The Rise of Diversity, Equity, and Inclusion (DEI) Practitioners in Academic Nursing

In the United States (U.S.), the roots of nursing intertwine deeply with the nation’s turbulent history of racial prejudice and segregation. In 1896, the Supreme Court legitimized racial segregation with Plessy v Ferguson (1896) and sanctioned racially exclusive healthcare and educational institutions. For decades, the landmark ruling promulgated the fictitious separate but equal doctrine that upheld the legality of racial discrimination and extended the life of racism. Differences in the resources used to educate Black nurses, harsh working conditions, and funding inequities for minority-serving institutions yielded disparate healthcare outcomes between black and white communities (Hine, 1989). Although the Supreme Court, over half a century later, concluded that separate systems were inherently unequal with Brown v the Board of Education (1954), the desegregation of educational institutions failed to resolve inequities or create a racially diverse nursing workforce.

The importance of a racially and ethnically diverse nursing workforce has been staunchly avowed across federal, national, and institutional levels.The importance of a racially and ethnically diverse nursing workforce has been staunchly avowed across federal, national, and institutional levels (American Association of Colleges of Nursing [AACN], 2017; Beard & Julion, 2016; Beard et al., 2020; Hine, 1989; Institute of Medicine, 2004; National League for Nursing [NLN], 2009; Sullivan Commission, 2004, USDHHA, 2017a). In 2016, the National Academies of Sciences, Engineering, and Medicine (NASEM, 2016) heralded diversity as a workforce priority in Assessing Progress on the Institute of Medicine Report: The Future of Nursing. The following year, the NLN (2017) published a Diversity & Inclusion Toolkit to strengthen diversity. The NLN, recognizing the historical factors in play, posited that increasing the racial and ethnic diversity of nursing would “…take tremendous effort and a candid examination and assessment of decades of practice and tradition that favored some and excluded others” (p. 3).

The reasons why the nursing profession has struggled to create a racially and ethnically diverse workforce are multifactorial.The reasons why the nursing profession has struggled to create a racially and ethnically diverse workforce are multifactorial. Historically, the racially homogenous nursing workforce has been attributed to the explicit exclusion of black nurses from white nursing programs, the false belief that black students were inferior, and the perpetuation of racism (Hine, 1989; Yoder, 1996; Barbee & Gibson, 2001). The historical narrative of nursing originated from a white Eurocentric female perspective that emphasized contributions of white women like Florence Nightingale while failing to include the attributes of historically racialized women like Mary Seacole. In addition, despite federally funded programs to improve access, highly restrictive admission and punitive progression policies, poor representation of minoritized faculty, financial constraints (National Advisory Council on Nurse Education and Practice, 2000), and a culture of institutional racism (Barbee & Gibson, 2001; Beard & Julion, 2016) have undermined efforts to bolster the diversity of nursing leading to and into the 21st century.

The purpose of this article is to illustrate the role of the Diversity Equity and Inclusion (DEI) practitioner in co-creating environments where all individuals feel a sense of belonging. The authors share the demographics of the nursing workforce along with factors that have undermined diversity efforts.

The Nursing Workforce

It is widely accepted that racial and ethnic diversity could help mitigate healthcare disparities by improving access to and the quality of healthcare. What is more, increasing the diversity of the nursing workforce is key to advancing health equity (NASEM, 2021). Diversity continues to be a highly sought ideal and a core value for many institutions. While diversity has increased, the nursing profession still has more work to do. When compared to the racial demographics of the United States, white nurses remain overrepresented in the profession (National Council of State Boards of Nursing [NCSBN] 2013; NCSBN 2018/19). White nurses constitute over 80% of the nursing population and 60.1% of society (U.S. Census Bureau, 2011). In comparison, Blacks are over 13% of the U.S population and only 6% of the nursing workforce (See Table 1).

...increasing the diversity of the nursing workforce is key to advancing health equity.Hispanics/Latinos are over 18% (and growing) of the U.S. population, and historically only 5.3% of the nursing workforce. The underrepresentation of minoritized groups in the nursing workforce, when compared to the U.S. population, also includes American Indian/Alaskan, Native Hawaiian/Pacific Islander groups (See Table 1). Conversely, the population of nurses who are Asian approximates well with their societal representation. However, it should be noted that their representation does not account for the vast intra-ethnic members of the Asian diaspora (See Table 1).

Efforts to strengthen diversity in nursing have not targeted race alone.Efforts to strengthen diversity in nursing have not targeted race alone. That is because the nursing profession also lacks gender diversity, with the vast majority of nurses (over 87%) being female (U.S. Bureau of Labor Statistics, n.d.). In addition, the racial demographics of faculty reflect a body of academicians who are 82% White, 9% Black/African American, 3.4% Hispanic/Latino, 2.9% Asian, and 93% female (NLN, 2021). Ideally, the nursing workforce should closely align with the racial, ethnic, and gender makeup of the U.S. population.

The Future of Nursing 2020-2030 report (NASEM, 2021) suggests that “a new generation of nurse leaders is now needed - one that recognizes the importance of diversity” (p. 10). Due to the impetus for greater diversity, some might believe that the primary role of the DEI practitioner is to reconcile the lack of racial/ethnic diversity in nursing. However, DEI Practitioners cannot focus exclusively on the demographic representation of nursing. They must widen their lens, move beyond diversity metrics and recognize their role, albeit still evolving.

Table 1. U.S Racial Population versus Nursing Racial Distribution

*USDHHS (2019, 2017b), ^U.S. Census Bureau (n.d.), #NCSBN (2013; 2018/19)

...they should be individuals who understand, respect, embrace, and advocate for teaching the totality of nursing history.The rise of DEI practitioners in academic nursing has become more important as institutions seek the goal of achieving health equity (NASEM, 2021). While DEI practitioners do not have to be members of historically racialized groups, they should be individuals who understand, respect, embrace, and advocate for teaching the totality of nursing history. The profession needs diverse representatives, informed nurses, and nurse leaders who can craft policies and practices, conduct and interpret nursing research, decide upon resource allocation and develop nursing curricula. This new generation of academic leaders must include dedicated DEI practitioners who have the skill sets to champion this vitally important work and create an ethos that yields a more racially and ethnically diverse nursing workforce.

The Scope of the DEI Practitioner Role in Academic Nursing

This individual often has access to high-ranking administrators.The DEI practitioner role is not monolithic and role descriptions vary. We ground the role of the DEI practitioner using the work of Williams and Wade-Golden (2007). The authors described the chief diversity officer as a senior-level position responsible for spearheading diversity initiatives. This individual often has access to high-ranking administrators. Williams and Wade-Golden (2007) characterized the role with three models: collaborative officer, unit-based, and portfolio divisional. The collaborative officer model highlights the one-person DEI practitioner office with administrative support to help coordinate and execute diversity events but there are no direct reports representing lower-level diversity offices. The unit-based model offers an expanded support staff model and access to and engagement with other departments. The portfolio divisional model features a model in which the DEI Practitioner has resources that include appropriate staff to support strategic goals and engagement and collaboration with high-ranking administrators.

Role Confusion: Chief Diversity Problem Solver vs. Chief Diversity Strategist

In academic nursing, one typically encounters the collaborative officer model.In academic nursing, one typically encounters the collaborative officer model. More often than not, the DEI practitioner is a full-time faculty member who is allocated a percentage of time for the DEI role. The percentage of time allocated ranges from 30% to 50%. Support staff is usually one individual who functions as a combination of administrative assistant and program coordinator. The DEI practitioner may receive additional financial compensation for the role. Furthermore, there is great variety in how the role is implemented within even the most commonly encountered collaborative officer model in academic nursing. Some nursing DEI practitioners are hired into the role and are afforded a clear job description. Conversely, other DEI practitioners are appointed by the dean and have no articulation of the position or role.

Often, DEI practitioners are appointed because of a hate crime, racial incident, or other negative events...Even with a clearly articulated role description, the DEI practitioner in academic nursing may be faced with challenges vis à vis the student, staff, and faculty expectations of the role. DEI practitioners were once tasked with duties little more than compliance officers who gathered and housed diversity data. Often, DEI practitioners are appointed because of a hate crime, racial incident, or other negative events concerning historically excluded populations within a school. Present-day DEI practitioners inhabit a more broadly defined leadership role. They are charged with leading a school of nursing’s strategic vision and goals for diversity, equity, and inclusion, though they often lack the resources and appropriate infrastructure to be successful in strategic efforts.

Settling the challenges associated with inadequate resources is the perception of the DEI practitioner role by nursing school students, staff, and faculty. Many academic nursing DEI practitioners are faced with being the “chief complaint officer” or “chief problem solver” where students, staff, and faculty report incidents of bias for the DEI practitioner to resolve. DEI practitioners might also be expected to solve all the inequities experienced in the school of nursing with lightning speed and with limited opportunities for partnership with others in the school.

Furthermore, DEI practitioners can expect that they will be called upon for community engagement activities occurring in the school. The authors found that DEI practitioners are called upon to provide services well established in a school of nursing and or within the wider university. For example, DEI practitioners may be asked by faculty and staff to provide information about financial aid resources and scholarships for students though there are fully staffed financial aid offices available to students. Sometimes, DEI practitioners are asked to provide counseling to students who have suffered harm because of a hate related incident. And while the DEI practitioner should be seen as a resource for these incidents, schools and universities are equipped with appropriately trained mental healthcare providers, counselors, and even chaplains who have been trained to counsel and treat students.

There are often countless requests for DEI practitioners to provide quick fixes for long- standing institutional challenges...There are often countless requests for DEI practitioners to provide quick fixes for long- standing institutional challenges, abbreviated versions of implicit bias training, and scripts on how to handle difficult conversations about race and racism. At the request of others, DEI practitioners also find themselves sharing their own personal experiences and serving as role models, informal advisors, and mentors for underrepresented minority nursing students. We do not suggest that any of these activities are insignificant. Rather, the examples serve to highlight that they add to the workload of DEI practitioners and may take away from the focus on strategic initiatives and transformational change for the school of nursing. It is emotionally and physically taxing work.

The DEI practitioner tends to spend a good amount of time problem solving, but the role encompasses so much more. Key areas for the DEI practitioner role and where they provide strategic leadership are: (a) institutional strategic planning, (b) diversity programming and education, (c) student support, (d) student, staff, and faculty recruitment, and (e) developing community partnerships.

DEI Practitioner Titles: What is in a Name?

...titling may seem inconsequential but titling matters and signifies the importance of the role and reporting structure.The titling of DEI practitioners in academic nursing ranges from diversity officer to associate dean and is likely dictated by available resources and the size of schools. A discussion of titling may seem inconsequential but titling matters and signifies the importance of the role and reporting structure. Williams and Wade-Golden (2013) described titling as an indicator largely dictated by status and influence along with where in the school of nursing the position may be situated. Diversity officer, for example, signals an individual who is no more than a compliance officer with no specific power to effect transformative DEI change. A Director of diversity, on the other hand, describes a DEI practitioner who may be primarily responsible for programs and activities to educate and raise DEI awareness among students, staff, and faculty. The title of “director” also does not indicate any decision-making authority or the capability to effect change.

In academia, titles linked to assistant dean, associate dean, and vice-dean positions are powerful in that they signify administrative leadership positions with a reporting structure linked to important decision-making authorities, such as department chairs, deans, and provosts. The status of these titles is recognized across schools of nursing as substantial leadership roles and that schools are interested in effecting strategic change versus meaningless performative DEI engagement.

While guided by an institutional vision, the work of DEI practitioners is collaborative in nature and requires an awareness of the broader DEI implementation landscape; this is true both within the discipline of nursing and across higher education and healthcare sectors. Formal networks provide DEI practitioners with critical resources necessary to systematically address the needs of their individual institutions, share best practices, and develop strategies to address national/international priorities (e.g., Future of Nursing 2020-2030). Formal groups fall into three categories: generalist, specialty sub-group, and collaborations.

At present, there is no dedicated nursing DEI organization...Generalist DEI organizations such as the National Association of Diversity Officers in Higher Education (NADOHE) provide the perspective of the rapidly evolving DEI landscape and offer professional development opportunities for current and aspiring diversity officers. At present, there is no dedicated nursing DEI organization, rather various nursing specialty organizations have developed DEI sub-groups in the form of committees, workgroups, task forces, and leadership networks. The AACN recently evolved its Diversity, Equity, and Inclusion Group (DEIG) into the Diversity, Equity, and Inclusion Leadership Network (DEILN). This transition from a group to a leadership network elevates the importance of DEI work to a central feature in the goal to eliminate disparities in nursing education and workforce development. To this end, the DEILN disseminates evidenced-based practices (via a faculty tool kit), convenes networking forums, and provides consultation services.

Finally, collaborative organizations such as the National Coalition of Ethnic Minority Nurse Associations (NCEMNA) collectively represent several specialty organizations each with its own specific DEI focus. As a collaborative, NCEMNA amplifies the collective voices of minority nurses. As numbers of DEI practitioners in academic nursing continue to grow, a critical consideration will be under what professional network structure/organization they should be organized in order to reduce membership fatigue and maximize collective impact.

DEI practitioners are frequently tasked with providing urgent consultation for situations of extreme distress, and often with inadequate support.Informal networks (i.e., 1:1 and small peer groups) further offer DEI practitioners with connection to the broader DEI landscape, however, these networks also frequently provide outlets for emotional support and psychological safety. DEI practitioners are frequently tasked with providing urgent consultation for situations of extreme distress, and often with inadequate support. Resulting high levels of stress left to linger within the DEI practitioner can lead to a high burnout rate.

Implications and Recommendations for Establishing a DEI Practitioner Position

A priority for this article is to catalyze efforts to not only establish the role of DEI practitioners, but to ensure that these individuals are poised to lead diversity, equity, and inclusion initiatives within their respective departments, colleges, or schools of nursing which will ultimately contribute to workforce diversity and health equity. As such, we include selected content of importance to the position.

To enact true change, DEI practitioners need to hold a leadership position...Authority/Leadership
To enact true change, DEI practitioners need to hold a leadership position, such as associate dean, or a commensurate role based on the leadership structure of the school. NADOHE (2020) stated, “institutional commitment to [DEI] requires leadership, coordination, resources, and evidence from the highest levels of administration and across all levels of the organization” (p.9). Diversity, equity, and inclusion leaders should have a leadership role that grants them the power needed to enact institutional change within their school or department. The Association of American Medical Colleges (AAMC), (2012) recommends positioning chief diversity officers in the dean’s, president’s, or CEO’s leadership cabinet.

Time
The time commitment of the DEI practitioner should, ideally, be based on the needs of the individual department, school, or college. By conducting a survey or needs assessment a school would be positioned to make an evidence-based determination of the percentage of time the DEI practitioner would devote to this position. A time allotment recommendation for a DEI practitioner in a lead role could start with a higher percentage (ranging from 80% to 100%) for an inaugural role/position and then a lower percentage (ranging from 50% to 80%) for a more established position.

...these efforts go largely unrecognized, under-compensated, and undervalued.In making this determination it is essential that the school be mindful of the diversity tax, especially when the role is being filled by a person of color. The diversity tax refers to the expectation that people of color disproportionately take on the burden of addressing and solving the diversity, equity, and inclusion issues in their organization (Ackerman-Barger, Boatright, et. al, 2020). DEI leaders tend to be deeply devoted individuals who feel called to support students and promote broadly the myriad issues related to diversity, equity, and inclusion. However, these efforts go largely unrecognized, under-compensated, and undervalued. For example, during merit and promotion processes when DEI efforts are not specifically valued, DEI contributions can be viewed as a distraction from other academic requirements such as teaching, scholarship, and service. Thus, DEI efforts not only are not recognized but may undermine career success.

This disparate ranking and titling make for a wide range of salaries among DEI practitioners in academic nursing.Salary/Compensation
Because the roles and titles of DEI practitioners are not standardized, salaries and other compensation are also inconsistent. Salaries tend to reflect the academic rank of the practitioner and/or the specific administrative title, which can range from coordinator to associate dean (AACN, 2021c). This disparate ranking and titling make for a wide range of salaries among DEI practitioners in academic nursing. Salaries and other compensation for DEI practitioners in academic nursing should be based on a model of work equity that centers on “function,” or what a practitioner is tasked to do. This will better accommodate the wide range of academic ranks/tracks as well as administrative titles that are available across nursing.

Resources and Staffing
It is important that chief diversity officers (DEI practitioners) are allocated sufficient resources to be successful in meeting the DEI mission of the school...It is important that chief diversity officers (DEI practitioners) are allocated sufficient resources to be successful in meeting the DEI mission of the school and to meet the expectations of their role. Aguilar and Bauer (WittKieffer, n.d.) noted that of the chief diversity officers they surveyed, less than 47% reported that they had adequate resources to fulfill their charge upon starting. AACN (2021a) recommended the following DEI budget items: salary and benefits for both DEI leadership and administrative support; funds for recruiting, faculty development, and retreats; and retention programs for underrepresented students. AAMC (2012) emphasized the importance of providing chief diversity officers with sufficient financial resources to “build partnerships, spark new initiatives, and work creatively with internal and external stakeholders to advance issues of diversity, equity, and inclusion” (p.18). Arnold and Kowalski-Braun suggested that “estimates for staffing, general fund dollars, and start-up costs should be based on a vision of a mature, fully staffed office or division” (2012, p. 31).

...there must be a sense of collective accountability and willingness to actively engage in DEI work from all members of the school.Without proper leadership positioning, titling, time allocation, salary, resourcing, and staffing there is a possibility of both DEI practitioner burnout and failure of DEI initiatives. For a school to succeed in its diversity, equity, and inclusion mission and to create sustained institutional change, there must be a sense of collective accountability and willingness to actively engage in DEI work from all members of the school (AACN, 2021a, Ackerman-Barger, Sandvold, et al., 2020; Dobbin & Kalev, 2016; Macy Foundation, 2021; Zambrana, et al., 2018).

Conclusion: Further Recommendations

This article has highlighted the historic and current lack of diversity in nursing and how it has fueled the need for and rise of DEI practitioners in academic nursing to address these and other issues. At the same time, national organizations have cited racism as a prevailing factor that threatens equity (AACN, 2021a; Copeland, 2020; NASEM, 2021). AACN (2021b), in The Essentials: Core Competencies for Professional Nursing Education, implicated racism as a critical factor that has undermined efforts to strengthen diversity. The document revealed that achieving equity and a racially and ethnically diverse nursing workforce requires the dismantling of structural racism. What is more, the report highlighted that academic nursing would have to interrupt policies and practices that eternalize racism and normalize discrimination. Additionally, leaders will have to examine the ways that nurses are prepared. Efforts to improve healthcare outcomes will suffer unless racism in nursing is acknowledged and dismantled (NASEM, 2021). While the rise of DEI practitioners is a welcomed change, it is not without challenges.

While the rise of DEI practitioners is a welcomed change, it is not without challenges.The role and scope of the DEI practitioners in academic nursing is not well defined which threatens to lessen their effectiveness. More must be done to clearly define the scope of these roles and put forth best practices that will assist nursing programs as more institutions move to put a DEI practitioner in place. For scope, we recommend reviewing the work of Williams and Wade-Golden (2013) who offered a few models that would work for a chief diversity officer, allotted a senior-level position with responsibility to spearhead diversity initiatives.

Given the relative newness of DEI practitioners, it is imperative to examine their impact...Additionally, there is a paucity of research that has examined outcomes associated with DEI practitioners in academic nursing. Given the relative newness of DEI practitioners, it is imperative to examine their impact on equity, inclusion and diversity goals in academic nursing and support development of the role and scope with evidence-based research.

To decrease confusion about the roles of DEI practitioners in academic nursing, the authors recommend that defining it within the domains of (a) institutional strategic planning, (b) diversity programming and education, (c) student support, (d) student, staff, and faculty recruitment, and (e) developing community partnerships. Borrowing from practices established by organizations such as the National Association of Diversity Officers in Higher Education, we further recommend establishing DEI practitioner roles in academic nursing with the authority needed to be effective. Titling should be at the senior administrative level (e.g., associate dean), with direct reporting to the leader of the school.

Positions must be set up for success with dedicated hardline funding and staffing based on the size and complexity of the school.Accordingly, these practitioners should receive appropriate administrative salaries/compensation, as well as adequate release time from other responsibilities such as teaching. They require sufficient time to devote to the numerous DEI duties; this should constitute a 50% appointment at a minimum. Lastly, DEI work has a cost to it. Positions must be set up for success with dedicated hardline funding and staffing based on the size and complexity of the school.

...leaders in academic nursing can facilitate the rise of DEI practitioners in such a way that they are also sustained over time...If done with a high level of intentionality, leaders in academic nursing can facilitate the rise of DEI practitioners in such a way that they are also sustained over time with long term impact. The authors expect outcomes to be an inclusive environment that fosters diversity among nursing students, faculty, and staff. In addition, fundamental changes to the nursing curriculum (although beyond the scope of this article) are needed to fully embrace DEI initiatives and dismantle structural and institutional racism. Long term, we expect to produce a DEI nursing workforce with practitioners who will support the collective goal of advancing health equity in our society.

Authors

Sheldon D. Fields, PhD, RN, FNP-BC, AACRN, FNAP, FAANP, FAAN
Email: sdf5275@psu.edu
ORCID ID: 0000-0002-5657-7920

Sheldon D. Fields is Research Professor and inaugural Associate Dean for Equity and Inclusion in the Ross and Carol Nese college of nursing at Penn State University, State College Pennsylvania. He is also currently the First Vice President of the National Black Nurses Association.

Mitchell J. Wharton, PhD, RN, FNP-BC, CNS
Email: mitchell_wharton@urmc.rochester.edu
ORCHID ID: 0000-0002-0411-3905

Mitchell J. Wharton is Associate Professor of Clinical Nursing and inaugural Associate Dean for Equity and Inclusion in the school of nursing at the University of Rochester, Rochester New York. He is a behavioral scientist and current treasurer of the National Association of Nurses in AIDS Care.

Kupiri Ackerman-Barger, PhD, RN, CNE, ANEF, FAAN
Email: packerman@ucdavis.edu
ORCID ID: 0000-0002-1247-1796

Kupiri Ackerman-Barger is Clinical Professor and Associate Dean for Health Equity, Diversity and Inclusion in the Betty Irene Moore School of Nursing – University of California Davis, Sacramento California. She is a well-respected diversity, equity and inclusion expert and trainer.

Lisa M. Lewis, PhD, RN, FAAN, FAHA
Email: lisaml@nursing.upenn.edu
ORCID ID: 0000-0003-3933-4692

Lisa M. Lewis is the Inaugural Calvin Bland Fellow, Associate Professor of Nursing and Africana Studies and Associate Dean for Equity and Inclusion in the school of nursing at the University of Pennsylvania, Philadelphia Pennsylvania. She is a NIH funded health disparities researcher with many years of experience.

Kenya V. Beard, EdD, AGACNP-BC, CNE, ANEF, FAAN
Email: kbeard@chamberlain.edu
ORCID ID: 0000-0002-8752-1807

Kenya V. Beard is Associate Provost for Social Mission & Academic Excellence at Chamberlain University, Chicago Illinois. She is currently chair of the Diversity and Inclusion committee of the American Academy of Nursing.