Author: Melillo, Karen Devereaux
Date published: July 1, 2013
There is a clear link between lack of diversity in the nursing workforce and nursing's ability to effectively address health disparities with high-quality, culturally competent care (AACN, 2011; Huston, 2008). Efforts to increase and maintain baccalaureate-prepared minority nurses to begin to reflect the diverse population needing culturally responsive, high quality care is a continuing goal of nursing education and practice. Because of this, initiatives focusing on increasing ethnic and cultural diversity of healthcare workers are of high priority. Despite modest gains in ethnic and racial minority representation in the nursing profession, the current nursing workforce does not mirror the U.S. population. Attempts to recruit, retain and graduate a diverse cadre of professional nurses remain a goal for nurse educators and nursing programs. The American Association of Colleges of Nursing (AACN) (2009) has identified the need to "attract students from underrepresented groups in nursing - specifically men and individuals from African American, Hispanic, Asian, American Indian and Alaskan native backgrounds" (p. 1). To address this critical need, the U.S. Health Resources and Services Administration (HRSA), Bureau of Health Professions, Division of Nursing, provided federal funding for Nursing Workforce Diversity (NWD) grants to colleges and universities. The purpose of tne NWD program is to provide funding for projects to increase nursing education opportunities for individuals from disadvantaged backgrounds through three major components: Pre-Entry Preparation, Retention, and Student Scholarships and /or Stipends.
In July 2008, the University of Massachusetts Lowell (UML) Department of Nursing received funding from the Bureau of Health Professions to support the Bring Diversity to Nursing (BDN) project. This funding, coupled witn funding from the Massachusetts Department of Public Health (MDPH), Reducing Racial and Ethnic Health Disparities: Workforce Development grant 20072010, allowed the Nursing Program to begin to address the needs in the northeast area of Massachusetts known as the Merrimack Valley.
UML is located in tne Merrimack Valley where the two largest cities are Lowell and Lawrence. These cities are culturally diverse and have Hispanic and/or Asian populations that are disproportionately higher than the state levels. Both socioeconomic and health disparities exist in Lowell and Lawrence. The city of Lowell has an estimated population of 98,766 with a growing number of individuals of Asian and Hispanic backgrounds. Twenty-four percent were not born in the U.S., and 17.5% of all persons in Lowell live below the poverty level, compared to 13% statewide (U.S. Census Bureau, 2006-2008a). The city of Lawrence has a population of 71,234. It, too, is an ethnically diverse city with a primarily Hispanic background representing nearly 71% of the population, ana 34.7% of its residents were not born in the U.S. In some areas of the Merrimack Valley, the Hispanic population has risen to more than 4.5 times that of the nation. Over 26.7% of all persons in Lawrence live below the poverty level (U.S. Census Bureau, 2006-2008b).
The overall number of baccalaureate-prepared nurses in the state of Massachusetts falls short of the number of nurses needed to provide culturally competent nursing care, especially when addressing tne ethnically diverse populations served. Data regarding the percent of minority nurses in the Merrimack Valley are not available. However, according to the 2002 senior nursing student survey commissioned by the Massachusetts Board of Registration in Nursing, Hispanic ethnicity was reported to be 3.0% compared to the representation in the state population of 6.8%, while the Asian /Pacific Islander was reported as 2.5% compared to the state population of 3.9% (Simons, 2002). The Massachusetts Association of Colleges of Nursing (2005) found that of all students graduating from diploma, associate degree and baccalaureate nursing programs in 2004, only 3.8% were of Hispanic background and 6.3% were from an Asian background; of these, only 0.8% of Hispanic and 5% of Asians obtained a baccalaureate degree.
Four BDN project objectives were to: (1) improve access to the nursing profession by recruiting minority and disadvantaged students through pre-entry initiatives at the elementary, middle and nigh school levels, (2) demonstrate the efficacy of a rigorous student nurse retention program, (3) provide stipends, scholarships, and educational technologies to qualified minority/ disadvantaged students who are accepted to, and successfully progress in, the BDN program and (4) increase culturally responsive and high quality health care by graduating diverse nurses who will provide nursing services to diverse populations. This paper will describe progress that the BDN project has made in meeting the four objectives
PRE-ENTRY REQUIREMENT INITIATIVES
Initiatives to promote nursing as a career choice and to recruit minority and disadvantaged students into the profession of nursing took place through high school and middle school workshops, elementary school readings, and efforts by minority nurse recruiters. The desire to promote nursing as a career choice to the youth in the Greater Merrimack Valley community has been a strategic goal for nursing faculty who participated in the project. The solid record of faculty volunteerism and community service to the cities of Lawrence and Lowell, along with the collaborative relationship of UML and the cities, served as the catalyst for the successful development of the project and its corresponding pre-entry recruitment activities. Partnering with both cities during the development of this project allowed for all stakeholders to have an active voice and provide input regarding the methods to achieve the project goals and objectives.
Data generated and analyzed from the pre- and posttests used in a summer 2007 pilot project were used to develop an online 29-question Nursing Awareness Survey. Tne survey was designed to assess the awareness of nursing as a career choice in middle and high school students from the Lawrence and Lowell public schools. Application to the UML Institutional Review Board was completed and exempt status/approval was granted. Permission also was obtained from both Superintendents of Lowell and Lawrence public schools to offer this online survey to public school students. The survey was posted on the BDN website to allow easy access and completion. There have been 1,595 respondents to the survey: 67% from Lawrence and 33% from Lowell, gender distribution: 51% girls and 49% boys; race and ethnicity: 45% Hispanic /Spanish, 28% Wnite, 15% Asian, 7% Black and 5% reporting Other. An overwhelming majority (92%) of participants responded that nursing was a career for both men and women. Of the total participants, 55% answered no to the question about being interested in nursing as a career, suggesting there is a current need for increasing awareness about and promoting nursing as a desirable career choice.
Middle and High School Workshops
A series of four one-hour interactive, age-appropriate, workshops were developed to introduce nursing as a career choice for middle and high school students. A total of 313 students have participated in workshops. The middle school Nursing as a Career Choice workshops were designed to stimulate interest in nursing and to help students begin to identify important academic and psychomotor skills nurses use daily and are summarized in a recent article (Knight, Abdallah, Findeisen, Melillo, & Dowling, 2011). The high school Introduction to Nursing workshops focused on helping interested students prepare for nursing as a college major. The importance of nigh school course selections (e.g. math, science), maintaining a strong grade point average (GPA), early preparation for tne Scholastic Achievement Tests (SATs) or the American College Testing exams (ACTs), and regular meetings with guidance counselors was emphasized. BDN staff work with any student who is interested in nursing and provide direction for pursuing a career in nursing.
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Elementary School Readings
Pre recruitment initiatives include promoting nursing through readings of the book Nurses by Menden and Armantrout (2006) to elementary school students by BDN faculty and student volunteers. The reading stimulates questions about: who can be a nurse, where nurses work, who knows a nurse, who has been taken care of by a nurse and how nurses help the community. Students eagerly share experiences with broken bones, sick family members, bicycle accidents and falls. The book, Nurses, has been read to 1,415 first and second grade students in 13 different schools.
Minority Nurse Recruiters
The minority nurse recruiters are essential members of the BDN team. They are graduates of the UML nursing program and live in the respective community to which they are assigned and therefore are able to identify with community members and also speak the language of the predominant minority populations within the community. The minority nurse recruiters participate in open houses at the University and high schools, outreach to the high schools and community colleges in Lowell and Lawrence, meet with interested students to review transcripts and SAT scores and assist students in high school course selection to enhance success in nursing. The minority nurse recruiters work closely with a dedicated UML admissions officer for the nursing program and guidance counselors at the respective nigh schools. The success of these recruitment efforts, along with those of the after-school workshops for middle and high school students in Lowell and Lawrence, is reflected in Table 1, which details the change in applications and acceptances from Lowell and Lawrence from 2004 to 2011. From 2004 to 2011, applications from Lowell High School soared 300% and from Lawrence 200%, while acceptances increased from Lowell by 800% and from Lawrence 500%.
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RECRUITMENT AND RETENTION ACTIVITIES FOR UML NURSING STUDENTS
The second arm of the BDN project is to recruit nursing students admitted to UML into the BDN retention program and to provide stipends, scholarships and educational technologies to assist students to be successful in passing the National Council Licensing Examination (NCLEX). The underlying goal is for students and graduates to give back to their respective communities and provide culturally competent and high quality nursing care to diverse populations. At UML, there was a 1.7% increase in the number of nursing students identifying as Asian/Pacific Island (6.7%), Black non-Hispanic (6.4%), or Hispanic/Latino (5.0%) in 2009 (18.1%) compared to 2008 (16.4%), with another 2.1% overall increase from 2009 to 2010 to 20.2% (UML Institutional Research, 2009, 2010). In a 2007 classroom survey of nursing students, self-reported race and ethnicity data by nursing students revealed that 12% of the student population represented racial and ethnic minorities; in 2011, University-wide data reveal that 20.2% of the nursing student population self-reported as racial and ethnic minorities (See Table 2, UML, Institutional Research, 2010). This further reflects the intensive efforts by the Nursing Program at recruitment and retention.
All nursing students admitted to the UML nursing program are invited to apply to become part of the BDN project. Application criteria include full-time enrollment for prelicensure students and full or part-time enrollment for RN-BS students. Priority is given to students of Hispanic and Southeast Asian descent, graduates of Lowell and Lawrence High Schools, ana students disadvantaged economically per federal guidelines (i.e. poverty level below 200% which in 2009 for a family of 4 was an income of $44,000 or less). Interested applicants submit a letter of interest with a 250-500 word essay describing their nursing goals, experience with barriers to academic success, and interest in serving in an area of critical nursing shortage. All candidates are interviewed by members of the BDN Enrollment Committee.
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In addition to competitive admission criteria, the BDN project provides a rigorous retention program. Table 3 summarizes the retention success of the BDN students since 2008-2009 through to 2010-2011. Best practices for the retention of nursing students with minority and disadvantaged backgrounds suggest a threefold approach (Amaro, Abriam-Yago, & Yoder, 2006; Bagnardi & Perkel, 2005; Davidhizar & Shearer, 2005; Dowell, 1996; Gardner, 2005; Yoder, 2001; Zuzelo, 2005). The BDN project provides support services to meet students' academic, personal, and socio-cultural needs. Stipends or scholarships, loan of laptop computers/software, and personal digital assistants (PDAs) or iPod touches are provided to assist students in their academic achievement. Students sign a contract accepting responsibility for fully participating in all of the BDN retention activities, including the loan of the technology equipment. Individual and small group tutoring, 24-hour access to web-based courses with video-recorded lectures, and teaching that incorporates culturally appropriate case studies and simulation scenarios are also available to BDN students. Students enroll in a one-credit nursing course focused on time management, reading, writing, and test-taking skills, as well as academic and clinical requirements expected for academic success. Prelicensure senior students receive an NCLEX review book and a 15-week online review course to assist with NCLEX-RN preparation.
The Coordinator of Diversity Support Services manages the academic component of the retention plan. Students meet with the Coordinator at least once a month, maintain an academic portfolio, and send an electronic journal weekly identifying their goal for the week, as well as how and when tney will achieve this goal. Sixty-seven percent of BDN students agree or strongly agree that participation in these academic services resulted in the improvement of academic skills (e.g. studying, test-taking). End-of-year student evaluations reported tutoring as the service most helpful for academic progression.
Individual counseling services are available if needed with the BDN Psychiatric Mental Health Nurse Practitioner who also served as a group facilitator for the monthly BDN student meetings. A survey of BDN students reveals that respondents agree or strongly agree that participation in support services resulted in the development or improvement of life management skills (e.g. computer and time management) and self-empowerment (e.g. test anxiety, stress and financial management) skills, 59% and 78% respectively.
Socio-cultural services include receptions celebrating cultural diversity day, volunteering with BDN elementary school readings and middle/high school workshops or UML open houses, pot-luck dinners, and making connections through online networking programs, email, and instant messaging. Students are also encouraged to participate in UML culturally diverse student associations. However, BDN students report that they want to learn about other cultures rather than join a culturally similar student organization. Fifty-eight percent of BDN students agree or strongly agree that participation in socio-cultural services resulted in development or improvement of cultural skills (e.g. broader understanding of other cultures).
GRADUATING DIVERSE NURSES
The academic, personal, and socio-cultural services of the retention program support BDN students' progression and graduation from the baccalaureate nursing program. In the first year, 2008-2009, 18 students were enrolled in the BDN project. In the second year, 20092010, 32 students were enrolled (7 seniors, 11 juniors, 8 sophomores, and 6 freshmen) and demographics included 6 males; 30 prelicensure and 2 RN-BS students; 7 Hispanic, 11 African-American, 11 Asian, and 3 unreported; and 10 are from Lowell High School. In year three, 2010-2011, 37 students were enrolled with 9 reporting Hispanic, 8 African-American, 19 Asian, and 3 more than One Race; 14 of these students were from Lowell High School and 3 were from Lawrence High School.
Table 4 summarizes BDN graduation and NCLEX-RN success rates. The program has 100% graduation rate (n=2) in Year 1 (2008-09), 100% (n=6) in Year 2 and 100% (n-=8) in Year 3. The program retention rate was 77% in Year 1, 90% in Year 2, and 92% in Year 3. One caveat that all project faculty agree on is that early intervention is more successful in promoting student progression than attempting to save students who have had long standing academic difficulties. Overall, BDN students are quite successful as evidenced by mean GPAs at the end of each year (see Table 5).
Reflection on the three years of the BDN project reveals the importance of the development and maintenance of partnerships to be successful. The project was met with enthusiasm by the partners, yet we have found that the partners function in different ways that make it necessary to tailor the implementation of the project to meet the needs not only of the project but also of the community partners. Project timelines are not always the same as partner timelines, so flexibility, patience, understanding and communication are key in regards to goals and time frames. BDN members also found that in tne enthusiasm to implement the pre-entry components of the project, it is necessary to be cognizant of one's own time. BDN members nave often over extended themselves which is reflected in exceeding the number of students that we had proposed to reach.
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The Coordinator of Diversity Support, advisors, counseling, tutoring and social networking are all viewed as essential components in the success of the retention component of the BDN project. The Coordinator of Diversity Support is the main contact person that students have. Students meet with the Coordinator to discuss academic goals, outcomes, and identify difficulties, with the Coordinator assisting students in finding support systems such as tutors, counselors, and study groups. Students maintain contact with the Coordinator through weekly e-journals and monthly face-to-face meetings. All nursing students are assigned a nursing faculty academic advisor. The advisor often is the main contact person that a student has to encourage application to BDN and is an important first line contact in promotion of the project.
The success of the BDN project is directly linked to the personnel involved. The vision and enthusiasm that initially brought the project to fruition has not waned throughout the project period. We have been fortunate to recruit an experienced grant project manager and graduate nursing research assistants that have assisted in the implementation of assessment survey, tutoring, and conducting workshops. Students in the BDN project also are asked to give back to the project through volunteer work. Students participated in open houses, career fairs, elementary school readings, as well as assisted with middle and high school workshops. Grant administration liaisons at HRSA and MDPH nave been invaluable in answering questions, dialoguing about the project, problem solving and have joined in tne success of tne project.
Using media to get the BDN promotional message out has been accomplished by partnering with the UML Art Department to develop a campaign for the project including promotional materials and a project logo. Students participating in pre-entry workshops receive BDN future nurse pins ana pencils. Partners display BDN posters and banners. Print media (e.g. newspapers, promotional brochures), radio, television appearances, a BDN website and professional conferences are utilized to promote the program and the success of the project. The BDN team remains committed to improving access to the nursing profession for minority and disadvantaged students through pre-entry recruitment and retention activities. It is the progression and graduation of BDN students that inspire faculty to continually learn, teach, advise, and celebrate in students' success and eventual practice as a professional nurse addressing health care needs and reducing health disparities in the Lowell and Lawrence communities and beyond.
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U.S. Census Bureau (2006-2008a). American community survey 3 year estimates: City of Lowell Massachusetts. Retrieved 04/12/10 from http:// factfinder. census. gov.
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Yoder, M. (2001). The bridging approach: Effective strategies for teaching ethnically diverse nursing students. Journal of Transcultural Nursing, 12, 319-325.
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"This project is supported in part by fundsfrom the Division of Nursing (DN), Bureau of Health Professions (BHPr), Health Resources and Services Administration (HRSA), Department of Health and Human Services (DHHS) under grant number D19HP09221-01-02 and title Nursing Workforce Diversity, 2008-2011. The information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by the Division of Nursing, BHPr, DHHS, or the U.S. Government. " Funding also was received from the Massachusetts Department of Public Health, "Reducing Racial and Ethnic Health Disparities: Workforce Development Grant", 2007-2012, for the pre-entry recruitment activities and faculty cultural competency workshops.
KAREN DEVEREAUX MELILLO, PHD, ANP-C, FAANP, FGSA, JACQUELINE DOWLING, PHD, RN, CNE, LISA ABDALLAH, PHD, RN, CNE, MARY FINDEISEN, PHD, RN, AND MARGARET KNIGHT, PHD, PMHCNS-BC
Karen Devereaux Melillo, PhD, ANP-C, FAANP, FGSA, is Professor and Chair, School of Nursing, University of Massachusetts Lowell; Jacqueline Dowling, PhD, RN, CNE, is an Associate Professor and Director, Baccalaureate Nursing Program, School of Nursing, University of Massachusetts Lowell; Lisa Abdallah, PhD, RN, CNE, is an Associate Professor and Associate Chair, School of Nursing, University of Massachusetts Lowell; Mary Fmdeisen, PhD, RN, Director, Graduate Nursing Programs, Endicott College, Beverly, MA, and Margaret Knight, PhD, PMHCNS-BC, is an Associate Professor, School of Nursing, University of Massachusetts Lowell.