Dr. Wong is Assistant Professor and Faculty, University of British Columbia School of Nursing, Culture, Gender, and Health Research Unit, and the Centre for Health Services and Policy Research, Vancouver, British Columbia; Dr. Seago is an Associate Professor, Mr. Keane is a Project Director, and Dr. Grumbach is a Professor, University of California, San Francisco (UCSF), San Francisco, California. Dr. Seago is also in the UCSF School of Nursing, Department of Community Health Systems. Dr. Grumbach is also Chair, Department of Family and Community Medicine, UCSF, and Chief, Family and Community Medicine, SF General Hospital. Mr. Keane is in the Center for California Health Workforce Studies, UCSF. Dr. Seago is a co-investigator and Dr. Gumbach is director, Center for California Health Workforce Studies, UCSF.
This study was funded by the California Endowment and Center for California Health Workforce Studies. The authors thank Andrew Alvarado, Lupe Vargas, and Giselle Garcia. Statistical advice was provided by Dr. Steven Gregorich, University of California, San Francisco, Medical Effectiveness Research Center for Diverse Populations.
Address correspondence to Sabrina T. Wong, PhD, RN, Assistant Professor and Faculty, University of British Columbia School of Nursing, Culture, Gender, and Health Research Unit, and the Centre for Health Services and Policy Research, 2211 Wesbrook Mall, T-161, Vancouver, British Columbia, Canada V6T-2B5; e-mail: firstname.lastname@example.org.
Ethnic diversity in the U.S. population is growing at a rapid pace. Since 2000, Latinos accounted for just more than half (3.5 million) of the U.S. population, and the number of Asian Americans grew at a faster pace (9%) than any other ethnically diverse group; in addition, the Latino and Asian American populations are expected to triple during the next 50 years (U.S. Census Bureau, 2004). Three states—California, Hawaii, and New Mexico—and the District of Columbia are home to the largest populations of Latinos and Asian Americans. The increasingly diverse ethnicity of the United States will continue to create social and political changes across the country, particularly in the area of health care where pressure on financing and delivery systems will grow to close the gap in health disparities (Buerhaus & Auerbach, 1999).
One way to improve the quality of care delivered to ethnically diverse populations is to increase the ethnic diversity of the health care workforce (Institute of Medicine [IOM], 1994, 2004). Health care providers from diverse ethnocultural backgrounds are significantly more likely than their non-Latino White counterparts to serve ethnically diverse and medically underserved communities (Cantor, Miles, Baker, & Barker, 1996; IOM, 2004; Moy & Bartman, 1995; Solomon, Williams, & Sinkford, 2001; Turner & Turner, 1996). Patients who have a choice of provider are more likely to select one from their own ethnic background (Bichsel & Mallinckrodt, 2001; Lopez, Lopez, & Fong, 1991; Saha, Taggert, Komaromy, & Bindman, 2000). Patients in ethnically concordant patient-provider relationships tend to be more satisfied with their overall health care (Cooper-Patrick et al., 1999; Saha, Komaromy, Koepsell, & Bindman, 1999). Past studies also indicate that ethnically diverse providers display better processes of care behaviors with ethnically diverse patients, compared with non-Latino White providers (Cooper-Patrick et al., 1999).
Despite growing evidence that a diverse health care workforce is needed, there continues to be slow growth in the number of ethnically diverse RNs—a cause for growing concern (Coffman, Rosenoff, & Grumbach, 2001). Moreover, the RN workforce continues to age and shrink (Buerhaus, Staiger, & Auerbach, 2000). Although there have been calls for increasing the overall education attainment of ethnically diverse students, particularly Latinos, as a critical factor in increasing the diversity of the RN workforce (Coffman et al., 2001), little work has examined what student characteristics and perceptions are related to institutional, dispositional, and situational factors affecting the successful completion of any nursing program. The purpose of this study was to examine whether student characteristics, particularly ethnocultural background, influence perceptions about dispositional, situational, and institutional factors and whether perceptions of institutional factors differ by school.
Lewin (1936) suggested that a person’s behavior (B) is a function of that person (P) and his or her psychological environment (E): B = f(P,E). That is, a person’s physical and social environment can interact to either be barriers or facilitators to the person’s goals. Building on the work of Lewin (1936), Cross (1981) developed a Chain of Response model focusing on barriers to participation in educational programs. Three categories of barriers were identified: institutional, dispositional, and situational. Institutional barriers include any difficulties encountered with the campus, such as faculty assistance or perceived campus diversity. Dispositional barriers refer to the student’s concept of self as a learner. Situational barriers refer to one’s particular life circumstances, such as financial resources or work interference.
In addition to barriers within these three constructs, there is likely a constellation of predictors of success (Astin & Oseguera, 2002; Norman, Buerhaus, Donelan, McCloskey, & Dittus, 2005; Stieren, 1981). The work of Cross (1981) and Pascarella (1982) provides the broad conceptual framework for this study that encompasses the institutional, dispositional, and situational constructs relevant to retention in nursing education and as predictors of success in completing the nursing program.
Setting and Sample
This study used the baseline data collected for a larger study. The goal of the larger study was to address California’s nursing shortage by providing additional assistance in training and career development to nursing students from diverse racial/ethnic backgrounds in California’s Central Valley. Twelve publicly funded colleges (8 community colleges, 4 state universities) across the state of California participated in this study.
All nursing students at the colleges were eligible to participate. After obtaining approval from the University of California, San Francisco’s institutional review board, a research team member administered the survey in classrooms of required nursing courses in each of the 12 colleges. Students were asked to report their perceptions of situational, dispositional, and institutional characteristics; career values; and sociodemographic characteristics. A total of 85% of nursing students in the selected classes completed the survey, which took an average of 18 minutes. Students were offered candy or pizza in appreciation of their time.
Institutional, Dispositional, and Situational scales were constructed using factor analysis techniques. We briefly report the internal consistency reliability and construct validity in this article, as it is described in detail elsewhere (Seago, Wong, Keane, & Grumbach, 2007). There were four Institutional scales: Peers (4 items, reliability = 0.83), Faculty (7 items, reliability = 0.90), Diversity (3 items, reliability = 0.72), and Overall Campus Experience (2 items, reliability = 0.81). The one Dispositional scale, Confidence in Ability (5 items), had an internal consistency reliability of 0.80. The two Situational scales, Financial Issues (3 items, reliability = 0.79) and Work Issues (2 items, reliability = 0.85), had adequate internal consistency reliabilities.
To perform construct validity testing, the scales were administered to two different groups of nursing students. Similar patterns, structure, and factor weights were found between the two groups. In addition, the factors correlated more highly with each other across the two groups than with other factors (data not shown).
All data were entered using Stata, version 8.0 (Stata Corporation, 2003). No outliers were found, and missing data were minimal (less than 5%). Institutional, Dispositional, and Situational scale scores were calculated as the mean responses to all subscale component items. If respondents answered fewer than 60% of subscale items, the respondent was dropped from that subscale analysis. All scores were converted to 0-to-100 scales; higher scores indicated higher frequency of the concept (e.g., a high interactions with peers score indicates more support). Two exceptions were the Situational Work Issues scale, in which a higher score meant fewer classes were missed due to employment, and the Situational Financial Issues scale, in which a higher score meant an easier time paying for school.
Dependent variables of interest included the institutional, dispositional, and situational factors. Four institutional factors were examined: peers, faculty, diversity, and overall campus experience. Students’ peers were rated on their academic skills, preparation for class, friendliness, and support of other students. Faculty were rated on how often they provided academic assistance (e.g., giving advice and guidance, helping with study skills, providing useful feedback), respect for students, and provision of emotional support. Campus diversity ratings were based on students’ perceptions that colleges supported diverse faculty, that diversity was taught, and that others were sensitive to people of their same racial/ethnic background. Overall campus ratings were based on a sense of community and the provision of counseling and advising. The dispositional factor examined was students’ confidence in their academic ability. The cost of attending college (e.g., affordability, financial aid) and work issues were the two situational factors.
Independent variables of interest included race/ethnicity (non-Latino White [reference category], African American, Latino, Asian, Filipino, Southeast Asian, and Other) and the different colleges. The Asian category included Chinese, Japanese, and Korean, and the Southeast Asian category included Vietnamese, Cambodian, and Laotian. We used multivariate analyses to assess the independent association of racial/ethnic background and the different colleges with the presence of institutional, dispositional, and situational factors.
In each of the seven regression models, we controlled for age, gender, marital status, household income ($0 to $16,000; $16,001 to $25,000; $25,001 to $35,000; $35,001 to $50,000; >$50,000), parent attending college, having dependent children, parent born outside the United States, and students born in the United States. All analyses were conducted using SAS, version 8.0 (SAS Institute, 2000). Multi-level modeling was used because it specifically adjusts for clustering of data within the colleges.
A total of 1,377 nursing students participated; 60% were from 8 community colleges, and 39% were from 4 state universities located in California’s Central Valley (1% did not identify where they were from) (Table). The mean age of these nursing students was 31, with the majority (87%) being women and more than half (57%) being married. Forty-four percent had at least one dependent child. The majority of students were non-Latino White (56%) or Latino (19%). Most students (63%) had at least one parent who had attended college, and 36% had at least one parent born outside the United States. A little less than one third (29%) reported a household income of >$50,000, and more than one third (38%) reported a household income between $0 and $25,000.
Bonferroni tests indicated mean scores on the Institutional Peers scale were different between Southeast Asian and non-Latino White students (p < 0.05). Mean scores for African American students were lower on the Institutional Faculty scale compared with non-Latino White, Latino, and Filipino students (p < 0.05). All other racial/ethnic groups, except Other, had lower mean scores on the Institutional Diversity scale compared with non-Latino White students (p < 0.05); African American respondents scored the lowest and lower compared with all other racial/ethnic groups (p < 0.05).
The Dispositional scale did not differ by racial/ethnic group. Of the two Situational scales, mean differences were found for the Financial Issues scale (p < 0.05); compared with non-Latino White students, African American, Latino, and Asian respondents had lower scores.
Institutional. Being a minority student was related to more negative perceptions of institutional diversity compared with being a non-Latino White student (p < 0.01). African American, Asian, and South East Asian respondents had the most negative perceptions of institutional diversity, even after the colleges were added to the model. Before adding the colleges, the specified model for Institutional Diversity explained 10% of the variance; adding the colleges explained an additional 5% of the model.
No relationship was found between students’ racial/ethnic background and the Institutional Overall Campus Experience scale. No student characteristics explained any variance in the institutional campus model, indicating poor model specification; adding the colleges increased the campus model specification to explain 2% of the variance. Students who were married (p < 0.05) had more positive perceptions of their campus, and those with incomes below $50,000, except for those reporting incomes between $25,001 and $35,000, had more negative perceptions of their campus (p < 0.05).
Students whose parents did not attend college had more negative perceptions of their peers (p < 0.05); African American students also had more negative perceptions of their peers (p < 0.05). Adding the colleges explained an additional 4% of the variance. Students at many colleges rated their peers’ academic skills, preparation for class, friendliness, and support of others more often as positive (p < 0.05).
African American students had fewer interactions with faculty compared with non-Latino White students (p < 0.001). Except for students attending two colleges, many students had positive interactions with the institution’s faculty (p < 0.001). Students perceived faculty as available to provide advice and guidance, respect, emotional support, assistance with study skills, useful feedback, and help with achieving goals and found faculty intellectually challenging. However, students attending three different colleges reported having more negative faculty interactions (p < 0.05). Adding the colleges explained an additional 5% of the variance.
Dispositional. No relationship was found between students from different racial/ethnic backgrounds and confidence in academic ability. Students whose income was less than $16,000 had lower confidence in their academic ability (p < 0.05). Adding the colleges, not surprisingly, did not explain any additional variance in this model; only 2% of the variance was explained by this model.
Situational. Compared with students in the highest income group, poorer students had less difficulty attending college (p < 0.001). All minority students, except Southeast Asian respondents, had more financial issues (p < 0.05) related to the cost of college. Students attending some of the schools reported less difficulty affording college (p < 0.05). Being male (p < 0.05), having dependent children (p < 0.05), and being an ethnic minority (African American: p < 0.05; Latino: p < 0.01; Asian: p < 0.01; Filipino: p < 0.05; Other: p < 0.05) were associated with more difficulty affording college. Whereas being male (p < 0.05) was associated with being able to attend class, having children meant more classes were missed (p < 0.05). Filipino students reported that work issues did not interfere with attending classes (p < 0.05). Students attending three different colleges reported work interference as a barrier to attending classes. The amount of variance explained in the regression models was 2% (Financial Issues) and 7% (Work Issues).
Discussion and Implications
The results of this study suggest that differing student characteristics and perceptions are important to institutional, dispositional, and institutional outcomes. These results fill an important gap in trying to examine which characteristics schools of nursing could pay more attention to in designing a more comprehensive approach toward the recruitment and retention of nursing students from diverse ethnic backgrounds. The 1994 IOM report, Balancing the Scales of Opportunity: Ensuring Racial and Ethnic Diversity in the Health Professions, outlined specific comprehensive changes in the structure and environment of K-12 and higher education, calling for the adoption of an achievement model for the education of minority students in which they would be challenged to complete rigorous science and math courses while receiving strong encouragement and mentoring from family, teachers, and community members. Importantly, but not surprisingly, these results suggest that some of the variation in student perceptions can be explained by the specific institutional environments represented by each individual school variable.
African American students from all of the institutions in this study, in particular, had less interaction with faculty and peers, yet faculty commitment to student success has long been considered a key ingredient to the successful progression of African American students (Buckley, 1980). With the almost 10% of African American faculty clustered in the southern United States (National League for Nursing, 2003) and limited numbers of African American faculty available to nurture and serve as role models to African American students, the commitment of majority faculty becomes essential to the success of these students (Campbell & Davis, 1996).
When compared with non-Latino White students, all students from diverse ethnocultural backgrounds, except Asian, had lower perceptions of institutional diversity. Minority students rated institutions lower in supporting diverse faculty, teaching about diversity, and being sensitive to people of their ethnic backgrounds. Past studies have also found that the degree to which students identify with the campus and students’ perceptions of faculty commitment to racial/ethnic issues are key to the retention of minority students (Buckley, 1980; Fleming, 1985; IOM, 2004; Vasquez, 1976). Many colleges were highly rated on faculty-student interaction, which is important because an institution’s faculty can influence important pedagogical changes, such as assigning readings on racial/ethnic or gender issues and increasing the use of active learning through relevant case studies (Hurtado, 2001; IOM, 2004).
Students did rate many institutions highly in terms of peer interactions and campus environment. All students, regardless of race/ethnicity, benefit from interaction with a diverse group of peers and faculty. Diversity experiences are related to learning outcomes (e.g., use of active thinking, intellectual engagement and motivation, academic skills), regardless of students’ academic, socioeconomic, or racial/ethnic background, institutional characteristics, and prior scores on learning outcome measures (Gurin, Dey, Hurtado, & Gurin, 2002).
On average, tuition and fees total $3,000 U.S. for an associate degree (if completed in four semesters) and $14,000 U.S. for a baccalaureate degree education in a public institution (National Center for Education Statistics, 2005). However, only 15% of nursing students from a national study reported using loans to finance their education (Norman et al., 2005). These study results suggest that California students who are economically poor are adept at using financial aid services at the various colleges to secure loans, scholarships, and bursaries to offset their tuition costs. Combined with rising costs of tuition and lack of available scholarships and bursaries (College Board, 2000; IOM, 2004; National Center for Education Statistics, 2000) to help defray the costs of attending college, it is likely that some students, especially those with children or who are married, work to support both their education and families.
The findings of this study should be interpreted with caution, given the cross-sectional nature of the sample; only students present at the time of survey distribution participated. Perceptions of students who were not present during the class or students who had recently withdrawn (voluntarily or involuntarily) were not obtained. The adjusted R2 for all models, except the Institutional Diversity factor, suggest that these variables explain less than 10% of the variance. Other unmeasured variables likely would increase the amount of variance explained. Finally, some of the racial/ethnic groups contained small samples. Clearly, more work needs to be done to understand what other unmeasured variables influence these scales and to ensure oversampling from different ethnocultural groups.
Despite these limitations, this study does provide insight into how educational organizations, in this case nursing schools, can influence institutional and situational barriers, which may help retain students from diverse ethnocultural backgrounds, those who are poor, and those who have children. More attention needs to be given to the intersecting vulnerabilities of nursing students who are from an ethnocultural group other than non-Latino White, who are economically poor, and who have children for them to successfully complete their nursing programs.
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Regression Models of Institutional, Dispositional, and Situational Scales
|Variable of Interesta||Institutional Scales||Dispositional Scale||Situational Scales|
| African American||—***||—***||—***||ns||ns||—*||ns|
| Southeast Asian||ns||ns||—***||ns||ns||ns||ns|
Table: Regression Models of Institutional, Dispositional, and Situational Scales