Anti–Diversity, Equity, and Inclusion Legislation: Potential Impacts on Oncology Nursing Workforce Diversity and Patient Health Outcomes

Abstract

More than 30 states have passed anti–diversity, equity, and inclusion (DEI) legislation prohibiting or restricting DEI initiatives in public colleges and universities. This article examines anti-DEI legislation and its potential impact on the diversity of the oncology nursing workforce and health-related patient outcomes.

AT A GLANCE

• ■ Oncology nurses can work with professional nursing organizations to educate legislators about the goals of DEI policies.

• ■ Mentorship programs developed by oncology nurses can increase the number of individuals from underrepresented groups in healthcare careers.

• ■ Oncology nurses can advocate for a diverse nursing workforce by testifying in opposition to policies that may result in reduced care and poor outcomes for patients with cancer.

The U.S. Department of Health and Human Services posits that laws and policies are vital determinants of health and well-being (Teitelbaum et al., 2021). They contribute to the environments in which people are born, learn, live, work, worship, play, and age. Laws and policies can stimulate positive behaviors or discourage harmful behaviors; they can improve or worsen physical or mental health; and they can increase or decrease health disparities, health equity, and health literacy (Teitelbaum et al., 2021). An example of how laws and policies can potentially affect the health and well-being of individuals and the population can be seen in the trend of anti–diversity, equity, and inclusion (DEI) legislation in the United States.

Anti-DEI legislation prohibits DEI initiatives in public colleges and universities that focus on promoting and increasing representation of students from historically underrepresented racial and ethnic groups. In addition, anti-DEI legislation often prohibits mandatory DEI training; limits using DEI statements in hiring staff; bars using race or ethnicity in admission decisions; and eliminates DEI-related positions in higher education, public offices, and industries (Murray et al., 2023).

As of May 2, 2024, about 30 states have passed or introduced more than 100 bills in the United States targeting DEI programs, funding, and practices at state-funded institutions (HR Specialist, 2024). In addition, 10 laws exist that ban DEI initiatives at state-funded colleges and other government institutions in Texas, Utah, Alabama, Idaho, Tennessee, Florida, South Dakota, and North Dakota (Lu, 2023).

Supporters of anti-DEI state legislation argue that DEI programs and initiatives are costly to taxpayers, infringe on academic freedom, and are discriminatory (Lee & Gluckman, 2023). Opponents of anti-DEI legislation equate these laws to censorship and a means to halt progress in addressing decades of inequality (Murray et al., 2023). This article examines anti-DEI legislation and its potential impact on the diversity of the oncology nursing workforce and health-related patient outcomes.

Oncology Nursing Workforce

Several factors contribute to health disparities in cancer care, such as a lack of access to high-quality care, cultural and religious beliefs, low socioeconomic status, language barriers, comorbidities, and other risk factors (Kale et al., 2023; Williams et al., 2024). The lack of a diverse oncology nurse workforce is also a barrier to quality cancer care (Carter, 2020; Williams et al., 2024).

The Future of Nursing 2020–2030 report from the National Academy of Medicine emphasizes the importance of a diverse nursing workforce to improve healthcare quality (National Academies of Sciences, Engineering, and Medicine, 2021), yet only 9.9% of RNs identify as Black or African American, 8.3% as Asian, 4.8% as Hispanic or Latino, 1.3% as two or more races, and 0.4% as American Indian or Alaska Native; only 9.1% self-identify as male (Minority Nurse, n.d.). Regarding oncology, Black people are underrepresented at every level of the medical oncology workforce, including clinical trial research (Winkfield et al., 2021). Similarly, according to the American Society of Clinical Oncology, despite their efforts to diversify the oncology physician and fellow workforce, female, African American, and Hispanic individuals continue to be underrepresented (Duma et al., 2022; Velazquez Manana et al., 2020). The lack of diversity in the nursing profession is multifactorial. Research indicates that nursing students who are Black, Asian, or from other historically underrepresented racial or ethnic groups may encounter racism, discrimination, bias from their instructors or peers, or feelings of isolation or being excluded, and may experience a lack of role models, all of which may affect recruitment and retention of a diverse oncology nursing workforce (Ackerman-Barger et al., 2020; Caffrey et al., 2023; Johnson et al., 2020; Murray et al., 2023).

A diverse oncology nursing workforce can improve the quality of care for patients with cancer from historically underrepresented and underserved groups, including those with Medicaid insurance or who are uninsured (Hassmiller, 2021). Diversity in the workforce strengthens cultural competence, improves patient– provider relationships through better communication and linguistic concordance, and increases patient adherence and satisfaction with care (Agarwal et al., 2022; Greenwood et al., 2020; Snyder et al., 2023; Takeshita et al., 2020; Williams et al., 2024). Equally, a lack of diversity in the oncology nursing workforce may contribute to cancer-related health disparities (Murray et al., 2023; Patel et al., 2020; Williams et al., 2024).

Because of the shortage of nurses from historically underrepresented groups and barriers to diversity in nursing, anti-DEI legislation will likely exacerbate the shortage of a diverse nurse workforce by impeding efforts to promote equity, inclusiveness, and understanding within the nursing profession (Adams et al., 2021). Advocacy for DEI is a component of developing a diverse oncology nursing workforce, reducing health disparities, and improving health-related patient outcomes (Carter, 2020; Murray et al., 2023).

Health-Related Patient Outcomes

Health disparities in oncology care exist across gender, race, and socioeconomic status (Owoyemi & Aakhus, 2021; Patel et al., 2020). For example, compared to White people with stomach, uterine, or prostate cancer, the mortality rate is twice as high for Black people (Siegel et al., 2024). Similarly, for Native Americans, the mortality rate is twice as high for cancers of the kidney, liver, and stomach compared to their White counterparts (Siegel et al., 2024). Another issue is the disproportionately low enrollment of patients from historically underrepresented groups in oncology clinical trials, which threatens the overarching goals of clinical trial research (Oyer et al., 2022; Roy et al., 2023).

Studies suggest that a diverse and representative healthcare workforce can improve health-related patient outcomes, access to care, and perception of care among patients from historically underrepresented groups (Agarwal et al., 2022; Greenwood et al., 2020; Snyder et al., 2023; Takeshita et al., 2020). For example, Snyder et al. (2023) reported that greater representation of Black primary care providers in the workforce was associated with improved survival-related outcomes in Black patients. Similarly, in a study of 32,041 patient–provider pairs, Malhotra et al. (2017) found a positive association with breast, colorectal, and cervical cancer screening in patients whose providers were the same gender. In contrast, there was an inverse association with cancer screening among Hispanic patients whose providers were of the same ethnicity (Malhotra et al., 2017). Conversely, implicit bias, race, and structural racism adversely affect social determinants of health, healthcare quality, and health-related patient outcomes (Macias-Konstantopoulos et al., 2023; Siegel et al., 2024).

In 2018, it was estimated that racial and ethnic disparities cost the U.S. economy about $451 billion, which signified an increase of 41% from 2014’s estimate of $320 billion (LaVeist et al., 2023). Consequently, a lack of diversity not only leads to health disparities but is also associated with higher healthcare costs (LaVeist et al., 2023; Murray et al., 2023).

Implications for Nursing

Based on the surge of anti-DEI legislation, nurses and their professional organizations may consider developing other strategies to recruit and retain a healthcare workforce that mirrors the population that they serve. Strategies that may increase recruitment and retention of a diverse oncology nursing workforce include the following (Murray et al., 2023; Patel et al., 2020):

• ■ Working with state and national professional nursing organizations to educate legislators about the goal of DEI initiatives

• ■ Offering testimony in opposition to policies that may result in reduced care and worse treatment outcomes for individuals across the cancer continuum and their families

• ■ Developing mentorship programs to increase the number of individuals from underrepresented groups in healthcare careers

• ■ Educating healthcare professionals about the impact of health disparities and structural racism on health-related patient outcomes

• ■ Increasing financial support for nursing research on healthcare disparities

• ■ Advocating to classify nursing as a science, technology, engineering, and mathematics degree to increase diversity and funding

Conclusion

Only time will determine the long-term consequences of anti-DEI legislation on diversity in the oncology nursing workforce and health-related patient outcomes. In the interim, nurses and their professional organizations may consider staying vigilant and advocating for policies and laws that will improve the recruitment and retention of nurses from historically underrepresented groups and embrace inclusiveness, diversity, and equity.

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Communities focuses on inequity in cancer care, the care of marginalized or underserved groups domestically or internationally, and financial toxicity. If you are interested in writing for this department, contact Associate Editor Maggie A. Smith, DNP, MSN-Ed, RN, OCN^®, at smith.maggie@comcast.net.