An Experiment in Success: Nursing Workforce Diversity Program Allows Schools to Test Models to Improve Recruitment, Retention of Underrepresented Groups

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In 1964, in response to existing and projected shortages in the nursing workforce, Congress passed legislation aimed at funding efforts to develop a more robust pool of registered nurses — effectively setting a positive precedent regarding the federal government’s support for educational nurse training programs. Since then, as the need for more nurses has increased, so has the need for a nursing workforce that better represents our country’s diverse citizenry.

With the goal of supporting efforts to recruit, retain, and graduate nurses from underrepresented and disadvantaged backgrounds, the Health Resources and Services Administration (HRSA) has awarded approximately $204 million in grants since 2014 to U.S. nursing schools through its Nursing Workforce Development (NWD) Program. Based on a social determinants framework, NWD selects as grant recipients programs that identify and aim to address the specific barriers faced by certain underrepresented populations.

[Above: Nursing students at American International College participate in a patient simulation.]

“NWD provides grants to schools of nursing and other eligible entities to strengthen and expand the comprehensive use of evidence-based strategies shown to increase the recruitment, enrollment, retention, and graduation of students from disadvantaged backgrounds in schools of nursing,” says an HRSA spokesperson. “[Grant] recipients must implement five evidence-based strategies under the social determinants framework that are successful in supporting nursing students from disadvantaged backgrounds from enrollment through graduation.”

These strategies involve access to diverse mentors and role models, academic and peer support, financial support, internal and external partnerships, and holistic admissions review processes. In addition, schools are required to monitor and report to HRSA progress toward meeting their program-specific goals.

“The recruitment strategies and approaches used are unique to each project and are based on the needs of the target student population,” according to the HRSA spokesperson. “One specific approach, for example, is the use of external partnerships. These partnerships may leverage resources from national [associations] or engage with community organizations that can help institutions recruit disadvantaged students, advise on diversity relations, and provide mentorship and service opportunities.”

Misty L. Wilkie
Misty L. Wilkie

Niganawenimaanaanig Project
Located near the three largest Indian reservations in Minnesota, Bemidji State University (BSU) has sought to attract more Native American students to its nursing program but has often struggled to do so, says Misty L. Wilkie, PhD, RN, an associate professor at the university.

“The number of American Indian students in our nursing program didn’t correlate with the needs of the [area’s] population, so we wanted to [figure out] what more we could do to draw students to our program,” she says.

After a long and arduous application process, BSU’s Department of Nursing was awarded a $1.9 million, four-year NWD grant in June 2017 to recruit and support up to 12 native nursing students through its Niganawenimaanaanig Project. While pre-nursing students are able to take advantage of the academic, cultural, and social support offered through the project, only those who have officially been accepted into BSU’s nursing program can receive financial assistance through the grant.

Participants in BSU’s Niganawenimaanaanig Project with program faculty, including Misty Wilkie (back, second from left)
Participants in BSU’s Niganawenimaanaanig Project with program faculty, including Misty Wilkie (back, second from left)

According to Wilkie, who serves as the project’s director, the program’s ultimate goal is to increase the enrollment of American Indian nursing students at BSU 75 percent by the fourth year of the grant. One way the school is working to achieve this is by using the funds to provide eligible students yearly scholarships of $4,000 — which Wilkie says covers half of annual tuition costs — and monthly stipends of $500 to individuals who continue to meet program requirements. In addition to goal-setting sessions at the beginning of each semester, participants must attend weekly faculty mentor meetings, monthly cultural activities, and tutoring for those who may be struggling in a course.

“[Often,] students don’t know how to or they don’t like to ask for help, and I have had many get to the point in a course where there’s no way to salvage their grade,” says Wilkie, who is Native American. “So at the weekly mentor meetings, we talk about what’s going on in their courses, what kinds of assignments they’re working on, what assignments they have coming up, and [students have] recognized that these meetings have kept them accountable.”

For many native students, leaving their reservation is often the most difficult part of making the decision to attend nursing school or college in general, which can pose unique challenges to recruitment. BSU uses the fact that these individuals often crave more knowledge about their culture to attract them to and retain them through the Niganawenimaanaanig Project.

“The cultural piece is really important because, for those students who move off the reservation to come [to campus], one of the biggest things that makes them leave school is loneliness. There is such a deep connection with the community for the students who come from reservations, and moving off the reservation is a big culture shock, and they [lose] that sense of community,” explains Wilkie. “So that’s part of what the grant is working on with the requirement to attend cultural activities.”

Since the program’s launch this fall, some of these activities have included a presentation about health disparities among Indian populations and, for Native American Heritage Month, a moccasin-making workshop, a ceremonial skirt-making workshop, and various speaker events. Wilkie says she would like to offer more events in the future, once she hires additional staff; in addition to serving as director, she is grant coordinator and the only faculty mentor for the project. “I would like to get to the point where we have an activity at least once a week that students can choose from,” Wilkie says. She also hopes to bring in a tribal elder to meet weekly with students to “pass on some traditional knowledge and wisdom.”

With only one semester of the project completed, Wilkie says she is already noticing increased interest by native students in BSU’s nursing program, and she hopes that this will be the start of a “long line of native nurses” graduating from the school.

“Our goal is to make [BSU] a destination for American Indian students,” says Wilkie, “[to become] known for the support that we provide them.”

Students from the University of Alabama’s Capstone College of Nursing attend the National Association of Hispanic Nurses 2017 national conference.
Students from the University of Alabama’s Capstone College of Nursing attend the National Association of Hispanic Nurses 2017 national conference.

BAMA-Latino Project
As the U.S. Hispanic population continues to grow, the University of Alabama’s Capstone College of Nursing has taken on the urgent and complex task of increasing the number of Latino nurses, specifically those with a bachelor’s degree or higher. In partnership with the National Association of Hispanic Nurses (NAHN), the college created the BAMA-Latino Project — BAMA stands for Alabama — to drive the recruitment of this important group using a four-year, $1.8 million NWD grant from HRSA (#D19HP30858-01-00).

“Only 4 percent of nurses … are Latino. This is a big concern because we have an increasing number of Latinos in our country, and we know that healthcare is improved … when people who look like you care for you,” says Norma G. Cuellar, PhD, RN, a professor of nursing and principal investigator for the grant. “Our goal is to increase the number of associate-degree nurses [who advance] to a baccalaureate level, and hopefully we will plant a seed to encourage them to get their master’s and then go on to get their doctorate.”

Launched in fall 2017, the program aims to recruit 20 Latino students for each year of the grant — for a total of 80 — to Capstone’s RN to BSN Mobility Program. Offered entirely online, it allows interested and eligible students from across the country to earn a bachelor of science in nursing (BSN) in two years. Cuellar believes the fact that it is online allows the college to reach more people, particularly those in rural areas where they may not have access to baccalaureate nursing programs.

Norma G. Cuellar
Norma G. Cuellar

She says that recruiting Latino students is often a difficult task because many are heads of households, work full-time jobs, and may struggle with the language barrier; in addition, Cuellar — who is Hispanic herself — says that these families often do not place much importance on earning advanced degrees. Thus, in addition to covering the cost of up to 12 credit hours of prerequisite courses, BAMA-Latino requires that students participate in resiliency training during their first semester. Offered as a one-semester, pass-fail class, it is designed to help participants overcome some of those barriers, Cuellar says.

“[The resiliency training] really builds their self-esteem and motivation,” she says. “They discuss things that have been barriers and how to handle them, and they do a lot of journaling.”

Another key component of the project is mentorship, with students assigned both an academic mentor in the college and a professional mentor from NAHN. Cuellar says these individuals are currently teaching the resiliency class, where they are getting to know the students and will be able to provide encouragement and support; they are able to communicate via the program’s online Blackboard. An additional mentorship program that will recruit BAMA-Latino alumni as mentors will launch in the spring.

Participants also benefit from attendance at NAHN national conferences, and the college typically offers stipends to cover the cost of attending. “This is an opportunity for them to see our Latino family in these leadership positions, how powerful we are and how much we are needed,” says Cuellar. At this year’s conference, members of BAMA-Latino’s first cohort will present on the effect of the resiliency training on their education.

“Many of them have told me how impactful that has been, that it has really changed their perception, and that they feel like it has given them some insight they never had before,” explains Cuellar.

Beyond the supports provided by the program, she says that the BAMA-Latino Project has greatly benefited from the holistic admission review component of NWD. With assistance from the American Association of Colleges of Nursing, the college has worked to improve its admissions process to ensure the acceptance and enrollment of Latino nursing students.— which Cuellar says often requires looking for specific personality traits.

“We know that just because you have a 4.0 GPA does not mean you are a kind, caring, compassionate nurse,” she explains. “So we’re looking at other [factors], … making sure that we get students who we feel will be engaged in the profession, [who] want to care for their patients, and [who will] be respectful and kind.”

Karen Rousseau
Karen Rousseau

Nursing Education Achievement Program
Serving a large population of low-income, first-generation, and ethnically diverse students who often struggle to remain enrolled, American International College (AIC) in Springfield, Mass., decided to allot much of the $347,008 it received from a 2016 NWD grant toward improving the attrition of its most vulnerable nursing students. For AIC, these tend to be juniors, who are often both ethnic minorities and have financial need, according to Karen Rousseau, PhD, RN, director of the Division of Nursing and a professor.

“We were looking to hopefully improve the retention of those students who we identified as coming from disadvantaged or ethnically diverse backgrounds,” says Rousseau, who is also program manager for the grant. “We chose junior year because that’s the time when students tend to drop out [or] often are not successful through a course and have to come back and repeat. For this population, sometimes that’s almost an insurmountable challenge because they can’t [afford to] come back.”

Students in AIC’s Nursing Education Achievement Program
Students in AIC’s Nursing Education Achievement Program

While she says these individuals are often African American or Puerto Rican, the NWD-funded Nursing Education Achievement Program (NEAP) is focused on supporting nursing students from all underrepresented and disadvantaged groups. And one key aspect of this is mentorship.

Through partnerships with the Western Massachusetts chapter of the National Hispanic Nurses Association, the Western Massachusetts Black Nurses Association, and Baystate Medical Center, the program connects participants with mentors working in the field. Students have also received financial support to attend conferences and other events hosted by these organizations, where they have had the opportunity to network with professional nurses. Rousseau says this aspect of NEAP is important for providing role models and promoting their awareness of professionalism.

“Some of these students [didn’t] have role models prior to this,” she says. “Especially [for those who are] first-generation, the connection to these outside groups and mentors is a tremendous opportunity for them.”

In addition to providing mentorship, NEAP requires that the 40 program participants — the first 26 of whom received a $1,000 scholarship — attend weekly tutoring and group counseling sessions as well as financial literacy workshops and study skills seminars. In the financial literacy sessions, they are taught money management, including the basics of student loan repayment, and in the study skills lessons, they learn how to organize notes and prepare for exams.

The counseling component allows students to discuss their stresses and concerns in a relatable, group setting, but they also have the option to engage in individual sessions if needed. Feedback from last year’s group counseling meetings resulted in NEAP adjusting its offerings to better address participants’ needs, says Rousseau.

“[We changed] some of those group [meetings]into cognitive mindfulness sessions because the students feel like dealing with anxiety is a major issue for them,” she explains. “Cognitive mindfulness is a process where people can learn how to focus themselves, decrease their anxiety, and be more mindfully present. That’s intended to assist them when they’re studying, open their minds, promote knowledge retention, and reduce anxiety around test taking.”

NEAP participants who attend the required activities receive monthly stipends to offset income they could be earning if not on campus, Rousseau says. “[Those] provide them with a little extra funding … to stay on campus longer,” she explains. “We found with our previous grants and activities that these things are available to the students, but they don’t attend because they’re working, because many of them have children and many levels of financial responsibility.”

According to Rousseau, the effects of offering these supports for underrepresented and disadvantaged junior nursing students are even better than AIC expected. In its first year — 2016-2017 — NEAP exceeded its goal of retaining 85 percent of all participants, with a 92 percent attrition rate. “We had a significant change in our success rate out of that class,” Rousseau says, “and we’re hoping that we’ll have the same results this year.”

She says HRSA’s NWD grant provided AIC the ability to “test out different strategies for student success” — an opportunity she believes is essential to improving diversity in the nursing workforce.

“When you look at a diverse population of nursing students, they come with a lot of different needs, and I think it’s important that we look at various ways to address those needs,” says Rousseau, “… not just providing a scholarship, because you can [do that] but students may still struggle to attend class or pass exams. So we need to find ways to help them not only be able to attend but to ultimately be successful [in nursing programs] … to diversify our workforce.”●

Alexandra Vollman is the editor of INSIGHT Into Diversity.