Diversity among Registered Nurses: Slow but Steady Progress

By Peter McMenamin posted 08-21-2015 12:28

  

Diversity among Registered Nurses: Slow but Steady Progress

Peter McMenamin, Ph.D.

ANA Health Economist

Revised: September 15, 2015

 

The occupation of registered nurse in the United States has long been understood to be predominantly female and mainly White. This is in part historical artifact[1]; also in part the result of discrimination, both gender-based and racial. Recent U.S. Census data developed near the time of the 2010 Decennial Census, however, demonstrate that the distribution of registered nurses (RNs) with respect to gender, race, and ethnic background has been changing as newer cohorts of nurses have entered the profession. 

While White female nurses remained 77 percent of the RNs over 70 years of age, for U.S. nurses under age 40 that percentage dropped by 12 points to less than two thirds of younger nurses. While this does not yet closely mirror the diversity distribution of the U.S. population, it represents a positive step in the right direction. In reviewing seven individual age groups from the over-70s to the under-40s, every succeeding younger group of RNs exhibits a lower concentration of White female nurses, i.e., more diversity.  Comparing nurses 60 years and older to the under-40 nurses and the U.S. population, the majority (White) nurse share has fallen and come closer to the U.S. majority population share. The African-American nurses’ percentage share of total young nurses was greater than the corresponding share of the nurses 60 or older, and, in fact, matched African-Americans’ percentage of the U.S. population. All of the other younger minority groups examined also exhibited increased percentages relative to those of the older nurses.

Introduction

This note constitutes a brief empirical review of RNs included in a particular U.S. Census data set used in assessing diversity as described below. Although there is some discussion of historical factors that have affected diversity of the RN labor force, the note does not address either specific programs that have been instituted to increase diversity in a national context or nursing specific initiatives or programs to attract minority students into nursing. The Census data in question present a 2006-2010 snapshot of RNs. 

Equal Employment Opportunity Commission Data Development

For the past five decades the Equal Employment Opportunity Commission (EEOC) has worked with the U.S. Census Bureau in the Department of Commerce to tabulate Census data with respect to diversity of the labor force. These data include detailed occupational statistics by race, ethnicity, and gender for persons in the labor force for local areas and the nation as a whole.  This effort is now conducted through the sponsorship of the EEOC, the Department of Justice, the Department of Labor, and the Office of Personnel Management. While in the past these efforts have been based on the use of the Decennial Census, the most recent tabulations used the American Community Survey (ACS).

The EEOC tabulations involve custom calculations of the employed civilian labor force aged 16 and older based on detailed occupational data by race, ethnicity, and gender. The current tabulations were developed from the five-year ACS (2006-2010). The ACS collected information continuously nearly every day from independent monthly samples over 60 months (January 2006-December 2010). This is the best source for detailed occupation data by race, ethnicity, and gender. This note examines data from those tabulations with respect to RNs, including selected advanced practice registered nurses (APRNs). For purposes of exposition, further use of the acronym RNs will connote all registered nurses including APRNs.

Small Sample Sizes

The data are derived from a large and complex sampling program across all professions. While RNs constitute one of the largest occupational groups, they represent just 1 percent of the U.S. population. Peter Buerhaus, PhD, RN, FAAN, has made extensive use of the ACS data; he has indicated that there are roughly 30,000 RN respondents in any single year’s ACS data. Although this is a substantial number of observations, when one starts partitioning the data by gender and age and race and ethnic background, the specific cells can get very sparsely populated very quickly. For this reason, (with one exception) separate analyses of APRNs are not reported. Those APRNs identified in the ACS include Nurse Practitioners (NPs), Certified Nurse-Midwives (CNMs), and Certified Registered Nurse Anesthetists (CRNAs).  Similarly, the large standard errors regarding the multiple race and the smallest single race categories would not allow valid statistical inferences as to whether their distributions were the same or radically different from the included categories with estimated populations of at least 100,000.  Those remaining population groups have been combined into a single, “all other” category.  All of these individual groups had population estimates less than 10,000 and the total population estimate for all other was 41,514.

Initial Overview

The 2006-2010 ACS data estimates indicate there were 2,522,990 registered nurses along with an additional 101,550 APRNs for a total of 2,624,540 RNs. With respect to the grand total, 76.3 percent were single race, not Hispanic (SRNH) Whites and 9.1 percent were male. The age groups available in the data set follow the EEOC design. Unfortunately, that design makes more difficult some of the comparisons between age groups and between RNs and the general population. Although four of the age groups are based on five year cohorts, respondents in their 60s are in a ten year cohort, and the “over 70 years old” cohort is unlimited. The youngest group includes respondents whose age is between 16 and 39. The expected age of new RNs will likely be in the 20s to perhaps low 30s, so RNs are likely to appear to be unrepresentative of the total U.S. population aged 16-39. There are no teenage RNs.

The data with respect to the over-70 cohort will be referenced, but that cohort represents a very small percentage of all RNs. For that reason, some comparisons use the combined cohort of RNs over 60, namely those 60-69 years old in addition to those over 70.

Exhibit 1

Exhibit 1 displays the distributions of RNs and the general employed U.S. population across five racial and ethnic backgrounds. The four largest of those groups are SRNH White, SRNH African-American, SRNH Asian, and Hispanic (who can be White only or other combinations).  Hereafter these groups will be referred to simply as White, African American, Asian, and Hispanic.  The ACS identifies 15 different race and ethnic background categories.  Single race Native Americans and Pacific Islanders and mixed race populations have been combined into a single all other category for this analysis. Those individual groups combined represent 2.1 percent of the general population and 1.6 percent of RNs. 

White RNs are overrepresented relative to the general population, more notably among female nurses: 76.9 percent of female RNs versus 68.4 percent of general population females. Among White males, RNs differ from the general population by 1.6 percent: 69.6 percent versus 67.9 percent.  African-American RNs much more closely represent the general population: 9.6 percent versus 9.1 percent for females; 9.5 percent versus 12.2 percent for males.  Asians are over-represented among RNs. For both males and females, Asians are 4.9 percent of the general population. Among RNs the shares are 7.5 percent and 11.9 percent, respectively. On the other hand, Hispanics are under-represented among RNs. Hispanic females are 4.3 percent of RNs compared to 15.7 percent of the general population. Hispanic males are 7.1 percent of RNs compared with 12.7 percent of the general population.  Finally, the all other group is a smaller share of RNs than its counterpart in the general population, but the difference for both genders is just 0.4 percent.

The EEOC age groupings make difficult any comparisons involving RN representativeness with respect to the general population. As mentioned above, there are no teenage RNs and only a few RNs will be observed in their early 20s. With respect to gender differences, the ACS U.S. employed population (16 and over) was 52.9 percent male. The RN population at the same time was 9.1 percent male. This did vary by race and ethnic background. Whites exhibited the smallest male percentage: 8.3 percent. In ascending order, African-Americans were at 9.0 percent; all other combinations—10.6 percent; Asians—13.7 percent; and Hispanics—14.1 percent.  Partly for this reason, the aggregate distribution of male nurses is more diverse across race and ethnic background than the distribution of female nurses.

Exhibit 2

Exhibit 2 illustrates the change in diversity among U.S. nurses over different age cohorts. There are seven age cohorts identified in the EEOC framework. Exhibit 2 also focuses on six gender-race-ethnic-background groups—for ease of presentation, only Whites are reported by gender. The height of the columns represents the percentage share of the age cohort for each of the six specified backgrounds. White female nurses dominate all of the other groups for all age cohorts. But that dominance is slowly falling. 77 percent of the nurses over age 70 were White females. Every succeeding younger group of RNs exhibits a lower concentration of White female nurses, i.e., more diversity. Correspondingly, although none of those background groups’ shares increased continuously across the increasingly younger age groups, each of the other background groups exhibits an upward trend. The upward trend in increasing diversity was smallest for the all other group. In increasing trend order were African-Americans, Hispanics, White males, and Asians.

Exhibit 3

Exhibit 3 illustrates the shift or difference in racial and ethnic percentage shares of RNs observed when comparing RNs 60 years and older to RNs under 40, in contrast to those shares in the employed U.S. population aged 16 and above. While the White share of RNs over 60 was 80.7 percent, for the RNs under 40 that share had fallen to 71.6 percent. Note that Whites were 68.2 percent of the general population. All of the identified minority population shares of RNs increased in the under 40 RNs compared to the over 60s. Among those younger RNs, the African-American share now just matches the general population at 10.5 percent. The Asian share of the younger RNs increased and continued to exceed the general population share. The Hispanic share of the youngest RNs was more than double that of the oldest RNs, although it was less than half of the general population share.  Finally, in the all other group the youngest RNs’ share came closer to the share of the U.S. population compared to the oldest RNs.

Changing the Course of an Ocean Liner

White females are 36.1 percent of the U.S. population. The White female percentage of the youngest cohort of RNs is still 65 percent of the total for that cohort. Over a 30 year difference from oldest to youngest, does that really represent progress to greater diversity? The challenge remains that there were 1,836,015 White female nurses in the ACS 2006-2010 snapshot, 70 percent of all RNs in that sample. There will not soon be mass changes in individual nurses’ race or gender; in the short run trying to change gender or ethnicity distributions would be like trying to change the course of an ocean liner in an instant. Recruitment of more diverse classes of student nurses can contribute to a change, but over the 2006-2010 timeframe the cohort of new nursing grads who had passed the RN qualifying NCLEX exam averaged only 125,000 new RNs each year. In 2008 there were 3.1 million licensed RNs in the United States. Even if there had been a radically more diverse class of new nurses entering the profession in any year, the concentration of female White nurses would not have changed appreciably. A big ship at sea cannot change course on a dime. 

Although the new classes of RNs become more diverse for many reasons[i], the change toward more diversity may accelerate due to a particular change at the other end of the age distribution, namely, retirement[ii]. The Bureau of Labor Statistics (BLS) in the U.S. Department of Labor has projected that 555,100 RNs will leave the labor force between 2012 and 2022. Further—based on an analysis of the 2008 National Sample Survey of Registered Nurses—after those retirements, there may be an additional 450,000 RNs in practice in 2022 who are 64 years of age or older. The bulk of those nurses will be leaving the labor force before 2030. In 2008 those nurses would have been at least 50 years old. 

The EEOC 2006-2010 Census ACS data indicate 74.8 percent of RNs 50 aged years or older were White female nurses: 730,185 RNs. Those 730,185 RNs amount to 39.8 percent of all U.S. White female RNs.  When those RNs withdraw from the profession through retirement or death, the balance will more quickly shift toward minority nurses, unlike the relatively minor increases in the shares represented by minority new nursing graduates. (Similarly, the National Sample Survey of Registered Nurses for 2008 indicated that there were 742,038 licensed RNs over age 50 whose highest nursing education was a diploma or ADN degree. As those RNs leave the labor force, the remaining balance will more quickly shift toward BSN or higher educational levels than has occurred with relatively minor increases in the shares of new nursing BSN graduates. The share of RNs with a BSN or higher may not hit 80 percent by 2020[iii], but that threshold may be passed soon thereafter.)

Gender Discrimination; Gender Differences

Gender discrimination with respect to registered nurses has taken many forms over the years. For example, many male nurses served in the military during the Civil War. However, in 1901 the Army Nurse Corps was formed, and only women could serve as nurses. Consequently military nursing changed from being predominately male to exclusively female. Not until 1955, after the Korean War, were men again permitted to serve as military nurses. On the civilian side, as late as 1982 men were forbidden to attend some state-supported nursing schools.  A U.S. Supreme Court decision at that time deemed that practice unconstitutional. Before the women’s liberation movement and the opening up of many occupations previously resistant to women’s participation, nursing had been one of the few occupations where women easily found acceptance. Educated, mainly White young women crowded into the profession.  In 1980 97.3 percent of RNs were women.  Twenty years later, it was still the case that 94.6 percent of U.S. registered nurses were women.[iv] 

Upon separate examination of gender differences, White RNs dominate both the female and male distributions of U.S. RNs across race and ethnic categories, 76.9 percent and 69.6 percent, respectively. In the general U.S. population Whites represent 68.4 percent of females and 67.9 percent of males. Whites thus are over-represented among RNs by 8.5 percentage points among women and 1.7 percentage points among men. 

Exhibit 4

  

Exhibit 4 illustrates the concentration of White RNs by gender and age cohort in the 2006-2010 ACS data. Both the female and male distributions might be inferred to show an increasing concentration of White RNs from the cohort older than 70 through the 60-69 year old cohort to the 55-59 year old cohort. For both genders, this was followed by a deconcentration of White RNs in the succeeding cohorts. With the exception of the 55-59 year old cohort, the White female RNs concentrations in all age cohorts have always appeared greater than those of the White males. (Among female RNs the White concentrations ranged from 81.7 percent to 72.5 percent. Among males RNs the range was 82.3 percent to 63.1 percent.)

One must remember to exercise caution with these data, particularly with respect to the estimated totals for males. The estimated number of all male RNs over age 70 was 985 or 4.0 percent of RNs of both genders in that age group. The number of actual ACS respondents who contributed to this estimate might have been in single digits. The male percentage of all RNs increased from 4.0 percent among the over 70s to 10.3 percent in the under 40 cohort with an estimated population of White RNs at 60,550. (An estimate of the male percentage of RNs based on employed RNs in the 2013 ACS data was 11.8 percent.[i])  The older cohorts of White RNs were estimated to each number roughly 25,000 or fewer.  The robustness of the individual cohorts’ White concentration may be subject to question, but the general pattern of results is consistent. The data do suggest that the concentration of White RNs has been diminishing in the younger cohorts of RNs. Further, it does appear that male RNs in the U.S. have had a more diverse population than females RNs with respect to race and ethnic background. Among the under 40s, female RNs were estimated to be 72.5 percent White, while male RNs were estimated to be 63.1 percent White.

In this regard, small sample sizes again require caution when examining gender or race/ethnic differences among APRNs identified in the 2006-2010 ACS data. Those ACS data indicate there were 101,550 NPs, CNMs, and CRNAs represented by respondents. In contrast, the 9.1 percent of all RNs estimated to represent all male nurses included in total just 238,420 nurses. Regarding gender, racial, and/or ethnic background, population characteristics of subpopulations representing 100,000 or fewer persons defy statistical significance. 

It should also be noted that the addition of Standard Occupational Classification (SOC) codes for NPs, CRNAs, and CNMs was officially introduced in 2010 version of the SOC. Possible recoding of pre-2010 ACS data might have added noise to the data for those selected APRNs.

Nonetheless, some patterns may be suggestive. For example, it is well known that nurse anesthetist practice has attracted proportionately more male nurses than many other specialties. With the possible exception of the over 70 age cohort, the male percentages of the enumerated CRNA cohorts indicate that this pattern was not a recent occurrence. (Note that the estimated number of male CRNAs over age 70 was only 45.) Over the entire set of CRNAs the male share was 42.8 percent compared to the 7.4 percent of NPs/CNMs who were male.

Exhibit 5

Male CRNAs

Age group

Percent male

Estimated totals

16-39

41.1 %

2,720

40-44

41.8 %

1,420

45-49

37.2 %

1,165

50-54

43.7 %

1,425

55-59

51.9 %

1,675

60-69

45.8 %

1,120

70+

16.7 %

45

all ages

42.8 %

9,570

Conclusion

The data document the continued predominance of White females among RNs. As noted, that is not likely to be quickly changed. But the data also do confirm modest progress in enhancing the diversity among RNs with respect to gender, race, and ethnic background. Exhibit 2 confirms the 2006-2010 snap shot of succeeding younger cohorts of RNs shown to be less and less concentrated with respect to White female nurses. Exhibit 3 demonstrates that same contrast between RNs 60 years and older and those RNs younger than 40. For all of the non-White race and ethnic background groups, representation among the under 40s was higher than that exhibited by the 60 and over group. With the exception of Asians, the under 40 race/ethnic background shares were closer to the U.S. national average than observed among RNs 60 years or older. Male nurses were also an increasing presence among nurses as a whole and in each of the race/ethnic background groups. The one exception involved CRNAs who have exhibited a much more balanced gender distribution across all age groups compared to any of the individual race or ethnic background groups. 

The anticipated retirement of the RNs who entered the profession in the mid-1970s to mid-1980s will more dramatically change the distribution of RNs by race and by educational background. Roughly three-quarters of a million U.S. nurses are White females over age 55 (in 2015). The BLS projects that 555,000 RNs will leave the labor force by 2022. Another 450,000 RNs still in the labor force will be aged 64 or older.  They will also be leaving the labor force between 2022 and 2030. BLS also projects that a total of 1.13 million vacancies for RNs will emerge between 2012 and 2022. If White male nursing students and minority nursing students of both genders continue to enter the profession, there will be a large number of opportunities for their placement. Finally, many of those anticipated to retire do not have a BSN degree, and this is the case for older White, African-American, Asian, and Hispanic RNs. As RNs whose highest nursing education accomplishments involve Diploma programs or Associate Degree programs also retire, the increase in the BSN proportion of RNs will accelerate. Although the profession may not achieve an 80 percent BSN share by 2020, it may hit that target early in the next decade.


Foot Note/End Notes

[1] The origin of the word nurse in late Middle English was a contraction of the earlier nourice—from Old French, from the late Latin nutricia, feminine of Latin nutricius, “(person) that nourishes.

[i] AACN Policy Brief, “The Changing Landscape: Nursing Student Diversity on the Rise” http://www.aacn.nche.edu/government-affairs/Student-Diversity-FS.pdf.   See also The Minority Fellowship Program, http://www.emfp.org.

[ii] Peter McMenamin, “2022: Where Have All Those Nurses Gone?” One Strong Voice, March 14, 2014

http://www.ananursespace.org/blogs/peter-mcmenamin/2014/03/14/rn-retirements-tsunami-warning?ssopc=1

[iii] Institute of Medicine, The Future of Nursing: Leading Change, Advancing Health,  October 2010

http://iom.nationalacademies.org/Reports/2010/The-Future-of-Nursing-Leading-Change-Advancing-Health.aspx.

[iv] HRSA, The Registered Nurse Population March 2000

http://bhpr.hrsa.gov/healthworkforce/rnsurveys/rnsurvey2000.pdf.

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