The nursing profession in the United States was experiencing a labor shortage and facing diversity and inclusion challenges prior to the COVID-19 pandemic.¹ Magnifying these problems was a shift in the nation’s population, both geographically and demographically.² The result was changes in both where nurses are needed in the healthcare system and the nursing skill set required to address healthcare needs of a far more diverse clientele of patients—in terms of race, ethnicity, sex, gender identity, age, living arrangements, socioeconomic status and primary language.³

The COVID-19 pandemic has complicated matters by exacerbating the nursing shortage and further highlighting diversity challenges within the nursing profession and the U.S. healthcare system.⁴ These problems are rooted in two critical facets of the current crisis.

The first significant component is the way in which the COVID-19 pandemic has evolved over time.⁵ Initially, the major coronavirus hot spots in the U.S. were concentrated in New York City and other major urban centers. Then the hot spots shifted to the Sunbelt. Most recently, the virus has spread rapidly in sparsely populated states in the upper Midwest and Mountain regions, as well as diverse states like California—in each instance causing major shifts in demand for nurses and other healthcare workers.

Further complicating matters is that some residents—dubbed coronavirus pandemic refugees—have responded by fleeing such hot spots, often relocating to smaller, less densely settled communities in the suburbs, exurbs and small towns—areas perceived to be safer because practicing social distancing is easier there.⁶ A significant share of the pandemic refugees appears to be wealthy individuals voting with their feet to protect themselves and their loved ones from the spread of the deadly virus.

In addition, the shift to remote work, implemented in some industries to reduce possible exposure to the deadly virus, created the impetus for some middle- and moderate-income homeowners and renters—mainly millennials and families with young children—also to flee coronavirus hot spots, especially urban centers with a high cost of living like New York, Seattle, San Francisco and Los Angeles. In some instances, this has led to the emergence of so-called “Zoom Towns” in amenity-rich, exurban and rural areas (especially in the western U.S.), where healthcare systems and other public services may not be adequate to accommodate the influx of newcomers.⁷

The second critical facet is the disparate impacts of the COVID-19 virus itself on older adults and people of color—individuals who are especially vulnerable because their immune systems and overall wellbeing have been severely comprised by the social determinants of health.⁸ Effective care of these individuals requires nurses and other healthcare staff with specific language fluencies, cultural competency and specialty care skills that are often in limited supply, especially in rural communities and economically distressed urban areas.

Healthcare systems across the U.S. have employed multiple strategies to address their pandemic-induced nursing shortages and other staffing needs.⁹ Action steps include extending nursing shift hours, recruiting retired and travel nurses, and drawing on military medical reinforcements. Yet personnel challenges remain as successive waves of the deadly virus decimate the existing nursing workforce.

Nurses on the frontlines of the COVID-19 pandemic are intensely committed to their profession and highly motivated to serve in the current crisis. However, forces beyond their control are driving staff turnover. They include:

• Mental health challenges and burnout due to daily exposure to virus-related trauma and loss of life
• Personal exposure to the virus, requiring quarantine or hospitalization, and, in some instances, leading to death
• Forced resignations to care for exposed family members or children requiring home schooling due to the pandemic¹⁰

These problems are especially acute for healthcare systems in rural communities. Such systems typically do not have the resources to recruit travel nurses and, even if they did, may not be attractive work destinations for nurses in this sector of the profession.¹¹ Moreover, for the existing nursing workforce, these communities usually lack networks of caregiving institutional supports that are typically more readily available in wealthy urban communities.

Elsewhere, we have highlighted nine specific steps the nursing profession must take to address the nursing shortage in general.¹² Here, we focus on two recommended actions as specific responses to staffing and diversity challenges that the COVID-19 pandemic has precipitated.

Organizational leaders and stakeholders in the nursing profession ecosystem must first develop a keen understanding and appreciation of how disruptive demographics are transforming and will continue to transform the nation’s workforce in the years ahead.¹³ Immigrants and native-born people of color are changing the complexion of the U.S. workforce—popularly referred to as the “browning” of America—at the same time that a large segment of the U.S. native-born, predominantly white population is aging out of the workforce—popularly referred to as the “graying” of America.¹⁴

Concerns about the browning and greying of America are polarizing issues in our nation’s current political and policy discourse.¹⁵ Political landmines notwithstanding,¹⁶ key stakeholders in the nursing profession must recognize and embrace as a core business strategy the pivotal role that people of color will play in the profession’s workforce of the future.¹⁷

Second, to compete successfully, especially given shifting workforce dynamics, organizational leaders will have to demonstrate commitment to dismantling systemic racism in the nursing profession ecosystem.¹⁸ At the same time, they must embrace the core principles of Diversity, Equity, Inclusion and Belonging (DEIB) in talent recruitment, development, retention and promotion, in the process creating what we refer to as reputational equity for the nursing profession.

Specifically, to create reputational equity, leadership must undertake a comprehensive DIEB audit of the entire nursing profession ecosystem. That is, they must critically review and evaluate policies, procedures and practices that govern the day-to-day operations of professional schools that train and produce the nursing workforce. The same must be done for the various components the U.S. healthcare system that rely on the talent the nursing education, training and certifying systems produce.

As we have shown elsewhere,¹⁹ this ecosystem-wide diagnostic assessment will identify regulatory, administrative and financial constraints and barriers that undergird the nursing shortage and inequities in nursing education, training and certification, as well as working conditions in healthcare settings. Key stakeholders in the nursing profession should use the checklist of the evidenced-based strategies, policies, tactics and procedures for developing reputational equity as a guide to fix problems uncovered in the DEIB organizational audit.²⁰

As the left panel of the table below shows, the checklist includes four intervention domains. Based on research on corporate reputational equity, we have populated table’s right panel with examples of specific implementable strategies, policies, tactics, procedures and practices that address the labor shortage and DIEB issues in the nursing profession.

Reputational Equity Checklist
Intervention Domain	Strategies, Policies, Tactics, Procedures and Practices
Leader behaviors and commitments	Housing allowances in scholarship and fellowship packages to support diverse nursing student recruitment and retention Invest in affordable housing to recruit and retain nurses in hospitals and other healthcare settings
Talent recruitment, development and retention	Advocate for immigration reforms that support temporary visas for foreign-born nurses, and place-based visas to help rural health systems recruit nurses from abroad Decrease the number of nursing students denied admission to nursing programs by advocating and incentivizing actions that would make teaching nursing an attractive career option Concentrate efforts to recruit male nurses
Workplace culture and climate	Address stereotyping, bias and discriminatory treatment of males in nursing education programs and work settings Close the pay gap between nurse educators and nurses in practice Establish and support caregiving networks Encourage DEIB courageous conversations
Community engagement and support	Support mental wellness, food security and residential stability for the nursing workforce Establish a nursing career pipeline program in schools with large historically marginalized student populations

We believe a fully executed DEIB audit using the reputational equity checklist will enable the nursing profession to “continuously recruit, train, employ, nurture and retain a diverse workforce with demonstrated cultural competencies to care for an increasingly more diverse client base.”²¹ At the same time, it will enhance the ability of healthcare entities—nationally and internationally—to be better prepared when confronted with the next major health crisis.

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• Keyword(s):
• covid-19 188
• disruptive demographics 30
• gender 30
• hospital 13
• inequality 94
• race 45
• rural communities 15