Younger, a recruiter for the school of nursing at UCLA, said she has heard stories from African-American nurses about patients who said they did not want an African-American nurse caring for them.

"I was shocked," she said. "But things like that happen in 2002. Some people are still like that."

Hospitals must find ways to show appreciation for the contribution minority nurses make, Louie said. Bilingual nurses often are asked to translate and interpret in addition to their regular nursing duties. "Many of these nurses feel they are taking on a double load," she said. "They feel used."

Some nurses from Asian or Hispanic backgrounds who speak only English may feel pressured or inadequate because they aren't bilingual, even though their non-Asian or non-Hispanic counterparts don't speak another language either.

Navarrette, who is more worried about passing his Spanish test than his board exams, said part of that pressure comes from his own expectations. Many-although by no means all-minority students go into nursing because they want to help their communities, which are often in desperate need of health care professionals.

Navarrette said his father told him he finally understood the importance of his chosen career after his experience with the nurses who cared for Navarrette's grandmother in a small hospital in Kansas.

He told Navarrette, "I know that you're going to be a nurse, but until I saw what they did, I didn't really know how important your job is-not just to the patient, but to the family."

Contact Cathryn Domrose at kaguilar@well.com