Background/Significance: The demand for culturally competent healthcare services in Delaware continues to rise, while its supply of culturally and ethnically diverse nurses remains stagnant. The growing inequality between the diversity of the residents and the healthcare workforce will worsen as Delaware’s minority population surpasses its present level (30%). Delaware’s African Americans and Latinos bear the brunt of health inequality ("Delaware primary care health needs assessment 2015", 2016). Most residents of the state live in medically underserved areas (MUA) or are designated as medically underserved populations (MUP). Likewise, much of the state’s three counties are designated as a health professional shortage area (HPSA)("Delaware 2010 MUAs and MUPs", 2010). Nursing education programs in Delaware are not producing sufficient numbers of minority nurses to create a critical mass that will reflect the racial/ethnic makeup of the state. Efforts to recruit and retain nursing students from diverse backgrounds is critical to ensure culturally and linguistically competent patient care.
A Nursing Workforce Diversity grant funded by the Health Services Resources Administration (HRSA) enabled the University of Delaware School of Nursing (UDSON) to develop a comprehensive evidence-based program of recruitment and retention focused on minority and underrepresented/disadvantaged undergraduate nursing students. The program utilized evidence-based interventions to address the structural and intermediary social determinants of health (SDH)(Metcalfe & Neubrander, 2016), with the overarching goal of increasing the diversity of the nursing workforce in Delaware.
The evidence indicates that financial needs, academic needs, social and emotional support, peer support, mentoring, and community partnerships are important aspects of recruiting and maintaining minority and underrepresented/disadvantaged nursing students (Berumen, Zerquera, & Smith, 2015; Dapremont, 2011; Degazon & Mancha, 2012; Ferrell, DeCrane, Edwards, Foli, & Tennant, 2016; "Healthy People 2020: Social Determinants of Health," ; Love, 2010; Nnedu, 2009; Tinto, 2006; Voss, Mathews, Fossen, Scott, & Schaefer, 2015; Wong, Seago, Keane, & Grumbach, 2008).
Purpose: Two goals of the evidence-based program described here focus on the effects of recruitment and retention of minority, and underrepresented/disadvantaged students over the course of three years.
Method: The University of Delaware School of Nursing conducted a 3-year evidence-based and comprehensive program to enhance nursing workforce diversity that was anchored in the Social Determinants of Health (SDH) Framework between July 1, 2014 and June 1, 2017. The program was conceived with a conscious awareness that diversity can only be fully cultivated when the highest levels of power and leadership at the university actively articulate and demonstrate articulate support (Levy, Heissel, Richeson, & Adam, 2016). Evidence-based features included: 1) financial support; 2) academic support; 3) social and emotional support; 4) peer support; 5) mentoring; and 6) community experiences in medically underserved areas (MUAs) and with medically underserved populations (MUPs).
Sample: Thirty-one undergraduate minority and/or underrepresented/disadvantaged nursing students (9 juniors, 9 sophomores, 11 freshmen) at the University of Delaware.
Procedure: Students from minority and/or underrepresented/disadvantaged backgrounds were recruited by the grant team as freshmen in the fall of 2014 (n=9), 2015 (n=9), and 2016 (n=11). Qualified students were interviewed by grant staff and offers to participate in the program were made to 29 students. Participants completed an initial survey to identify personal, family, and financial strengths and challenges. The results were used to develop individualized support for participants. These included: 1) financial support (scholarships, monthly stipends); 2) academic support (Retention Coordinator/advisor; one-on-one and group tutoring; nursing specific study skills; test-taking skills, note-taking skills, time management, organizational skills; writing support through the university writing center); 3) social and emotional support (social and cultural events targeted to participants) 4) peer support through the university counseling center and a peer mentoring program); 5) professional development (individualized professional development strategies, resume writing, job search skills); 6) leadership experiences (Student Nurses Organization and Minority Student Nurses Organization; 7) experience in MUAs and/or MUPs (e.g. partnerships with agencies that serve rural or underserved areas in the state).
Analysis: Data included information on retention rates; use and evaluation of program support resources, satisfaction with the program (e.g. financial support, academic advising, tutoring, university Writing Center, leadership opportunities, participation in cultural events), and GPA.
Results: Twenty-seven of 29 participants remain in the program (93.10%). One student decided to pursue a different major and a second student left the program for personal and financial reasons. All students achieved at least the minimum GPA to remain in the nursing program. Academic advisement by, and individual meetings with, the Retention Coordinator were highly valued by participants. Financial support ranked high with program participants, as did referrals to other support services (e.g., one-on-one and group tutoring, monthly group meetings of program participants, emotional and social support from the Retention Coordinator and peers, professional and leadership opportunities in the Student Nurses Organization and Minority Student Nurses Organization) community service (e.g., blood pressure screening; recruitment at area high schools). Participants currently hold leadership positions in the Student Nurses and Minority Nurses Organizations and one participant is an officer in the Men in Nursing program in the school of nursing. The participants provided input on aspects of the program which they did not find helpful. These included group counseling/support sessions, inconvenient group meeting times, and a desire for more community outreach. Overall satisfaction with the program over the course of the three years was 4.96 (0=lowest score; 5=highest score).
Discussion: As seen in the literature, financial and academic support were highly valued by participants and were the primary reasons that many gave for their success in the nursing program. The Retention Coordinator (also was also the academic advisor for all participants) was referred to in glowing terms for helping the participants with academic, financial, and personal issues. We believe that dedicating one individual to advise all of the program participants is essential to successful retention. Participants were very active in community organizations that served minority populations. For example, several participated in a church based organization which provided education and outreach to people with HIV/AIDS. Others were active in the Delaware Preconception Peer Education program which focused on outreach to minority high school students. Still others were active in Lori’s Hands (Delaware-based non-profit providing community-based services for chronically ill, and predominantly underserved/low income, seniors).
Conclusion: This evidence-based approach was successful in recruiting and retaining minority and underrepresented/disadvantaged nursing students over the course of the three years of the program.