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A Historically Black University's Baccalaureate Enrollment and Success Tactics for Registered Nurses
A HISTORICALLY BLACK UNIVERSITY'S BACCALAUREATE ENROLLMENT AND SUCCESS TACTICS FOR REGISTERED NURSES JENNIFER BROWN, PHD,* AND BENNIE L. MARSHALL, EDD† A nursing department at a historically Black university has implemented a program designed to increase the enrollment and success of minority/disadvantaged students. This effort is consistent with the national initiative to increase the capacity and diversity of the nursing workforce. Previous research reveals that the percentages of minority students who enroll in and complete baccalaureate nursing programs are disproportionate to the percentages of minorities in the general population. Minority patients are less likely to be cared for by a nurse of similar ethnicity, creating a cultural variance that has been associated with health disparities. The project employs strategies to increase student enrollment, retention, and success, as well as the cultural competence of students and faculty. Program evaluation includes numerous internal measures and national benchmarking of key outcomes. Initial results include a 20% increase in student enrollment, a 25% increase in retention, and a 14% increase in National Council Licensure Examination pass rate. Program strengths and future directions are discussed. (Index words: Minority students; Recruitment; Retention) J Prof Nurs 24:21–9, 2008. A 2008 Elsevier Inc. All rights reserved.
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URRENTLY, THE UNITED States' nursing workforce is experiencing two negative trends that are in dire need of attention. First, there has been a steady decline in the supply of nurses while the number of persons in need of health care is rising. Second, too few minority nurses are available to serve an increasing minority population. To address these concerns, the Nursing Department at Norfolk State University (NSU) has developed a program for increasing the enrollment and success of minority/disadvantaged students. The project, aptly named “Baccalaureate Enrollment and Success Tactics for RNs” (BESTRN), aims to identify and satisfy the unique needs of this student population through a number of recruitment and retention strategies, including, but not limited to, innovative
⁎Assistant Professor, School of Nursing, Virginia Commonwealth University, Richmond, VA. †Professor, Department Chair, Department of Nursing, Norfolk State University, Norfolk, VA. Address correspondence to Dr. Brown: Assistant Professor, School of Nursing, Virginia Commonwealth University, PO Box 980567, Richmond, VA 23298-0567. E-mail: [email protected] 8755-7223/$ - see front matter
marketing and public awareness campaigns, a variable program pace, technology-enhanced learning opportunities, faculty and peer mentoring, student scholarship and funding advisement, and early identification and intervention for special learning needs. In so doing, student satisfaction with the program and associated support services has increased. Additionally, efforts have been made to ensure that graduates are culturally competent and oriented to reducing health disparities. The purpose of this article is to describe strategies that have been employed to increase the recruitment, retention, and licensure success rate of minority/ disadvantaged students in a baccalaureate nursing program as well as methods to raise faculty and student awareness of and involvement in activities that promote cultural diversity in nursing.
Background The Projected Supply, Demand, and Shortage of Registered Nurses: 2000–2020 report, which was released by the National Center for Health Workforce Analysis (2002), identified a 6% shortage of nurses in the year 2000 and estimated this to rise to 12% and 29% in 2010 and 2020, respectively. The demand for registered nurses is
Journal of Professional Nursing, Vol 24, No 1 (January–February), 2008: pp 21–29 A 2008 Elsevier Inc. All rights reserved.
21 doi:10.1016/j.profnurs.2007.06.006
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expected to increase by 25% between 2000 and 2020 (U.S. Department of Health and Human Services, Bureau of Health Professions, Division of Nursing, 2000; Institute for the Future, 2003). Factors that have contributed to the increased demand for nurses include general population growth, increasing percentage of elderly in the population, increased per capita demand for health care services, and trends in health care financing that have resulted in increased demand for varied types of health care services. Factors that have influenced the supply of nurses include declining numbers of nursing school graduates, the aging of the nursing workforce, declines in relative earnings, and the emergence of alternative career opportunities. Research has shown that an insufficient supply of nurses has a negative impact on health care cost, quality, and access (Virginia Initiative for Nursing Education [VINE], n.d.). The U.S. Department of Health and Human Services, Bureau of Health Professions, Division of Nursing (2000) Sample Survey reports that of the approximately 2.2 million nurses in the country, less than 10% are minorities and approximately 5% are male. The workforce clearly is not reflective of the general population, which is 28% minority and 49.9% male. Moreover, the U.S. census predicts that the minority population will increase by 60% by 2010 (West, 2001). A study conducted by the Institute of Medicine (Long, 2003) found that racial and ethnic minorities have a higher incidence of receiving poor quality care, illness, disability, and death at earlier ages than Caucasians. The report by the Sullivan Commission (2004) on minorities in the health professions asserts that increasing diversity will improve the overall health of our nation and strengthen cultural competence within our health care providers. Madeline Leinenger's Theory of Transcultural Nursing may explain this in its assertion that in order for nurses to provide effective care, they must recognize and value the diversity and universality of their patients (Leinenger, 1995). Nurses and patients develop rapport more easily when they share similar backgrounds or ethnicity. Further, minority nurses are more likely to obtain their education and employment within their community and they are more likely to live in areas where there are shortages of providers (National Advisory Council in Nurse Education and Practice, 2000; Soroff, Rich, Rubin, Strickland, & Plotnick, 2002). Although a number of national initiatives have been introduced over the years in an attempt to address racial disparities in the health care workforce, these efforts have provided little empirically sound data that identify factors affecting recruitment, retention, and employment of minority students. The National Advisory Council on Nurse Education and Practice (NACNEP) asserts that “under-representation of minorities in nursing education perpetuates under-representation of minorities in the nursing workforce” (Rami, 2003, p. 7). The literature cites numerous reasons for the disparate number of minority nurses (Childs, Jones, Nugent, & Cook, 2004; Rami, 2003; West, 2001). First, there is evidence that
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minority students lack adequate preparation and guidance to apply and obtain acceptance into a nursing program. High school education is generally of significantly lower quality for minority and disadvantaged students (Nieto, 1996). Second, many minority students find college unaffordable. Rising tuition rates, lack of awareness of scholarships, and stricter eligibility requirements for financial assistance are among the problems faced by this population. In 2001, the median income for Whites was 40% higher than that of Blacks and 39% higher than that of other minorities. Third, institutional barriers including inadequate mentoring, overly restrictive admission criteria, and shortage of minority faculty discourage students from becoming or staying interested in a nursing education. It is important to identify a pool of potential minority nursing students and ascertain what characteristics make a program feasible and desirable both to enter and to complete. This requires larger sample sizes across multiple sites and all regions. A study conducted by Stewart and Cleveland (2003) surveyed non-White nursing students to identify problems occurring in nursing programs. They found that the top three concerns were the lack of recruitment of minority students, perceived institutional racism, and the common belief of high school and university staff that non-Whites are not smart enough for nursing. Although 2-year programs and vocational schools have been successful in recruiting minorities, diploma and associate degree nurses are often unable to obtain upperlevel positions, thereby keeping minority nurses on the lower end of the career ladder (Williams, n.d.). Efforts need to focus on encouraging minority nursing students to seek a baccalaureate degree (bachelor of science in nursing [BSN]). NSU's BESTRN program is consistent with the national initiative to increase the capacity and diversity of the nursing workforce. It addresses goals set forth in the NACNEP Nursing Workforce Agenda (2000) related to identifying educational programs that promote diversity. In addition, the project seeks to satisfy specific objectives set forth by the Sullivan Commission (2004) to nursing education programs, including the following: to decrease health disparities by increasing workforce diversity, to strengthen cultural competency within our society, to increase minority student support services, and to increase collaboration with communities. Finally, the BESTRN project responds directly to recommendations set forth by the Advisory Committee to the Governor on the Future of Nursing Workforce and the State Council of Higher Education for Virginia (2004) to increase nursing education program capacity, to develop a recruitment plan that targets underrepresented populations, and to develop means of financial assistance for disadvantaged students. Moreover, it applies directly to Healthy People 2010 Objective 1-8, which calls for increasing the proportion of all degrees awarded to members of underrepresented racial and ethnic groups in the nursing field, more specifically to increase African American representation to 13% of the nursing workforce (U.S. Department
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of Health and Human Services, 2000). As suggested by Debra Williams (n.d.), the best nursing student recruitment plan is not enough if you cannot keep the students such that they graduate and become nurses! Furthermore, in 2000, the American Association of Colleges of Nursing (AACN) issued a statement recommending that the baccalaureate degree become the entry point for professional nursing practice. This suggestion continues to cause great alarm today as only 40% of the nursing workforce hold baccalaureate degrees and the proportion is even smaller for minority nurses (31.6%; AACN, 2005). The results of a study by Aiken, Clarke, Cheung, Sloane, and Silber (2003) support the AACN recommendation as postsurgical patients cared for by baccalaureate-prepared nurses had lower rates of morbidity and mortality than patients cared for by nurses with alternate forms of educational preparation. A report from the VINE (2004) asserts that to enroll and graduate more students, a nursing program needs more qualified faculty, more space, more technology resources, more clinical placements/collaboration with community partners, and strategies to reduce attrition. In light of these recommendations, the NSU Department of Nursing developed a program specifically targeting its baccalaureate students in an effort to promote a culturally diverse professional workforce.
Theoretical Framework A framework for examining influences of higher education outcomes, originally proposed by Stark, Lowther, Hagerty, and Orczykk (1986), served as the foundation for the development of the BESTRN program. The conceptual model proposes that external and internal influences (including sociocultural, economic, political, and pedagogical characteristics) combine with process design to facilitate or impede achievement of program outcomes. In designing the BESTRN project, the external and internal factors were identified and then considered as facilitators or barriers to program success.
External Influences Perhaps one of the most influential factors of a nursing program is its location. NSU, located in Norfolk, VA, primarily services students from the Hampton Roads area, which consists of seven cities (Chesapeake, Hampton, Newport News, Norfolk, Poquoson, Portsmouth, and Virginia Beach). Nine general medical surgical, two military, and four specialized (pediatric or psychiatric) hospitals are located in this area. Statistics from the 2000 census as cited in the Hampton Roads Community Assessment report that the region is 98% urban with a population of 1.3 million (Sentara Healthcare Foundation, 2004). Its residents are 51% female, and more than 40% are minority (33% are African American). Fourteen percent of the population does not have health care insurance; 15% of persons who are more than 25 years of age do not have a high school degree, and more than 28% of the population has an
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income below poverty level. Heart disease is the leading cause of death, and 25.4% of the population in the Hampton Roads area has high blood pressure. Fifty-nine percent of the region's residents are overweight, and five of the cities have a low birth weight rate higher than the statewide rate, thus increasing morbidity, mortality, and associated costs. In light of statistics that show the incidence of hypertension and adult obesity to be significantly higher in the minority as compared to the Caucasian population (Freid, Prager, MacKay, & Xia, 2003), it is essential to find minority providers to deliver nursing interventions because an understanding of cultural values is essential in combating these chronic conditions. On a more positive note, health care is one of the top three industry employers in the region. This translates to more employment opportunities and greater job security, two selling points for the minority/ disadvantaged student who seeks a higher education that provides an almost guaranteed return. According to the Virginia Heath Statistics Report (Virginia Department of Health, Center for Health Statistics, 2005), six out of seven of the cities have at least one census tract designated as a health professional shortage area (dental, mental health, or primary care services), a medically underserved area, or both. Further, the State Council of Higher Education for Virginia (Advisory Committee to the Governor on the Future of Nursing Workforce and the State Council of Higher Education for Virginia, 2004) reports that Hampton Roads is one of the regions in the state expected to experience the greatest population growth between 2000 and 2010 and is the region with the second largest projected increase in registered nurse demand. Clearly, NSU is located in an area where there is a great need for health care professionals to provide health promotion, disease and illness prevention, and chronic care. The NSU nursing program is not only needed but also sustained by the community. A nursing program is also influenced by the philosophical tenets of its parent institution. NSU is Virginia's largest public historically Black university and the seventh largest historically Black college and university (HBCU) member institution in the nation with an annual enrollment of approximately 6,200 students. NSU grants the largest number of undergraduate degrees to African American students in the Commonwealth of Virginia. The University's Institutional Strategic Plan urges its educators and administrators to increase enrollment to meet state demands; to become more actively involved in the recruitment of students and faculty, community service, and outreach; to improve retention and graduation rates; and to participate in enhancing organizational effectiveness and efficiency. The University's mission focuses on “providing an affordable, high-quality education for an ethnically and culturally diverse student population.” The educational programs at NSU are reflective of its mission. It has the distinction of being the most integrated of Virginia colleges and universities. The
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applicant pool at Norfolk State is 87% African American, 3% Asian, 2% Hispanic, and 8% Caucasian. A large number of its students are first-generation college attendees and are of low socioeconomic status. The most recent statistics (2002) reflect that 23 HBCUs offered BSN programs with a combined enrollment of 4,200 students. NSU is among the three largest HBCU nursing programs (Journal of Blacks in Higher Education, 2002).
Internal Influences A nursing program is influenced by a number of internal factors including its composition of students and faculty. With the exception of age and gender, the student demographics of the Department of Nursing are generally reflective of the university as a whole. In 2005, the composition of NSU nursing student population was 80% African American, 11.5% other minorities, and 8.5% Caucasian. More than 75% of the students were classified as in-state and most of these came from the Hampton Roads region. The estimated mean age of students in the Department of Nursing is 30, which is 5 years older than the university average. Only 5% of nursing students are male, which is still significantly below the population; however, this number is improving. The department serves 531 students, including prenursing students, with 260 actively enrolled in nursing programs. The NSU Department of Nursing offers associate of science and bachelor of science degree programs in nursing, which are fully accredited by the National League for Nursing Accrediting Commission and approved by the Virginia Board of Nursing. Currently, there are three baccalaureate tracks: a 2-year RN-to-BSN program, an accelerated second-degree curriculum designed for students with a bachelor of science or master of science/ master of arts in a nonnursing discipline, and an LPN to BSN accelerated track. More than a third of the nursing students are enrolled in a BSN program, and the pool of RN to BSN applicants is largely composed of its associate degree nursing (ADN) graduates. Because NSU does not offer a traditional BSN track, first-time college students must complete the ADN program before becoming eligible for the BSN program. The department receives approximately 75–100 new applications each year for the BSN program. In 2004, 75 eligible applicants with a nonnursing baccalaureate degree were seeking 1 of the 40 available spaces to pursue a BSN degree. More than 70% of BSN students report that they maintain employment outside of school, with more than 75% working full-time. The students have preconceptions about the amount of schoolwork and time investment required. In short, the expectations of the students enrolling in an NSU baccalaureate nursing program include the desire of academic success in as short a period as possible and the ability to manage a complex work/social life and school. Student expectations, characteristics, and behaviors have a significant impact on the success of a program; consequently, these attributes must be considered in the development of the BESTRN strategies.
Recognizing the rapidly increasing diversity in the United States and of higher education, and in support of NSU's mission to educate an ethnically and culturally diverse student body, the faculty and staff of the Department of Nursing are committed to promoting an educational environment that values, respects, and reflects diversity. Diversity includes consideration of socioeconomic class, gender, age, religious beliefs, social orientation, and disabilities, as well as race and ethnicity. Recognizing and valuing diversity also means acknowledgement, appreciation, and support of different learning styles, ways of interaction, and teaching methodologies. In addition, the department's goals are consistent with those of the university: to increase flexibility in programming, to create a student-centered environment, and to improve student advisement, student satisfaction, program success, and outcomes. All university students' success, satisfaction, and perceptions of the quality of academic advisement are assessed using the National Survey of Student Engagement (NSSE) and the University Student Exit Survey.
Facilitators A number of factors have facilitated the success of NSU's nursing program. Federal and state initiatives proposed by influential stakeholders including the National League for Nursing Accrediting Commission, Southern Association of Colleges and Schools, State Council of Higher Education of Virginia (SCHEV), and Virginia Board of Nursing have emphasized the need to increase the capacity and diversity of the nursing workforce (Southern Regional Education Board, 2004). These organizations have offered their constituents opportunities to seek funding for program expansion and have created a culture in which nursing curricular change and innovation are accepted. Not only has the environment provided the department with some direction, it has fostered accountability as well. For example, the Virginia Scorecard produced by SCHEV is one such instrument that sets the standard by which institutions select and measure performance indicators. In addition, the trend of increased minority access to higher education has helped increase the applicant pool through the design of more appropriate admission requirements and expanded scholarships. The program feels supported by the university as reflected in the Institutional Strategic Plan, the critical success factors, student support resources, and funding priorities at the university level. As previously supported by Tucker-Allen (2003), the departmental faculty composition (91% minority) can also be identified as a facilitator because the students and instructors share commonalities that enhance supportive mentoring, role modeling, and cultural sensitivity (Abriam-Yago, n.d.).
Barriers Several factors are thought to have a negative influence on the nursing program's success. A major concern, although not unique to NSU's nursing department, is the
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faculty shortage. The national, state, and local shortage of nurses and nursing educators makes program expansion challenging as there are only 12 full-time faculty and 12 part-time faculty for 260 enrolled students and 280 prenursing students. Despite baccalaureate program accreditation preference for doctorally prepared faculty, only three NSU nursing faculty possess a doctorate degree. It has become increasingly difficult to find qualified faculty to fill existing vacancies, much less expand enrollment (Heller & Lichtenberg, 2003). Also, as inpatient units struggle to cover staffing by using agency nurses, availability of and consistency within student clinical sites are hard to come by. In addition, the persistence of significant minority achievement gaps inhibits the program attainment potential. In comparison to Caucasians, ethnic and racial minorities have lower Scholastic Aptitude Test results and advanced placement standings, both measures of high school scholastic aptitude that are predictive of college performance. Further, the cumulative college grade point averages are lower for African Americans than any other racial group. Another issue is the typically low economic status of the students at NSU: More than 85% receive some type of financial aid, and many are first-generation college students. This, coupled with the higher average age of NSU students, creates a challenge as most must balance significant work and family responsibilities with school. NSU's nursing department has been traditionally known for its ADN program, which was established in 1955. Offering no traditional baccalaureate track, a substantial proportion of nursing students enroll in the ADN program despite national and regional efforts to standardize the educational requirements of a registered nurse to require baccalaureate preparation. Again, this barrier is not unique to NSU; rather, it is a regional problem. In the United States, in 2000, 53% of the nation's nurses were enrolled in baccalaureate degree programs, whereas in Hampton Roads, only 30% of registered nurses are baccalaureate prepared. The problem appears to be increasing as greater numbers of community colleges and vocational schools are offering associate degrees. Over the past 5 to 10 years, the National Council Licensure Examination for Registered Nurses (NCLEX-RN) pass rate for ADN programs has not been consistently 80% or greater. This track record could have a potentially negative impact on BSN student recruitment and success. However, it should be noted that most of NSU's ADN program applicants would not be eligible or competitive for direct admission into a baccalaureate program; by entering the ADN track, a student is able to begin a nursing program while strengthening his or her general education and related science coursework so that he or she is then eligible to enter the baccalaureate program and earn a BSN in one additional year.
The BESTRN program utilizes a wide variety of strategies to recruit students and faculty. The Nursing Admissions Coordinator and faculty participate in university and departmental open houses both on and off campus. In addition, the department hosts high school counselors annually and makes numerous site visits to local grade schools, particularly those with high minority populations, providing students with up-to-date information about admission requirements, program offerings, and scholarship opportunities. In addition, department representatives visit LPN, diploma, and ADN programs in the region. Faculty and students have established partnerships with minority community organizations to offer health fairs and other outreach services. NSU has established a K-12 summer program called “Operation Grow-a-Nurse” to stimulate children's interest in nursing by exposing them to nursing activities and teaching them cardiopulmonary resuscitation and first aid. Aside from marketing and advertising with a modern image, the department has sought nontraditional ways to recruit students and faculty by networking with local health care organizations. Successful collaborations have included local hospitals offering scholarships to current or future employees, providing student externship opportunities, and participating in an instructor exchange program in which hospital employees assist in teaching. Based on the reported success of accelerated programs as a strategy for recruitment (Bennett, Bremner, & Sowell, 2003), the department has created accelerated programs as well as opportunities for flexibility in program pace. In addition to the design and implementation of strategies for student recruitment, the BESTRN program addresses faculty recruitment. NSU has taken an active role as a member of the Tidewater Consortium, a group of nursing schools in the region collaborating through a SCHEV planning grant, to devise creative ways to increase nursing faculty in Virginia. The department hosts activities for nurses in the community, such as lectureships and meetings of professional nursing organizations, to increase interest and awareness of its nursing programs and vacancies. Further, the department has adopted some of the faculty recruitment and retention strategies proposed by the AACN (2003). Faculty workload has been decreased through the increased utilization of Internet and simulation technology for tutorial and remediation activities. Standard learning/training tools can effectively substitute for a portion of face-to-face faculty contact. Partnering with local health care agencies to obtain a pool of clinical adjunct faculty has helped to reduce the size of course and clinical sections.
Program Description
Retention and Success Strategies
NSU's BESTRN program has four key components: recruitment, retention, success, and cultural competence.
The NSU Nursing Department engages in a variety of strategies to improve student retention and success.
Although these are interdependent, the faculty designed specific strategies to address each area.
Recruitment Strategies
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Faculty measure student knowledge using several widely accepted formative and summative evaluation tools. Meds Publishing (Learning System 2000) and Nursing Essentials computerized learning tools are used throughout nursing courses to allow practice, remediation, and assessment of course outcomes. Health Education Systems Incorporated (HESI) Specialty and Custom Exams are used prior to completion of each clinical course to assess effectiveness of the teaching/learning process and to ensure that the student has adequate knowledge to proceed to the next level. Prescriptive remediation programs are designed based on student performance on these assessments as the tools identify areas of weakness. At the end of the program, students utilize an online review course (Silvestri modules) and must meet a minimum score on the HESI Exit Exam to successfully graduate. This intervention is designed to ensure that the student is prepared adequately to take the NCLEX-RN. Finally, the department strives to create a more diversified curricula, routinely updating course content to address current health care trends, as this strategy has been associated with increased student learning satisfaction (Childs et al., 2004). The department utilizes a number of surveys to assess student satisfaction and success. The department analyzes the nursing cohort from the NSSE and Graduate Student Exit Survey, two instruments disseminated to students throughout the university, to assess student satisfaction with learning, campus climate, advisement, and faculty; likelihood to recommend; and perceptions of customer service. Moreover, in 2004, the department began using the Educational Benchmarking Instrument (EBI) to assess the quality of instruction, curriculum, academic environment, resources, role development, cultural competency, and accessibility of the program. This tool allows the department to compare itself with other nursing programs across the nation. In addition, the nursing department has created several of its own surveys. The Alumni Survey is distributed to all nursing students 6 months after graduation to obtain information related to whether or not the alumnus has taken and passed the NCLEX-RN, has become employed, and feels adequately prepared for the profession. The Employer Survey is distributed to employers of recent NSU nursing graduates to assess their satisfaction with the alumnus' level of knowledge and performance. Lastly, the BESTRN project investigators developed the Student Assessment to have enrolled students identify factors they perceive to be affecting their performance (i.e., test anxiety, study skills, family responsibilities). This assessment is conducted biannually. Based on feedback from these instruments, the department has begun implementing a number of strategies to improve students' satisfaction and engagement. To keep the attention of today's entertainmenthungry society, faculty utilize integrative teaching/learning strategies including the incorporation of multimedia, case studies, student presentations, group work, discussions, and local continuing education events as standard
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components of courses. Students have become more actively involved in the learning process. With an increased emphasis on customer service, the department offers a monthly forum called Voices Day in which students “voice” their questions, concerns, and suggestions to faculty. In addition, a student–faculty liaison committee is utilized as a vehicle for improving student– faculty relations. Students and faculty collaborate to produce a departmental newsletter as a method of increasing student involvement, communication, and unity. Efforts are made to involve students in departmental, campus-wide, and community-based grant projects such as the Substance Abuse and Mental Health Services Administration HIV/AIDS Initiative. The department has encouraged the growth of existing student organizations and extracurricular activities such as the Student Nurses Association and Chi Eta Phi Nursing Sorority. In 2004, the NSU Nursing Honor Society for Baccalaureate Nurses was established with the goal of securing a Sigma Theta Tau International Nursing Honor Society charter. In addition, the ADN Student Honor Society was formed as a means to encourage these students, who would not be eligible to join Sigma Theta Tau, to continue their professional and educational pursuits. These organizations are not only providing student recognition but also increasing student involvement with nurses in the community through mentoring, fund-raising, and interaction. Student satisfaction with the program is contingent upon open lines of communication. New students and faculty are assigned peer mentors. The department offers informational sessions to newly accepted students to prepare them with test-taking strategies, critical thinking, study and writing skills, and so forth. Faculty utilize Blackboard to enhance frequent student–instructor interaction outside the classroom. To improve the quality of advisement, students are assigned to a nursing faculty who is currently teaching the student. Multiple opportunities have been created for student remediation. Faculty are required to offer “content mastery sessions” following a test to provide a formalized review of the test content to all students who did not pass. Moreover, a program has been established to provide paid and volunteer peer tutors for students who are struggling. Faculty are given incentives to participate in a tutoring program as well (1 hour of tutoring substitutes for 2 of the weekly office hours faculty are required to offer). The department offers a summer program to incoming students who have science, math, or writing problems to provide the foundation necessary for success. Finally, nursing faculty have hosted departmental writing workshops reinforcing grammar, American Psychological Association style, and writing skills compatible with nursing coursework.
Strategies to Promote Cultural Competence The BESTRN program utilizes existing resources and develops additional methods for promoting cultural competence. International students are encouraged to
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utilize the University's International Student and Scholar Service, which provides assistance including personal counseling, academic advising, travel information, and interpretation and explanation of immigration laws and serves as a link between the University and U.S. governmental agencies, foreign embassies, and foreign governments. The department receives an increasing number of immigrant students who are nonnative English speakers including those from Africa and Asia (e.g., the Philippines) and has established a support program for English as a second language students. Efforts are being made to create a learning environment that is conducive to their unique needs. The University promotes awareness of its cultural foundations by requiring all students to complete a three-credit course in African American Perspectives. In addition, the nursing curriculum further encourages the cultural competence of its students through a Bioethics/ Multiculturalism course and service-learning experiences in underserved communities. Finally, measures have been taken to expand upon nursing faculty opportunities to participate in teaching/learning workshops that emphasize considerations for special needs and cultural diversity.
Program Results Two years into its implementation, the program leaders have begun to evaluate BESTRN effectiveness by examining the results of the various assessment measures and comparing the recent results with results from previous years as well as national benchmarks. Numerous achievements have been made in each of the critical areas: enrollment, retention, success, and cultural competence. Improvements have occurred in the volume and quality of the applicant pool as well as enrollment capacity. Fund-raising efforts have led to substantial increases in alumni giving and university support so that a greater number of BSN students receive financial assistance. Recruitment of ADN students into the BSN program has increased. Of the ADN students who graduated in May 2004, 22% (n = 60) entered directly into the BSN program; this increased to 29.8% (20 out of 67) of the May 2005 graduates and 38.7% (24 out of 62) of the May 2006 graduates. The number of spaces for second-degree BSN students has increased from 40 in 2004 to 50 at present, with a plan for additional increases upon hiring of additional faculty. The Student Assessment Survey, which was designed and distributed specifically for the project, examines factors influencing students' academic success. Students evaluated the influence of the following “critical success” factors: critical thinking, reading, writing, test taking, and study skills; test anxiety, time management, computer and Internet access, and family and financial obligations; bonding with students and faculty; faculty availability and advisement; academic workload, program pace, clinical prep, and homework on their performance. Six factors have been significantly associated with a student's report of difficulty passing (Table 1). Quite a few of the
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relationships between critical success factors were statistically significant (r ≥ .6), with “bonding with faculty” and “advisement” representing the strongest relationship (r = .89), but factor analysis showed that there is little practical significance for most of these relationships. While the factor analysis separated the 22 factors into three major groups with predictive values of approximately 56%, 21%, and 14%, the categories could not be labeled as any meaningful concepts. Further, no significant relationship existed between age, gender, or student status (full-time vs. part-time) and any of the critical success factors; however, this finding may have been confounded by the sample homogeneity, as it consisted primarily of young, female, full-time students. The investigators compared the survey results over the past few years and found that there were only three areas in which students felt the department had not improved: advisement, faculty availability, and student bonding. Consequently, these areas have become a point of focus for improvement initiatives; however, the researchers attribute student dissatisfaction with faculty advisement and availability as due, in part, to faculty turnover and a change in the assignment of advisees, which occurred between these years, because students may have felt they were being shifted from one faculty member to another. The results of the EBI survey provided insight into several issues. The department began using the EBI in 2004; thus, internal comparison was limited, but the response rate went from about 60% to almost 100%. Improvements from 2004 to 2005 occurred in the areas of role development, core knowledge, and quality of nursing instruction. In comparing 2005 and 2006 survey results, improvements occurred in all areas (satisfaction with work/class balance, facilities, classmates, the program's effectiveness at instilling professional values, technical skills and core competencies, role development) except for quality of instruction. It is unclear why the students rated quality of instruction less favorably in 2006; hence, this will be closely monitored in upcoming years. Overall, the NSU Nursing Department 2006 results were poorer than its six selected “benchmark” schools, the Carnegie sample, and the EBI population of participating
Table 1. Critical Success Strategies That Affect Student Performance Factor Test taking Workload Pace Study skills Advisement Bonding with faculty
ss
df
MS
F
Significance
11.012 62.074 29.087 85.775 14.010 112.19 15.180 57.709 24.674 98.076 19.199 96.610
1 68 1 63 1 67 1 61 1 66 1 66
11.01 0.913 29.087 1.362 14.010 1.675 15.180 0.946 24.674 1.486 19.199 1.464
12.06
.001
21.363
.000
8.366
.005
16.046
.000
16.604
.000
13.116
.001
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institutions. This finding endorses continued use of the tool for benchmarking purposes; further, it highlights the need for further improvement so that minority-serving nursing programs provide students with a quality of education that meets or exceeds peer institutions. The retention and success rates have improved as well. The graduation rate for the students who started in May 2004 was 71%, as compared to 80% for students who began in May 2005 and an expected 90% for students who began in May 2006 and will graduate June 2007. The NCLEX pass rate on first attempt has risen from 58% in 2005 to 82% in 2006. Gains have been made in the cultural competence of faculty and staff. The Department's Student Assessment attempted to assess cultural diversity using two items: student ratings of program adequacy with respect to cultural competency and cultural diversity. The results from these measures were inconclusive as less than 25% of the students answered these items. The researchers suspect that the items were overlooked because of the placement in their own box at the bottom of the page. On the other hand, the NSSE and EBI measures of cultural competency showed that NSU programs, including nursing, scored significantly above the norm in terms of meeting students' needs in terms of learning about and exposure to a diversity of cultures. In addition, the nursing department hosted several programs that enhanced the cultural competence of faculty and students, including a History of African American Nurses in Virginia Program, a Health Disparities Workshop, an HBCU HIV Education project, and a faith-based service– learning partnership with a minority health coalition.
Conclusions and Future Directions The NSU BESTRN program has demonstrated significant achievements. Over 2 years, the nursing department has successfully increased student enrollment by 20% (despite a general decline in University enrollment), increased student retention by 25%, and improved the first-attempt NCLEX pass rate by 14%. New strategies for increasing student and faculty volume are being tested as the BESTRN program continues to evolve. Based on its reported success as a recruitment strategy (Dessner, Mosser, & Reno, 1998; Lerner & Cohen, 2003), the department is developing an “Intro to Nursing” course for prospective nursing students. In the meantime, the freshman orientation course “UNI 101” has been enhanced to include more information about the nursing program, its expectations, and core values to increase awareness throughout the university. The establishment of community partnerships has allowed for the increase of RN–BSN annual enrollment capacity to 60 as clinical placements expand beyond school and health department settings to include local and national health education initiatives such as “Heart Truth,” “Project Power,” and “Let's Get Real.” In an attempt to offer even more flexibility with program pace and hours, a combined distance-learning/onsite weekend-only accelerated RN–BSN program began in Spring
2006 and enrollment grows each semester. Although the department lost six full-time faculty during this period, it has experienced overall growth with the recruitment of four new full-time faculty in 2004, two in 2005, four in 2006, and numerous additional adjunct faculty. In January 2007, the department hired a full-time Student Recruiter/Advisor who is an alumna of the program. This individual collaborates with the admission coordinator to expand recruitment strategies, as well as to find methods for increasing the availability of student scholarship and other financial and academic supportive resources. Supplementary retention methods have been employed to increase student satisfaction and success. Nursing faculty are encouraging early interventions with referrals to tutors and study groups, and the NSU Nursing Honor Society has assisted in developing a mentor program. Faculty are engaging in the process of examining changes in the NCLEX-RN test plan, nursing curricula of other schools, and the current evidence base of nursing education across the nation to determine what revisions need to be made to the nursing curriculum and prerequisite courses. Cultural competence continues to be promoted through increased faculty and student participation in externships and service learning activities. In keeping with the philosophy of continuous quality improvement, the NSU Nursing Department will continue to engage in the development, implementation, and evaluation of enrollment, retention, and success strategies. The BESTRN program has only just begun!
References Abriam-Yago, K. (n.d.). Mentoring to empower. Retrieved November 18, 2004, from http://www.minoritynurse.com/ features/undergraduate/02-14-01d.html. Advisory Committee to the Governor on the Future of Nursing Workforce and the State Council of Higher Education for Virginia. (2004). Condition of nursing and education in the Commonwealth. Richmond, VA: Author. Aiken, L. H., Clarke, S. P., Cheung, R. B., Sloane, D. M., & Silber, J. H. (2003). Educational levels of hospital nurses and surgical patient mortality. Journal of the American Medical Association, 290, 1617–1623. American Association of Colleges of Nursing. (2000). Position statement: The baccalaureate degree in nursing as minimal preparation for professional practice. Washington, DC: Author. American Association of Colleges of Nursing. (2003). White paper: Faculty shortages in baccalaureate and graduate nursing programs: Scope of the problem and strategies for expanding the supply. Washington, DC: Author. American Association of Colleges of Nursing. (2005). 2004– 2005 enrollment and graduations in baccalaureate and graduate programs in nursing. Washington, DC: Author. Bennett, D. N., Bremner, M. N., & Sowell, R. K. (2003). Developing an accelerated BSN program: The KSU partnership model. In H. R. Feldman (Ed.), The nursing shortage. New York: Springer Publishing Co., Inc. Childs, G., Jones, R., Nugent, K. E., & Cook, P. (2004). Retention of African-American students in baccalaureate nursing programs: Are we doing enough? Journal of Professional Nursing, 20, 129–133.
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Dessner, S. H., Mosser, F. T., & Reno, B. A. (1998). A course for prospective nursing students. Nurse Educator, 23, 8–11. Freid, V. M., Prager, K., MacKay, A. P., & Xia, H. (2003). Health, United States, 2003. Hyattsville, MD: National Center for Health Statistics. Heller, B. R. & Lichtenberg, L. P. (2003). The role of nursing schools in addressing the shortage. In H. R. Feldman (Ed.), The nursing shortage. New York: Springer Publishing Co., Inc. Institute for the Future. (2003). Health care workforce: Future supply and demand. Health and healthcare 2010 (2nd ed.). Princeton, NJ: Jossey-Bass. Journal of Blacks in Higher Education, 34. Retrieved November 13, 2004, from http://www.jbhe.com/news_views/ 34_nursing.html. Leinenger, M. (1995). Transcultural nursing: Concepts, theories, research, and practices. (2nd ed.). New York: McGraw-Hill. Lerner, H. & Cohen, B. J. (2003). Recruiting students into nursing. Nurse Educator, 28, 8–9. Long, K. A. (2003). The Institute of Medicine report, health professions education: A bridge to quality. Policy, Politics, and Nursing Practice, 4, 259–262. National Advisory Council in Nurse Education and Practice. (2000). National agenda for nursing workforce: Racial/Ethnic diversity. Washington, DC: U.S. Department of Health and Human Services. National Center for Health Workforce Analysis. (2002). Projected supply, demand, and shortage of registered nurses: 2000– 2020. Rockville, MD: Bureau of Health Professions, U.S. Department of Health and Human Services. Nieto, S. (1996). Affirming diversity: The sociopolitical context of multicultural education. (2nd ed.). Portland, OR: Book News, Inc. Rami, J. S. (2003). Educating a diverse workforce, minority students: Recruitment, retention and graduation. National Advisory Council in Nurse Education and Practice Report to the Secretary of Health and Human Services and the Congress. Washington, DC: U.S. Department of Health and Human Services, HRSA, Bureau of Health Professions. Sentara Healthcare Foundation. (2004). Hampton Roads community assessment. CD-ROM provided by Sentara Healthcare, Norfolk, VA.
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Soroff, L., Rich, E., Rubin, A., Strickland, R. D., & Plotnick, H. D. (2002). A transcultural nursing educational environment: An imperative for multicultural students. Nurse Educator, 27, 151–154. Southern Regional Education Board. (2004). Report of the Council on Collegiate Education for Nursing. Retrieved December 1, 2005, from http://www.sreb.org/programs/nursing/presentations/2004_Survey_Results.xls. Stark, J. S., Lowther, M., Hagerty, B. M., & Orczykk, C. (1986). A conceptual framework for the study of pre-service professional programs in colleges and universities. Journal of Higher Education, 57, 231–236. Stewart, S. & Cleveland, R. (2003). A pre-college program for culturally diverse high school students. Nurse Educator, 28, 107–110. Sullivan Commission. (2004). Missing persons: Minorities in the health professions. Retrieved November 18, 2004, from http://www.sullivancomission.org. Tucker-Allen, S. (2003). Increasing minority nurses means increasing minority nursing faculty members. Association of Black Nursing Faculty Journal. Retrieved November 10, 2005, from http://findarticles.com/p/articles/mi_m0MJT/is_1_14/ ai_98250416. U.S. Department of Health and Human Services. (2000). Healthy people 2010. (2nd ed.). Washington, DC: U.S. Government Printing Office. U.S. Department of Health and Human Services, Bureau of Health Professions, Division of Nursing. (2000). National sample survey of registered nurses. Rockville, MD: Author. Virginia Department of Health, Center for Health Statistics. (2005). The health of minorities in Virginia, 2003. Richmond, VA: Author. Virginia Initiative for Nursing Education. (2004). Facts about Virginia's nursing shortage. Retrieved November 10, 2004, from http://www.nursesvine.org/facts.html. West, J. (2001). Recruitment and retention critical to minority health professionals. Closing the Gap, 10. Williams, D. (n.d.). Reach out, we'll be there. Retrieved November 13, 2004, from http://www.minoritynurse.com/ features/undergraduate/02-14-01d.html.
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URRENTLY, THE UNITED States' nursing workforce is experiencing two negative trends that are in dire need of attention. First, there has been a steady decline in the supply of nurses while the number of persons in need of health care is rising. Second, too few minority nurses are available to serve an increasing minority population. To address these concerns, the Nursing Department at Norfolk State University (NSU) has developed a program for increasing the enrollment and success of minority/disadvantaged students. The project, aptly named “Baccalaureate Enrollment and Success Tactics for RNs” (BESTRN), aims to identify and satisfy the unique needs of this student population through a number of recruitment and retention strategies, including, but not limited to, innovative
⁎Assistant Professor, School of Nursing, Virginia Commonwealth University, Richmond, VA. †Professor, Department Chair, Department of Nursing, Norfolk State University, Norfolk, VA. Address correspondence to Dr. Brown: Assistant Professor, School of Nursing, Virginia Commonwealth University, PO Box 980567, Richmond, VA 23298-0567. E-mail: [email protected] 8755-7223/$ - see front matter
marketing and public awareness campaigns, a variable program pace, technology-enhanced learning opportunities, faculty and peer mentoring, student scholarship and funding advisement, and early identification and intervention for special learning needs. In so doing, student satisfaction with the program and associated support services has increased. Additionally, efforts have been made to ensure that graduates are culturally competent and oriented to reducing health disparities. The purpose of this article is to describe strategies that have been employed to increase the recruitment, retention, and licensure success rate of minority/ disadvantaged students in a baccalaureate nursing program as well as methods to raise faculty and student awareness of and involvement in activities that promote cultural diversity in nursing.
Background The Projected Supply, Demand, and Shortage of Registered Nurses: 2000–2020 report, which was released by the National Center for Health Workforce Analysis (2002), identified a 6% shortage of nurses in the year 2000 and estimated this to rise to 12% and 29% in 2010 and 2020, respectively. The demand for registered nurses is
Journal of Professional Nursing, Vol 24, No 1 (January–February), 2008: pp 21–29 A 2008 Elsevier Inc. All rights reserved.
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expected to increase by 25% between 2000 and 2020 (U.S. Department of Health and Human Services, Bureau of Health Professions, Division of Nursing, 2000; Institute for the Future, 2003). Factors that have contributed to the increased demand for nurses include general population growth, increasing percentage of elderly in the population, increased per capita demand for health care services, and trends in health care financing that have resulted in increased demand for varied types of health care services. Factors that have influenced the supply of nurses include declining numbers of nursing school graduates, the aging of the nursing workforce, declines in relative earnings, and the emergence of alternative career opportunities. Research has shown that an insufficient supply of nurses has a negative impact on health care cost, quality, and access (Virginia Initiative for Nursing Education [VINE], n.d.). The U.S. Department of Health and Human Services, Bureau of Health Professions, Division of Nursing (2000) Sample Survey reports that of the approximately 2.2 million nurses in the country, less than 10% are minorities and approximately 5% are male. The workforce clearly is not reflective of the general population, which is 28% minority and 49.9% male. Moreover, the U.S. census predicts that the minority population will increase by 60% by 2010 (West, 2001). A study conducted by the Institute of Medicine (Long, 2003) found that racial and ethnic minorities have a higher incidence of receiving poor quality care, illness, disability, and death at earlier ages than Caucasians. The report by the Sullivan Commission (2004) on minorities in the health professions asserts that increasing diversity will improve the overall health of our nation and strengthen cultural competence within our health care providers. Madeline Leinenger's Theory of Transcultural Nursing may explain this in its assertion that in order for nurses to provide effective care, they must recognize and value the diversity and universality of their patients (Leinenger, 1995). Nurses and patients develop rapport more easily when they share similar backgrounds or ethnicity. Further, minority nurses are more likely to obtain their education and employment within their community and they are more likely to live in areas where there are shortages of providers (National Advisory Council in Nurse Education and Practice, 2000; Soroff, Rich, Rubin, Strickland, & Plotnick, 2002). Although a number of national initiatives have been introduced over the years in an attempt to address racial disparities in the health care workforce, these efforts have provided little empirically sound data that identify factors affecting recruitment, retention, and employment of minority students. The National Advisory Council on Nurse Education and Practice (NACNEP) asserts that “under-representation of minorities in nursing education perpetuates under-representation of minorities in the nursing workforce” (Rami, 2003, p. 7). The literature cites numerous reasons for the disparate number of minority nurses (Childs, Jones, Nugent, & Cook, 2004; Rami, 2003; West, 2001). First, there is evidence that
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minority students lack adequate preparation and guidance to apply and obtain acceptance into a nursing program. High school education is generally of significantly lower quality for minority and disadvantaged students (Nieto, 1996). Second, many minority students find college unaffordable. Rising tuition rates, lack of awareness of scholarships, and stricter eligibility requirements for financial assistance are among the problems faced by this population. In 2001, the median income for Whites was 40% higher than that of Blacks and 39% higher than that of other minorities. Third, institutional barriers including inadequate mentoring, overly restrictive admission criteria, and shortage of minority faculty discourage students from becoming or staying interested in a nursing education. It is important to identify a pool of potential minority nursing students and ascertain what characteristics make a program feasible and desirable both to enter and to complete. This requires larger sample sizes across multiple sites and all regions. A study conducted by Stewart and Cleveland (2003) surveyed non-White nursing students to identify problems occurring in nursing programs. They found that the top three concerns were the lack of recruitment of minority students, perceived institutional racism, and the common belief of high school and university staff that non-Whites are not smart enough for nursing. Although 2-year programs and vocational schools have been successful in recruiting minorities, diploma and associate degree nurses are often unable to obtain upperlevel positions, thereby keeping minority nurses on the lower end of the career ladder (Williams, n.d.). Efforts need to focus on encouraging minority nursing students to seek a baccalaureate degree (bachelor of science in nursing [BSN]). NSU's BESTRN program is consistent with the national initiative to increase the capacity and diversity of the nursing workforce. It addresses goals set forth in the NACNEP Nursing Workforce Agenda (2000) related to identifying educational programs that promote diversity. In addition, the project seeks to satisfy specific objectives set forth by the Sullivan Commission (2004) to nursing education programs, including the following: to decrease health disparities by increasing workforce diversity, to strengthen cultural competency within our society, to increase minority student support services, and to increase collaboration with communities. Finally, the BESTRN project responds directly to recommendations set forth by the Advisory Committee to the Governor on the Future of Nursing Workforce and the State Council of Higher Education for Virginia (2004) to increase nursing education program capacity, to develop a recruitment plan that targets underrepresented populations, and to develop means of financial assistance for disadvantaged students. Moreover, it applies directly to Healthy People 2010 Objective 1-8, which calls for increasing the proportion of all degrees awarded to members of underrepresented racial and ethnic groups in the nursing field, more specifically to increase African American representation to 13% of the nursing workforce (U.S. Department
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of Health and Human Services, 2000). As suggested by Debra Williams (n.d.), the best nursing student recruitment plan is not enough if you cannot keep the students such that they graduate and become nurses! Furthermore, in 2000, the American Association of Colleges of Nursing (AACN) issued a statement recommending that the baccalaureate degree become the entry point for professional nursing practice. This suggestion continues to cause great alarm today as only 40% of the nursing workforce hold baccalaureate degrees and the proportion is even smaller for minority nurses (31.6%; AACN, 2005). The results of a study by Aiken, Clarke, Cheung, Sloane, and Silber (2003) support the AACN recommendation as postsurgical patients cared for by baccalaureate-prepared nurses had lower rates of morbidity and mortality than patients cared for by nurses with alternate forms of educational preparation. A report from the VINE (2004) asserts that to enroll and graduate more students, a nursing program needs more qualified faculty, more space, more technology resources, more clinical placements/collaboration with community partners, and strategies to reduce attrition. In light of these recommendations, the NSU Department of Nursing developed a program specifically targeting its baccalaureate students in an effort to promote a culturally diverse professional workforce.
Theoretical Framework A framework for examining influences of higher education outcomes, originally proposed by Stark, Lowther, Hagerty, and Orczykk (1986), served as the foundation for the development of the BESTRN program. The conceptual model proposes that external and internal influences (including sociocultural, economic, political, and pedagogical characteristics) combine with process design to facilitate or impede achievement of program outcomes. In designing the BESTRN project, the external and internal factors were identified and then considered as facilitators or barriers to program success.
External Influences Perhaps one of the most influential factors of a nursing program is its location. NSU, located in Norfolk, VA, primarily services students from the Hampton Roads area, which consists of seven cities (Chesapeake, Hampton, Newport News, Norfolk, Poquoson, Portsmouth, and Virginia Beach). Nine general medical surgical, two military, and four specialized (pediatric or psychiatric) hospitals are located in this area. Statistics from the 2000 census as cited in the Hampton Roads Community Assessment report that the region is 98% urban with a population of 1.3 million (Sentara Healthcare Foundation, 2004). Its residents are 51% female, and more than 40% are minority (33% are African American). Fourteen percent of the population does not have health care insurance; 15% of persons who are more than 25 years of age do not have a high school degree, and more than 28% of the population has an
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income below poverty level. Heart disease is the leading cause of death, and 25.4% of the population in the Hampton Roads area has high blood pressure. Fifty-nine percent of the region's residents are overweight, and five of the cities have a low birth weight rate higher than the statewide rate, thus increasing morbidity, mortality, and associated costs. In light of statistics that show the incidence of hypertension and adult obesity to be significantly higher in the minority as compared to the Caucasian population (Freid, Prager, MacKay, & Xia, 2003), it is essential to find minority providers to deliver nursing interventions because an understanding of cultural values is essential in combating these chronic conditions. On a more positive note, health care is one of the top three industry employers in the region. This translates to more employment opportunities and greater job security, two selling points for the minority/ disadvantaged student who seeks a higher education that provides an almost guaranteed return. According to the Virginia Heath Statistics Report (Virginia Department of Health, Center for Health Statistics, 2005), six out of seven of the cities have at least one census tract designated as a health professional shortage area (dental, mental health, or primary care services), a medically underserved area, or both. Further, the State Council of Higher Education for Virginia (Advisory Committee to the Governor on the Future of Nursing Workforce and the State Council of Higher Education for Virginia, 2004) reports that Hampton Roads is one of the regions in the state expected to experience the greatest population growth between 2000 and 2010 and is the region with the second largest projected increase in registered nurse demand. Clearly, NSU is located in an area where there is a great need for health care professionals to provide health promotion, disease and illness prevention, and chronic care. The NSU nursing program is not only needed but also sustained by the community. A nursing program is also influenced by the philosophical tenets of its parent institution. NSU is Virginia's largest public historically Black university and the seventh largest historically Black college and university (HBCU) member institution in the nation with an annual enrollment of approximately 6,200 students. NSU grants the largest number of undergraduate degrees to African American students in the Commonwealth of Virginia. The University's Institutional Strategic Plan urges its educators and administrators to increase enrollment to meet state demands; to become more actively involved in the recruitment of students and faculty, community service, and outreach; to improve retention and graduation rates; and to participate in enhancing organizational effectiveness and efficiency. The University's mission focuses on “providing an affordable, high-quality education for an ethnically and culturally diverse student population.” The educational programs at NSU are reflective of its mission. It has the distinction of being the most integrated of Virginia colleges and universities. The
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applicant pool at Norfolk State is 87% African American, 3% Asian, 2% Hispanic, and 8% Caucasian. A large number of its students are first-generation college attendees and are of low socioeconomic status. The most recent statistics (2002) reflect that 23 HBCUs offered BSN programs with a combined enrollment of 4,200 students. NSU is among the three largest HBCU nursing programs (Journal of Blacks in Higher Education, 2002).
Internal Influences A nursing program is influenced by a number of internal factors including its composition of students and faculty. With the exception of age and gender, the student demographics of the Department of Nursing are generally reflective of the university as a whole. In 2005, the composition of NSU nursing student population was 80% African American, 11.5% other minorities, and 8.5% Caucasian. More than 75% of the students were classified as in-state and most of these came from the Hampton Roads region. The estimated mean age of students in the Department of Nursing is 30, which is 5 years older than the university average. Only 5% of nursing students are male, which is still significantly below the population; however, this number is improving. The department serves 531 students, including prenursing students, with 260 actively enrolled in nursing programs. The NSU Department of Nursing offers associate of science and bachelor of science degree programs in nursing, which are fully accredited by the National League for Nursing Accrediting Commission and approved by the Virginia Board of Nursing. Currently, there are three baccalaureate tracks: a 2-year RN-to-BSN program, an accelerated second-degree curriculum designed for students with a bachelor of science or master of science/ master of arts in a nonnursing discipline, and an LPN to BSN accelerated track. More than a third of the nursing students are enrolled in a BSN program, and the pool of RN to BSN applicants is largely composed of its associate degree nursing (ADN) graduates. Because NSU does not offer a traditional BSN track, first-time college students must complete the ADN program before becoming eligible for the BSN program. The department receives approximately 75–100 new applications each year for the BSN program. In 2004, 75 eligible applicants with a nonnursing baccalaureate degree were seeking 1 of the 40 available spaces to pursue a BSN degree. More than 70% of BSN students report that they maintain employment outside of school, with more than 75% working full-time. The students have preconceptions about the amount of schoolwork and time investment required. In short, the expectations of the students enrolling in an NSU baccalaureate nursing program include the desire of academic success in as short a period as possible and the ability to manage a complex work/social life and school. Student expectations, characteristics, and behaviors have a significant impact on the success of a program; consequently, these attributes must be considered in the development of the BESTRN strategies.
Recognizing the rapidly increasing diversity in the United States and of higher education, and in support of NSU's mission to educate an ethnically and culturally diverse student body, the faculty and staff of the Department of Nursing are committed to promoting an educational environment that values, respects, and reflects diversity. Diversity includes consideration of socioeconomic class, gender, age, religious beliefs, social orientation, and disabilities, as well as race and ethnicity. Recognizing and valuing diversity also means acknowledgement, appreciation, and support of different learning styles, ways of interaction, and teaching methodologies. In addition, the department's goals are consistent with those of the university: to increase flexibility in programming, to create a student-centered environment, and to improve student advisement, student satisfaction, program success, and outcomes. All university students' success, satisfaction, and perceptions of the quality of academic advisement are assessed using the National Survey of Student Engagement (NSSE) and the University Student Exit Survey.
Facilitators A number of factors have facilitated the success of NSU's nursing program. Federal and state initiatives proposed by influential stakeholders including the National League for Nursing Accrediting Commission, Southern Association of Colleges and Schools, State Council of Higher Education of Virginia (SCHEV), and Virginia Board of Nursing have emphasized the need to increase the capacity and diversity of the nursing workforce (Southern Regional Education Board, 2004). These organizations have offered their constituents opportunities to seek funding for program expansion and have created a culture in which nursing curricular change and innovation are accepted. Not only has the environment provided the department with some direction, it has fostered accountability as well. For example, the Virginia Scorecard produced by SCHEV is one such instrument that sets the standard by which institutions select and measure performance indicators. In addition, the trend of increased minority access to higher education has helped increase the applicant pool through the design of more appropriate admission requirements and expanded scholarships. The program feels supported by the university as reflected in the Institutional Strategic Plan, the critical success factors, student support resources, and funding priorities at the university level. As previously supported by Tucker-Allen (2003), the departmental faculty composition (91% minority) can also be identified as a facilitator because the students and instructors share commonalities that enhance supportive mentoring, role modeling, and cultural sensitivity (Abriam-Yago, n.d.).
Barriers Several factors are thought to have a negative influence on the nursing program's success. A major concern, although not unique to NSU's nursing department, is the
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faculty shortage. The national, state, and local shortage of nurses and nursing educators makes program expansion challenging as there are only 12 full-time faculty and 12 part-time faculty for 260 enrolled students and 280 prenursing students. Despite baccalaureate program accreditation preference for doctorally prepared faculty, only three NSU nursing faculty possess a doctorate degree. It has become increasingly difficult to find qualified faculty to fill existing vacancies, much less expand enrollment (Heller & Lichtenberg, 2003). Also, as inpatient units struggle to cover staffing by using agency nurses, availability of and consistency within student clinical sites are hard to come by. In addition, the persistence of significant minority achievement gaps inhibits the program attainment potential. In comparison to Caucasians, ethnic and racial minorities have lower Scholastic Aptitude Test results and advanced placement standings, both measures of high school scholastic aptitude that are predictive of college performance. Further, the cumulative college grade point averages are lower for African Americans than any other racial group. Another issue is the typically low economic status of the students at NSU: More than 85% receive some type of financial aid, and many are first-generation college students. This, coupled with the higher average age of NSU students, creates a challenge as most must balance significant work and family responsibilities with school. NSU's nursing department has been traditionally known for its ADN program, which was established in 1955. Offering no traditional baccalaureate track, a substantial proportion of nursing students enroll in the ADN program despite national and regional efforts to standardize the educational requirements of a registered nurse to require baccalaureate preparation. Again, this barrier is not unique to NSU; rather, it is a regional problem. In the United States, in 2000, 53% of the nation's nurses were enrolled in baccalaureate degree programs, whereas in Hampton Roads, only 30% of registered nurses are baccalaureate prepared. The problem appears to be increasing as greater numbers of community colleges and vocational schools are offering associate degrees. Over the past 5 to 10 years, the National Council Licensure Examination for Registered Nurses (NCLEX-RN) pass rate for ADN programs has not been consistently 80% or greater. This track record could have a potentially negative impact on BSN student recruitment and success. However, it should be noted that most of NSU's ADN program applicants would not be eligible or competitive for direct admission into a baccalaureate program; by entering the ADN track, a student is able to begin a nursing program while strengthening his or her general education and related science coursework so that he or she is then eligible to enter the baccalaureate program and earn a BSN in one additional year.
The BESTRN program utilizes a wide variety of strategies to recruit students and faculty. The Nursing Admissions Coordinator and faculty participate in university and departmental open houses both on and off campus. In addition, the department hosts high school counselors annually and makes numerous site visits to local grade schools, particularly those with high minority populations, providing students with up-to-date information about admission requirements, program offerings, and scholarship opportunities. In addition, department representatives visit LPN, diploma, and ADN programs in the region. Faculty and students have established partnerships with minority community organizations to offer health fairs and other outreach services. NSU has established a K-12 summer program called “Operation Grow-a-Nurse” to stimulate children's interest in nursing by exposing them to nursing activities and teaching them cardiopulmonary resuscitation and first aid. Aside from marketing and advertising with a modern image, the department has sought nontraditional ways to recruit students and faculty by networking with local health care organizations. Successful collaborations have included local hospitals offering scholarships to current or future employees, providing student externship opportunities, and participating in an instructor exchange program in which hospital employees assist in teaching. Based on the reported success of accelerated programs as a strategy for recruitment (Bennett, Bremner, & Sowell, 2003), the department has created accelerated programs as well as opportunities for flexibility in program pace. In addition to the design and implementation of strategies for student recruitment, the BESTRN program addresses faculty recruitment. NSU has taken an active role as a member of the Tidewater Consortium, a group of nursing schools in the region collaborating through a SCHEV planning grant, to devise creative ways to increase nursing faculty in Virginia. The department hosts activities for nurses in the community, such as lectureships and meetings of professional nursing organizations, to increase interest and awareness of its nursing programs and vacancies. Further, the department has adopted some of the faculty recruitment and retention strategies proposed by the AACN (2003). Faculty workload has been decreased through the increased utilization of Internet and simulation technology for tutorial and remediation activities. Standard learning/training tools can effectively substitute for a portion of face-to-face faculty contact. Partnering with local health care agencies to obtain a pool of clinical adjunct faculty has helped to reduce the size of course and clinical sections.
Program Description
Retention and Success Strategies
NSU's BESTRN program has four key components: recruitment, retention, success, and cultural competence.
The NSU Nursing Department engages in a variety of strategies to improve student retention and success.
Although these are interdependent, the faculty designed specific strategies to address each area.
Recruitment Strategies
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Faculty measure student knowledge using several widely accepted formative and summative evaluation tools. Meds Publishing (Learning System 2000) and Nursing Essentials computerized learning tools are used throughout nursing courses to allow practice, remediation, and assessment of course outcomes. Health Education Systems Incorporated (HESI) Specialty and Custom Exams are used prior to completion of each clinical course to assess effectiveness of the teaching/learning process and to ensure that the student has adequate knowledge to proceed to the next level. Prescriptive remediation programs are designed based on student performance on these assessments as the tools identify areas of weakness. At the end of the program, students utilize an online review course (Silvestri modules) and must meet a minimum score on the HESI Exit Exam to successfully graduate. This intervention is designed to ensure that the student is prepared adequately to take the NCLEX-RN. Finally, the department strives to create a more diversified curricula, routinely updating course content to address current health care trends, as this strategy has been associated with increased student learning satisfaction (Childs et al., 2004). The department utilizes a number of surveys to assess student satisfaction and success. The department analyzes the nursing cohort from the NSSE and Graduate Student Exit Survey, two instruments disseminated to students throughout the university, to assess student satisfaction with learning, campus climate, advisement, and faculty; likelihood to recommend; and perceptions of customer service. Moreover, in 2004, the department began using the Educational Benchmarking Instrument (EBI) to assess the quality of instruction, curriculum, academic environment, resources, role development, cultural competency, and accessibility of the program. This tool allows the department to compare itself with other nursing programs across the nation. In addition, the nursing department has created several of its own surveys. The Alumni Survey is distributed to all nursing students 6 months after graduation to obtain information related to whether or not the alumnus has taken and passed the NCLEX-RN, has become employed, and feels adequately prepared for the profession. The Employer Survey is distributed to employers of recent NSU nursing graduates to assess their satisfaction with the alumnus' level of knowledge and performance. Lastly, the BESTRN project investigators developed the Student Assessment to have enrolled students identify factors they perceive to be affecting their performance (i.e., test anxiety, study skills, family responsibilities). This assessment is conducted biannually. Based on feedback from these instruments, the department has begun implementing a number of strategies to improve students' satisfaction and engagement. To keep the attention of today's entertainmenthungry society, faculty utilize integrative teaching/learning strategies including the incorporation of multimedia, case studies, student presentations, group work, discussions, and local continuing education events as standard
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components of courses. Students have become more actively involved in the learning process. With an increased emphasis on customer service, the department offers a monthly forum called Voices Day in which students “voice” their questions, concerns, and suggestions to faculty. In addition, a student–faculty liaison committee is utilized as a vehicle for improving student– faculty relations. Students and faculty collaborate to produce a departmental newsletter as a method of increasing student involvement, communication, and unity. Efforts are made to involve students in departmental, campus-wide, and community-based grant projects such as the Substance Abuse and Mental Health Services Administration HIV/AIDS Initiative. The department has encouraged the growth of existing student organizations and extracurricular activities such as the Student Nurses Association and Chi Eta Phi Nursing Sorority. In 2004, the NSU Nursing Honor Society for Baccalaureate Nurses was established with the goal of securing a Sigma Theta Tau International Nursing Honor Society charter. In addition, the ADN Student Honor Society was formed as a means to encourage these students, who would not be eligible to join Sigma Theta Tau, to continue their professional and educational pursuits. These organizations are not only providing student recognition but also increasing student involvement with nurses in the community through mentoring, fund-raising, and interaction. Student satisfaction with the program is contingent upon open lines of communication. New students and faculty are assigned peer mentors. The department offers informational sessions to newly accepted students to prepare them with test-taking strategies, critical thinking, study and writing skills, and so forth. Faculty utilize Blackboard to enhance frequent student–instructor interaction outside the classroom. To improve the quality of advisement, students are assigned to a nursing faculty who is currently teaching the student. Multiple opportunities have been created for student remediation. Faculty are required to offer “content mastery sessions” following a test to provide a formalized review of the test content to all students who did not pass. Moreover, a program has been established to provide paid and volunteer peer tutors for students who are struggling. Faculty are given incentives to participate in a tutoring program as well (1 hour of tutoring substitutes for 2 of the weekly office hours faculty are required to offer). The department offers a summer program to incoming students who have science, math, or writing problems to provide the foundation necessary for success. Finally, nursing faculty have hosted departmental writing workshops reinforcing grammar, American Psychological Association style, and writing skills compatible with nursing coursework.
Strategies to Promote Cultural Competence The BESTRN program utilizes existing resources and develops additional methods for promoting cultural competence. International students are encouraged to
AN HBCU'S BACCALAUREATE ENROLLMENT AND SUCCESS TACTICS FOR RNS
utilize the University's International Student and Scholar Service, which provides assistance including personal counseling, academic advising, travel information, and interpretation and explanation of immigration laws and serves as a link between the University and U.S. governmental agencies, foreign embassies, and foreign governments. The department receives an increasing number of immigrant students who are nonnative English speakers including those from Africa and Asia (e.g., the Philippines) and has established a support program for English as a second language students. Efforts are being made to create a learning environment that is conducive to their unique needs. The University promotes awareness of its cultural foundations by requiring all students to complete a three-credit course in African American Perspectives. In addition, the nursing curriculum further encourages the cultural competence of its students through a Bioethics/ Multiculturalism course and service-learning experiences in underserved communities. Finally, measures have been taken to expand upon nursing faculty opportunities to participate in teaching/learning workshops that emphasize considerations for special needs and cultural diversity.
Program Results Two years into its implementation, the program leaders have begun to evaluate BESTRN effectiveness by examining the results of the various assessment measures and comparing the recent results with results from previous years as well as national benchmarks. Numerous achievements have been made in each of the critical areas: enrollment, retention, success, and cultural competence. Improvements have occurred in the volume and quality of the applicant pool as well as enrollment capacity. Fund-raising efforts have led to substantial increases in alumni giving and university support so that a greater number of BSN students receive financial assistance. Recruitment of ADN students into the BSN program has increased. Of the ADN students who graduated in May 2004, 22% (n = 60) entered directly into the BSN program; this increased to 29.8% (20 out of 67) of the May 2005 graduates and 38.7% (24 out of 62) of the May 2006 graduates. The number of spaces for second-degree BSN students has increased from 40 in 2004 to 50 at present, with a plan for additional increases upon hiring of additional faculty. The Student Assessment Survey, which was designed and distributed specifically for the project, examines factors influencing students' academic success. Students evaluated the influence of the following “critical success” factors: critical thinking, reading, writing, test taking, and study skills; test anxiety, time management, computer and Internet access, and family and financial obligations; bonding with students and faculty; faculty availability and advisement; academic workload, program pace, clinical prep, and homework on their performance. Six factors have been significantly associated with a student's report of difficulty passing (Table 1). Quite a few of the
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relationships between critical success factors were statistically significant (r ≥ .6), with “bonding with faculty” and “advisement” representing the strongest relationship (r = .89), but factor analysis showed that there is little practical significance for most of these relationships. While the factor analysis separated the 22 factors into three major groups with predictive values of approximately 56%, 21%, and 14%, the categories could not be labeled as any meaningful concepts. Further, no significant relationship existed between age, gender, or student status (full-time vs. part-time) and any of the critical success factors; however, this finding may have been confounded by the sample homogeneity, as it consisted primarily of young, female, full-time students. The investigators compared the survey results over the past few years and found that there were only three areas in which students felt the department had not improved: advisement, faculty availability, and student bonding. Consequently, these areas have become a point of focus for improvement initiatives; however, the researchers attribute student dissatisfaction with faculty advisement and availability as due, in part, to faculty turnover and a change in the assignment of advisees, which occurred between these years, because students may have felt they were being shifted from one faculty member to another. The results of the EBI survey provided insight into several issues. The department began using the EBI in 2004; thus, internal comparison was limited, but the response rate went from about 60% to almost 100%. Improvements from 2004 to 2005 occurred in the areas of role development, core knowledge, and quality of nursing instruction. In comparing 2005 and 2006 survey results, improvements occurred in all areas (satisfaction with work/class balance, facilities, classmates, the program's effectiveness at instilling professional values, technical skills and core competencies, role development) except for quality of instruction. It is unclear why the students rated quality of instruction less favorably in 2006; hence, this will be closely monitored in upcoming years. Overall, the NSU Nursing Department 2006 results were poorer than its six selected “benchmark” schools, the Carnegie sample, and the EBI population of participating
Table 1. Critical Success Strategies That Affect Student Performance Factor Test taking Workload Pace Study skills Advisement Bonding with faculty
ss
df
MS
F
Significance
11.012 62.074 29.087 85.775 14.010 112.19 15.180 57.709 24.674 98.076 19.199 96.610
1 68 1 63 1 67 1 61 1 66 1 66
11.01 0.913 29.087 1.362 14.010 1.675 15.180 0.946 24.674 1.486 19.199 1.464
12.06
.001
21.363
.000
8.366
.005
16.046
.000
16.604
.000
13.116
.001
28
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institutions. This finding endorses continued use of the tool for benchmarking purposes; further, it highlights the need for further improvement so that minority-serving nursing programs provide students with a quality of education that meets or exceeds peer institutions. The retention and success rates have improved as well. The graduation rate for the students who started in May 2004 was 71%, as compared to 80% for students who began in May 2005 and an expected 90% for students who began in May 2006 and will graduate June 2007. The NCLEX pass rate on first attempt has risen from 58% in 2005 to 82% in 2006. Gains have been made in the cultural competence of faculty and staff. The Department's Student Assessment attempted to assess cultural diversity using two items: student ratings of program adequacy with respect to cultural competency and cultural diversity. The results from these measures were inconclusive as less than 25% of the students answered these items. The researchers suspect that the items were overlooked because of the placement in their own box at the bottom of the page. On the other hand, the NSSE and EBI measures of cultural competency showed that NSU programs, including nursing, scored significantly above the norm in terms of meeting students' needs in terms of learning about and exposure to a diversity of cultures. In addition, the nursing department hosted several programs that enhanced the cultural competence of faculty and students, including a History of African American Nurses in Virginia Program, a Health Disparities Workshop, an HBCU HIV Education project, and a faith-based service– learning partnership with a minority health coalition.
Conclusions and Future Directions The NSU BESTRN program has demonstrated significant achievements. Over 2 years, the nursing department has successfully increased student enrollment by 20% (despite a general decline in University enrollment), increased student retention by 25%, and improved the first-attempt NCLEX pass rate by 14%. New strategies for increasing student and faculty volume are being tested as the BESTRN program continues to evolve. Based on its reported success as a recruitment strategy (Dessner, Mosser, & Reno, 1998; Lerner & Cohen, 2003), the department is developing an “Intro to Nursing” course for prospective nursing students. In the meantime, the freshman orientation course “UNI 101” has been enhanced to include more information about the nursing program, its expectations, and core values to increase awareness throughout the university. The establishment of community partnerships has allowed for the increase of RN–BSN annual enrollment capacity to 60 as clinical placements expand beyond school and health department settings to include local and national health education initiatives such as “Heart Truth,” “Project Power,” and “Let's Get Real.” In an attempt to offer even more flexibility with program pace and hours, a combined distance-learning/onsite weekend-only accelerated RN–BSN program began in Spring
2006 and enrollment grows each semester. Although the department lost six full-time faculty during this period, it has experienced overall growth with the recruitment of four new full-time faculty in 2004, two in 2005, four in 2006, and numerous additional adjunct faculty. In January 2007, the department hired a full-time Student Recruiter/Advisor who is an alumna of the program. This individual collaborates with the admission coordinator to expand recruitment strategies, as well as to find methods for increasing the availability of student scholarship and other financial and academic supportive resources. Supplementary retention methods have been employed to increase student satisfaction and success. Nursing faculty are encouraging early interventions with referrals to tutors and study groups, and the NSU Nursing Honor Society has assisted in developing a mentor program. Faculty are engaging in the process of examining changes in the NCLEX-RN test plan, nursing curricula of other schools, and the current evidence base of nursing education across the nation to determine what revisions need to be made to the nursing curriculum and prerequisite courses. Cultural competence continues to be promoted through increased faculty and student participation in externships and service learning activities. In keeping with the philosophy of continuous quality improvement, the NSU Nursing Department will continue to engage in the development, implementation, and evaluation of enrollment, retention, and success strategies. The BESTRN program has only just begun!
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