It is of concern that the nursing workforce in the United States lacks the cultural diversity of the populations it serves (American Association of Colleges of Nursing [AACN] Task Force on Diversity and Opportunity, 1997; AACN Task Force on the Vision of Baccalaureate and Graduate Nursing Education, 1997; Bessent, 1997; The Center for the Health Professions, 1998a, 1998b; National League for Nursing [NLN] Commission on a Workforce for a Restructured Health Care System, 1997; Sales, 1997; Senate Labor Reauthorization of Health Professions Programs, 1995). Only 8% to 10% of RNs have ethnic minority backgrounds, in contrast with 22% to 25% of the United States population (AACN Task Force on the 'Vision of Baccalaureate and Graduate Nursing Education, 1997; Senate Labor Reauthorization of Health Professions Programs, 1995). In addition, according to the NLN Commission on a Workforce for a Restructured Health Care System (1997), the number of Black and Hispanic students graduating from RN prelicensure programs* has decreased since 1989, and there have been minimal increases in proportions of American Indian and Asian graduates. Enrollment and the number of graduates from ethnic minority backgrounds in practical and vocational nursing programs are proportionately higher than in RN prelicensure programs. Nationally, vocational nursing programs increased enrollment of students from ethnic minority backgrounds to 30% and the number of graduates to 26% in the 1995 class (NLN Commission on a Workforce for a Restructured Health Care System, 1997).
Similarly, the cultural diversity of the California RN workforce is not equal to its population. California eliminated its legislative imperative for affirmative action in 1996 through Proposition 209. This action has affected many public institutions, including educational systems. However, positive changes are occurring. Data indicate that the number of nurses from ethnic minority backgrounds is increasing due to greater numbers of students from diverse backgrounds entering nursing programs, as well as greater numbers of foreign nursing graduates living and working in California (California Department of Consumer Affairs, Board of Registered Nursing [BRN], 1998). The proportion of non-White nurses increased from 21% in 1990 to 33% in 1997. In addition, the percentage of nurses age 30 or younger who are from ethnic minority backgrounds has been increasing since 1990 (i.e., 27% in 1990; 38% in 1993; 51% in 1997) (California Department of Consumer Affairs, BRN, 1999). Students who completed RN prelicensure programs in 1997 to 1998 included those who were White (52%), Hispanic (14%), Asian (13%), Filipino (9%), Black (7%), Native American (1%), and other (4%) (California Department of Consumer Affairs, BRN, 1999). However, the disparity between the population and the nursing workforce remains a concern.
As programmatic solutions to supply and demand issues are addressed, they must be considered in the context of California's rich diversity. A workforce that is both culturally diverse and culturally competent is required. Cultural competence is related to, but not synonymous with, cultural awareness, knowledge, understanding, and sensitivity (Lister, 1999). Cultural competence is the ability to integrate cultural knowledge and sensitivity-enhancing skills within the helping process (Weaver, 1999) as it "honors the racial, cultural, ethnic, religious, and socioeconomic diversity of families" (p. 217). Even more broadly, cultural competence implies sensitivity and responsivity to culture, race, ethnicity, gender, age, socioeconomic status, and sexual orientation (Brant et al., 1999). In California, a state that is among the most diverse in the United States, it is unlikely that there always will be an exact match between patient groups and nursing personnel. Therefore, it is imperative that nursing personnel be prepared as culturally competent and sensitive caregivers.
California Strategic Planning Committee for Nursing
The California Strategic Planning Committee for Nursing (CSPCN) was initiated in 1992 with the goal of ensuring an adequately prepared nursing workforce to meet the needs of people living in California. Funded by donations from nursing organizations, health care organizations, service providers, regulatory agencies, health planning agencies, and foundations, the CSPCN collected data on nursing supply and demand, identified directions for positive change, and implemented policy initiatives. A cultural diversity work group was responsible for ensuring that issues of cultural and ethnic diversity were addressed as a central theme within the CSPCN activities.
Cultural Diversity Survey
Tb obtain information, a survey related to retention, recruitment, and cultural competence and sensitivity issues was developed for deans and directors of nursing education programs in California. The purpose of the survey was to identify:
* Successful recruitment and retention strategies for students from ethnically and culturally diverse backgrounds.
* Barriers to recruitment and retention of these students.
* Strategies to ensure cultural competence and sensitivity among students and graduates.
Two surveys were designed, one for RN prelicensure programs and one for vocational nursing programs. Because RN prelicensure programs annually report the ethnicity of newly admitted and graduating students to the California Board of Registered Nursing, current student ethnicity information was requested only on the survey for vocational nursing programs. Both surveys included a question related to whether the institution's program actively recruits ethnically diverse students. A checklist of 10 potential recruitment strategies was developed from a literature search and discussion among faculty groups. Recruitment strategies included items such as "contacts with ethnically diverse faculty" and "advertising." Registered nurse prelicensure surveys also included a checklist of four successful retention strategies, including "mentoring program" and "providing remedial coursework, such as English as a second language." Both surveys included a checklist of eight barriers to retention and recruitment, including "lack of support from family and significant others." A checklist containing seven items was included to identify strategies used within programs to ensure cultural competence and sensitivity. Items included "clinical experiences" and "specific coursework." Space was provided following each checklist to write additional strategies or barriers.
The instruments were reviewed by a panel of four experts who were educators and/or staff members from regulatory agencies responsible for ensuring educational standards statewide in RN preiicensure or vocational nursing programs. All experts concurred with the items included, and no additional items were added. The survey then was mailed to all RN prelicensure and vocational nursing program administrators in California in 1998 (N = 175). Respondents from 86 programs returned surveys, for a response rate of 49.1%. Of these, 44.2% were from vocational nursing programs (n = 38), 39.5% were from associate degree nursing programs (n = 34), and 16.3% were from baccalaureate programs (n = 14).
Of the 86 respondents, 48% (n = 41) indicated that at the time of the survey they were actively recruiting ethnically diverse students for their programs. Vocational nursing programs were more likely (58%) than baccalaureate degree (43%) or associate degree (39%) programs to be actively recruiting ethnically diverse students. In addition, 16 vocational nursing programs indicated they attracted students from ethnically diverse backgrounds without recruitment efforts.
Successful Recruitment Strategies
Half of California's nursing programs were actively recruiting diverse students. In vocational nursing programs, the most frequently used strategy was advertising. Among baccalaureate and associate degree programs, admission criteria, scholarships, group information sessions, and/or off-campus health fairs were 4 methods commonly used to attract diverse students. An alternative strategy included active recruitment in high schools, and even elementary schools. Some schools encouraged and facilitated student visits to program facilities and sometimes included tours of clinical facilities. One respondent stated that "making certain all advertising reflects diverse students in photos" was important, although their "most successful approach is personal recruitment by diverse candidates who refer others to our program." Two other respondents indicated that the location of the nursing program in an urban setting with an ethnically diverse community and involvement of "ethnic admissions counselors and ethnic student recruiters" contributed to successful recruitment. One vocational nursing program mentioned recruiting through ongoing English as a second language classes.
Successful Retention Strategies
At least one third of RN prelicensure programs relied on four retention strategies - financial assistance, mentoring programs, counseling, and remedial coursework. Successful mentoring programs included one or more of the following:
* Support from one-to-one facultystudent relationships or the Big Brothers Big Sisters of America program.
* Support from ethnic faculty.
* Graduates or RNs of similar ethnic backgrounds serving as role models.
* Peer mentoring programs.
* Scholars-in-service program with students involved in community projects.
Another successful retention strategy was the use of counseling, which included at least one of the following:
* Individual meetings with an instructor for English as a second language.
* Ethnically diverse counselors.
* Faculty and/or nurses employed through student health programs.
* Specific types of counseling, such as crisis intervention, psychological services, and/or student health.
* Individual encouragement by faculty or staff.
* Faculty following up with students with low grade point averages at midterm, implementing a remediation plan, and continued follow up, including during clinical experiences.
* Classes on test-taking strategies.
* Evaluation for learning disabilities.
Several RN prelicensure programs offered total learning assistance courses or programs with or without skills assessment. Services were provided to individual students or groups and could focus on reading improvement, writing skills, paper writing, pronunciation and verbal skills, studying for tests, or peer counseling.
Faculty-supervised remediation was another strategy used to help ethnically diverse students in both theory and clinical courses. Faculty often encouraged students to get involved with group study sessions, computer-assisted instruction, or other diverse teaching strategies. One program encouraged group study from the beginning of the curriculum. Another program offered preparation classes that coincided with lectures and skills instruction. One respondent mentioned a unique retention strategy of being a "visible presence in the community," which also may serve as a recruitment strategy.
Barriers to Success
The most common barriers for ethnically diverse students in all programs were financial and educational. Adequacy of financial resources was a problem in 79% of baccalaureate degree, 62% of associate degree, and 40% of vocational nursing programs. The educational barrier often related to speaking English as a second language or inadequate academic preparation. Several programs reported that a lack of ethnically diverse faculty also was a barrier.
For vocational nursing program respondents, additional barriers for students fell primarily into the following categories:
* Difficulty handling patients in clinical settings.
* Perceptions of hospital staff as unsupportive.
* Differences in cultural beliefs.
One respondent noted low reading ability in English as a barrier.
Respondents from RN prelicensure programs described additional educational barriers, including:
* Verbal and written skills, primarily for individuals for whom English is a second language.
* Underdeveloped critical thinking and test-taking skills.
* Possible undiagnosed learning disabilities.
Miscellaneous barriers for students in RN prelicensure programs included cultural biases against nursing as a profession and poor time management skills (i.e., difficulty managing academic and family priorities).
Many programs included activities within their curricula designed to ensure culturally competent and sensitive graduates. Activities noted by vocational nursing and RN prelicensure program respondents included academic exercises, such as cultural and religion presentations; clinical experience postconferences; required skills laboratory courses; case studies; written assignments; and class/cooperative groups that demonstrated how misunderstandings arise and prior assumptions lead to erroneous conclusions. In addition, program respondents indicated positive experiences with the following strategies:
* Having primary instructors enroll in coursework about culture and culturally diverse populations.
* Having an ethnically diverse student population.
* Selecting positive role models in clinical agencies.
* Promoting a supportive faculty attitude.
Several respondents indicated that they offered extensive curriculum content to ensure awareness of California's cultural diversity. For example, diversity was presented as a program thread with development from "awareness" in the first semester to "cultural sensitivity" in the last semester. One program encouraged volunteerism among ethnically diverse people as a learning opportunity for students. An RN prelicensure program administrator indicated that faculty selected clinical experiences in home health "especially geared for diverse patient experiences." Several RN prelicensure program respondents mentioned using cultural fairs as a learning experience. Cultural fairs are annual experiences in which faculty and students share traditions, music, and food.
Baccalaureate degree, associate degree, and vocational nursing programs in California have shown significant progress in recruiting ethnically and culturally diverse students. Approximately half of California nursing program respondents were actively recruiting diverse students using a variety of strategies. In vocational nursing programs, the most common strategy was advertising. Among baccalaureate and associate degree programs, admission criteria, scholarships, group information sessions, and off-campus fairs were the most commonly used strategies.
At least one third of programs responding to the surveys offered financial assistance, mentoring programs, counseling, and remedial coursework in their efforts to retain ethnically diverse students. The most common barriers for ethnically diverse students were financial and educational, often related to speaking English as a second language or inadequate academic preparation. In all programs, there was a lack of ethnically diverse faculty.
Successful retention and recruitment strategies identified in this study are similar to those identified by others (AbriamYago, Yoder, & Kataoka-Yahiro, 1999; Bessent, 1997; Grossman et al., 1998; MaIu & Figlear, 1998). Additional strategies not documented in this study that others found successful include cultural immersion programs (Jones, Bond, & Mancini, 1998; St. Clair & McKenry, 1999), systematic student assessment using a model of interrelated factors that may affect educational success (Davidhizar, Dowd, & Giger, 1998), and faculty reflections on the traditional academic worldview, compared with those of specific ethnic groups (Dickerson & Neary, 1999; Zollo, 1998).
All program respondents noted inclusion of cultural competence and sensitivity content -within their educational programs. Similar to findings by Grossman et al. (1998), the most common instructional method was integration of content throughout the curriculum.
Many strategies for recruiting and retaining a diverse nursing student population, while reducing barriers to success, will be needed to ensure a culturally and ethnically diverse nursing workforce that meets the health care needs of people in California. In addition, assurance of cultural competence and sensitivity in all nurses is required not only in nursing education programs but as an ongoing, lifelong experience.
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