Plan, do, check, and act can serve as a framework. 

Takeaways:

• Lack of diversity impacts patient care and nurses’ experience in the profession.
• Nurse leaders can support diversity by confronting unintentional and intentional bias.
• The Plan, Do, Check, and Act process can help promote diversity in nursing.

Healthcare disparities have long existed for patients from underrepresented populations. Evidence suggests that, in the United States, these patients are more likely to receive subpar quality care. In addition, a lack of diverse representation in healthcare has been tied to adverse outcomes. The diversity gap persists despite reports by various national organizations, including the Institute of Medicine’s landmark report In the Nation’s Compelling Interest: Ensuring Diversity in Health Care Workforce. Diversifying the nursing workforce isn’t moving at the same pace as the minority–majority demographic crossover projected in the United States by 2043. This forecast, reinforced by well-documented reports such as the Future of Nursing 2020–2030: Charting a Path to Achieve Health Equity, shows the emergent need for expediting diversity in nursing.  

Diversity symbolizes a healthcare system where the medical team and administrative staff embody various experiences and backgrounds. It emboldens self-awareness by accepting and celebrating the richness of each individual. Nurse leaders play a critical role in promoting staff diversity. (See The importance of diversity in nursing.)

How nurse leaders can promote staff diversity 

Many local, regional, and national organizations emphasize diversity and employ it as their strategic frameworks. However, more needs to be done to enhance these initiatives. Building an intentional infrastructure will turn diversity from words into action, creating a diverse and inclusive pathway that allows staff to grow and flourish. In addition, diversity, inclusion, and equity (DI&E) can serve as a process to help healthcare organizations implement improvement programs in parallel with other initiatives.  

Nursing leaders and staff must be prepared to nurture an environment that embraces and celebrates differences and ensures all levels of nursing have the skillsets to integrate equitable care for diverse populations. Nurse leaders must support diversity by quickly confronting unintentional and intentional bias that acts as a barrier to diversity. They can help promote a diverse workplace with the Plan, Do, Check, and Act (PDCA) process.   

Roadmap to promoting diversity in nursing  

DI&E is complex, elusive, and messy. PDCA provides a structure for defining strategic goals, developing interventions, using data to assess whether interventions are working, and implementing the plan on a broader scale or continuing to monitor for improvements. The PDCA cycle allows organizations to start small, measure often, and tweak frequently for sustained change.  

Plan 

Create a robust DI&E committee that reports to the organization’s board of directors. The committee will serve as a meaningful access point that offers a distinct perspective and determines whether a problem exists within the organization. The board of directors will use the DI&E committee to establish goals and implement strategies.  

• Goal 1: Ensure nursing leadership commitment.
• Goal 2: Enhance and cultivate an inclusive organization culture. 
• Goal 3: Develop and sustain a diverse, inclusive, and equitable nursing workforce.

Do 

Leadership buy-in and commitment are critical to enhancing DI&E in nursing. Nursing leadership engagement demonstrates a concrete pledge to leverage and supply assets for success. 

• Goal 1: Ensure nursing leadership commitment. 
  • Provide resources for DI&E activities and intervention. 
  • Demonstrate commitment and model the importance of DI&E in daily behavior by developing an organizational action plan, including educational initiatives and monitoring progress. 
  • Enhance supervisory and administrative accountability by ensuring that all levels of nursing have access to DI&E learning material. 
  • Incorporate measurable DI&E elements in organizational leaders’ department performance plans. 
• Goal 2: Enhance and cultivate an inclusive nursing culture.
  • Nurture a fair, supportive, and convivial work environment that takes advantage of diverse individuals’ abilities and skills. 
  • Enhance or incorporate diversity as a vital component of the nursing onboarding initiative for all new employees, leaders, and staff. 
  • Incorporate bi-annual and annual interviews and surveys of nurses and nurse leaders to determine DI&E strengths and target opportunities for improvement.
  • Institutionalize DI&E by implementing listening sessions for nursing staff to voice their concerns. Encourage open and respectful dialogue about diversity.
  • Through continuous learning and discussion, enhance mindfulness and cultivate DI&E competency.
  • Ensure that qualified internal nursing candidates have an opportunity to compete for career enhancement and develop a nursing mentorship program for both nurses and nurse leaders to assist with career growth. 
  • Use a diverse and inclusive panel during the hiring process. 
• Goal 3: Grow and sustain a diverse, inclusive, and equitable workforce.
  • Collaborate with human resources to define outreach and recruitment initiatives to broaden the diversity pool. 
  • Leverage various geographic regions, academic sources, and diverse professional organizations to attract underrepresented groups. 
  • Establish and maintain a partnership with underrepresented organizations and invite them as guest speakers to organizational town halls and executive meetings to create alliances and bridge gaps. 
  • Promote internships to diverse groups to create pipelines through targeted outreach. 

Check 

The DI&E committee should rely on data to understand the organization’s current diversity status, make recommendations, and measure results.  

• Evaluate DI&E processes with data and metrics to identify gaps.
• Periodically review and analyze nursing workforce demographics to assess if they match those of the population served.
• Generate nursing diversity reports and present or display them for all to access. 
• Maintain diversity as a quality measure. 

Act 

Based on the data, the DI&E committee can determine the initiative’s success and then take steps to promote it throughout the organization or continue to monitor it and make improvements.  

• DI&E sustainability doesn’t always materialize at the conclusion of the intervention. Assimilation must be continuous throughout the intervention, implementation, and beyond. 
• To maintain DI&E long-term sustainability, nurses and nurse leaders must adapt and modify interventions according to changing circumstances. The quality improvement road­map to enhancing DI&E isn’t static; it should continue to evolve. 

Make a commitment 

The general health of the nation requires delivering equitable care to a racially and ethnically diverse population. Nursing, nursing organizations, and nursing affiliates must make a commitment to enhance DI&E by ensuring that the workforce reflects the population it serves. Quality improvement initiatives aimed at increasing DI&E can help us keep that promise.

Dewi Brown-DeVeaux is the director of nursing at NYU Langone Health in New York City, New York. Brittany Richards is an assistant professor at the New York City College of Technology.

References 

American Association of Colleges of Nursing. Fact Sheet: Enhancing Diversity in the Nursing Workforce. April 2019. aacnnursing.org/Portals/42/News/Factsheets/Enhancing-Diversity-Factsheet.pdf  

Baker C, Chinaka O, Stewart EC. The time is now: Why we must identify and address health disparities in sport and recreation injury. Inj Epidemiol. 2021;8:25. doi:10.1186/s40621-021-00320-2 

Institute of Medicine (US) Committee on Institutional and Policy-Level Strategies for Increasing the Diversity of the U.S. Healthcare Workforce; Smedley BD, Stith Butler A, Bristow LR (eds.). In the Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce. Washington, DC: National Academies Press; 2004. 

Knudsen SV, Laursen HVB, Johnsen SP, Bartels PD, Ehlers LH, Mainz J. Can quality improvement improve the quality of care? A systematic review of reported effects and methodological rigor in plan-do-study-act projects. BMC Health Serv Res. 2019;19(1):683. doi:10.1186/s12913-019-4482-6 

National Academies of Sciences, Engineering, and Medicine. The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity. Washington, DC: National Academies Press; 2021.