Journal of Nursing Education

Major Article 

Underrepresented Students’ Perspectives on Institutional Climate During the Application and Admission Process to Nursing School

Cheryl L. Woods-Giscombe, PhD, PMHNP-BC; Pamela Johnson Rowsey, PhD, RN; Shawn M. Kneipp, PhD, ANP-BC, APHN-BC; Clint W. Owens, MSN, RN; Karen M. Sheffield, MSN, CNM; Kayoll V. Galbraith, BSN, RN; Sama Hammad, MSN, BSN; Tamryn Fowler, MSN, RN, CNL; Eric A. Hodges, PhD, FNP-BC; Vicky Kowlowitz, PhD; G. Rumay Alexander, EdD, RN

Abstract

Background:

A growing body of literature has focused on issues related to recruitment and retention to enhance diversity in nursing. This study was designed to identify barriers and supports encountered by underrepresented students when applying to nursing school.

Method:

Twenty-two underrepresented baccalaureate nursing students participated in two focus groups. Applied thematic analysis was used to organize the data and identify major themes.

Results:

Students expressed the importance of having (a) navigators in the offices of admissions and student affairs to provide encouragement, support, and information during the application process; (b) tailored programming for underrepresented students; (c) financial aid guidance; (d) timely feedback about admissions decisions; (e) a clear and easily navigated Web site; and (f) negotiation and acculturation to know the right things to do and say during the application and admissions process.

Conclusion:

Findings provide direction for developing programming and collaborations to enhance the institutional climate for underrepresented nursing applicants. [J Nurs Educ. 2015;54(5):261–269.]

Dr. Woods-Giscombe is Assistant Professor, and Dr. Kneipp is Associate Professor, Healthcare Environments Division, Dr. Johnson Rowsey is Associate Professor, Adult & Geriatric Division, Mr. Owens is doctoral student, Ms. Sheffield is doctoral student, Ms. Galbraith is doctoral student, Ms. Hammad is doctoral student, Ms. Fowler is Clinical Instructor, Dr. Hodges is Associate Professor, Family Health Division, Dr. Kowlowitz is Program Evaluator, and Dr. Alexander is Clinical Associate Professor and Director, Office of Multicultural Affairs, School of Nursing, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.

This project was supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS), grant D19HP24298: Nursing Workforce Diversity, “Careers Beyond the Bedside.” The information or content and conclusions in this article are those of the authors and should not be construed as the official position or policy of, nor should any endorsements be inferred by the HRSA, the HHS, or the U.S. Government.

Dr. Woods-Giscombe received support from the Robert Wood Johnson Foundation Nurse Faculty Scholars Program and the Center for Health Equity Research at The University of North Carolina at Chapel Hill. The remaining authors have disclosed no potential conflicts of interest, financial or otherwise.

The authors thank Kevin Grandfield for his valuable editorial assistance.

Address correspondence to Cheryl L. Woods-Giscombe, PhD, PMHNP-BC, Assistant Professor, School of Nursing, The University of North Carolina at Chapel Hill, 404 Carrington Hall, CB # 7460, Chapel Hill, NC 27599-7460; e-mail: Cheryl.Giscombe@unc.edu.

Received: October 03, 2014
Accepted: January 21, 2015

Abstract

Background:

A growing body of literature has focused on issues related to recruitment and retention to enhance diversity in nursing. This study was designed to identify barriers and supports encountered by underrepresented students when applying to nursing school.

Method:

Twenty-two underrepresented baccalaureate nursing students participated in two focus groups. Applied thematic analysis was used to organize the data and identify major themes.

Results:

Students expressed the importance of having (a) navigators in the offices of admissions and student affairs to provide encouragement, support, and information during the application process; (b) tailored programming for underrepresented students; (c) financial aid guidance; (d) timely feedback about admissions decisions; (e) a clear and easily navigated Web site; and (f) negotiation and acculturation to know the right things to do and say during the application and admissions process.

Conclusion:

Findings provide direction for developing programming and collaborations to enhance the institutional climate for underrepresented nursing applicants. [J Nurs Educ. 2015;54(5):261–269.]

Dr. Woods-Giscombe is Assistant Professor, and Dr. Kneipp is Associate Professor, Healthcare Environments Division, Dr. Johnson Rowsey is Associate Professor, Adult & Geriatric Division, Mr. Owens is doctoral student, Ms. Sheffield is doctoral student, Ms. Galbraith is doctoral student, Ms. Hammad is doctoral student, Ms. Fowler is Clinical Instructor, Dr. Hodges is Associate Professor, Family Health Division, Dr. Kowlowitz is Program Evaluator, and Dr. Alexander is Clinical Associate Professor and Director, Office of Multicultural Affairs, School of Nursing, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.

This project was supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS), grant D19HP24298: Nursing Workforce Diversity, “Careers Beyond the Bedside.” The information or content and conclusions in this article are those of the authors and should not be construed as the official position or policy of, nor should any endorsements be inferred by the HRSA, the HHS, or the U.S. Government.

Dr. Woods-Giscombe received support from the Robert Wood Johnson Foundation Nurse Faculty Scholars Program and the Center for Health Equity Research at The University of North Carolina at Chapel Hill. The remaining authors have disclosed no potential conflicts of interest, financial or otherwise.

The authors thank Kevin Grandfield for his valuable editorial assistance.

Address correspondence to Cheryl L. Woods-Giscombe, PhD, PMHNP-BC, Assistant Professor, School of Nursing, The University of North Carolina at Chapel Hill, 404 Carrington Hall, CB # 7460, Chapel Hill, NC 27599-7460; e-mail: Cheryl.Giscombe@unc.edu.

Received: October 03, 2014
Accepted: January 21, 2015

The growing diversity of the U.S. population and the trend of health inequities are two of the five evolving challenges to the health care system identified in the Institute of Medicine’s Future of Nursing report (2010). Reports from the Health Resources and Services Administration’s (HRSA’s) Division of Nursing summit highlighted that increasing diversity in nursing can strengthen the nursing workforce and contribute to the aim of quality, safe, and accessible health care, as well as health equity and the prevention and elimination of health disparities (Heinrich, 2014; Phillips & Malone, 2014; Wakefield, 2014). The HRSA summit also highlighted the dearth of underrepresented racial and ethnic minorities, individuals from disadvantaged backgrounds, and men in nursing (White, Zangaro, Kepley, & Camacho, 2014). Although individuals who identify as ethnic or racial minorities accounted for 37% of the population in the United States in 2012 (U.S. Census Bureau, 2012), only 19% of RNs are identified as underrepresented or ethnic minority (American Association of Colleges of Nursing [AACN], 2014). In the nursing workforce, 83% are White, 6% are African American, 6% are Asian, 3% are Hispanic, 1% are American Indian/Alaskan Native, and 1% are Native Hawaiian/Pacific Islander. Men comprise approximately 7% of the nursing workforce (AACN, 2014). Although the demographics of current nursing students demonstrate a higher degree of diversity than the nursing workforce (AACN, 2014), a gap exists between the demographics and those of the general public, highlighting the need to successfully recruit and retain underrepresented nurses into the profession.

Approximately 10 years ago, former U.S. Surgeon General Dr. Louis Sullivan established a commission on diversity in the health care workforce (Sullivan Commission, 2004). The Sullivan Commission (2004) identified diversity among health professionals as an important social justice issue. Three major principles were identified as being critical to achieving the goal of diversity: (a) change in culture and practices of health professions schools, (b) identification of new and nontraditional paths to health professions education, and (c) high commitment to diversity from institutional leadership (Sullivan Commission, 2004). The report specifically detailed that counseling potential students on application procedures and providing mentoring to disadvantaged students who express interest in health professions could be key strategies to enhancing diversity. The Sullivan Commission’s report also highlighted the importance of “institutional climate,” defined as:

the collective social, cultural, and psychological attitudes and values that prevail within an institution and which demonstrate—particularly as seen from the viewpoint of minority students and faculty—whether the institution truly welcomes minorities. In essence, institutional climate is the real or perceived manifestations of an institution’s commitment to diversity. For minority students, institutional climate exerts a profound effect on the quality of the educational experience and directly influences a student’s sense of comfort and security. Institutional climate also directly affects a student’s academic persistence and scholastic success. (p. 83)

Institutional climate influences psychological dynamics and provides students with environmental cues about whether they are welcome and whether they are expected to succeed (Sullivan Commission, 2004). During the application process, students receive early overt and latent communication from faculty and staff about whether they should persist in pursuing admission to a particular nursing program and indirect messages regarding whether they should persist in entering the nursing field. Therefore, the application and admissions process and the institutional climate during that process are critical early elements along a continuum of steps to enhance the recruitment, retention, and successful graduation of underrepresented students.

Since the publication of the Sullivan Commission report (2004) and the Institute of Medicine’s report on health inequities (Smedley, Stith, & Nelson, 2003), there has been an increase in publications and programs that provide information on initiatives and good practices for successfully achieving the goal of diversity in nursing programs. Strategies have included preadmission counseling, skill building, tutoring, stipends, support groups, and peer mentoring. Prenursing initiatives to encourage and attract high school students have tailored recruitment campaigns to attract underrepresented ethnic and cultural groups, including men; enhanced curricula to promote diversity and learning outcomes; and promoted images of nursing that are positive and highlight the financial and career rewards of the profession (Dapremont, 2013; Gilchrist & Rector, 2007; Gordon & Copes, 2010; Loftin, Newman, Gilden, Bond, & Dumas, 2013). However, few publications have focused on the perceptions of underrepresented, disadvantaged, or male nursing students regarding how institutional climate influences the application and admission process and how this process could be modified to positively affect diversity. Because the application and admission process is the gateway to nursing school, it is important to understand these processes from the perspective of underrepresented, disadvantaged, or male applicants to increase diversity.

Purpose

The current study is a component of the HRSA-funded Careers Beyond the Bedside (CaBB) program (Johnson Rowsey, Kneipp, & Woods-Giscombe, 2013). The specific aims of the CaBB program are to (a) increase the number of underrepresented students enrolled in undergraduate programs, (b) increase the success and completion rates of current and future enrolled underrepresented undergraduate students, and (c) increase the number of graduates of the undergraduate program who apply to and are accepted to graduate nursing programs. The CaBB program is composed of (a) preentry preparation, (b) academic retention activities, and (c) student support in the form scholarships or stipends to eligible participants (Johnson Rowsey et al., 2013; Kneipp et al., 2014). A more comprehensive description of the CaBB program can be found elsewhere (Johnson Rowsey et al., 2013). The purpose of the current study is to identify the barriers and supports encountered by under-represented, disadvantaged, or male individuals during the application and admissions process.

Method

Design, Participants, and Procedure

This qualitative, descriptive study included two focus groups, with 22 underrepresented baccalaureate nursing (BSN) students. The authors received institutional review board approval prior to recruiting participants. An e-mail was sent to all under-represented, disadvantaged, or male students identified by the office of admissions and student services. Students interested in participating in the study were ensured that participation would be completely voluntary and anonymous. The students were then directed to enroll in the study, using a secure online portal for a focus group session. No one involved with grading the students or in a position to make decisions regarding admission for any advanced education program was involved in recruiting or moderating the focus groups.

The two focus groups were held on one evening in two separate, private classrooms. Given that the focus groups took place during the typical dinner hour, students who participated were provided with pizza and a beverage. Demographic data of the participants were collected (Table). Each focus group was facilitated by two students (C.W.O., K.M.S., K.V.G., S.H.) enrolled in the school of nursing’s Doctor of Philosophy (PhD) program, who represented historically underrepresented groups in nursing and had been trained by a faculty member (S.M.K.) with expertise in conducting focus groups. All interviews included a standardized set of open-ended questions that were developed using an iterative process involving all the HRSA project’s faculty team members and PhD student coinvestigators to ensure that the questions facilitated measurement of what was intended to be measured in the study. A preliminary set of questions was developed by two faculty members (S.M.K., V.K.) and distributed to other faculty members for review and revision. Finally, the questions were distributed to the PhD student coinvestigators for review. At each stage of review, the questions were assessed for characteristics including relevance, complexity, ambiguity, and logical flow. In addition, at the end of the interviews, participants were asked whether there was any content they wanted to add that was not elicited from the established interview questions.

Focus Group Participants’ (N = 22) Demographic Characteristics

Table:

Focus Group Participants’ (N = 22) Demographic Characteristics

During the focus groups, participants’ names were not used; instead, study identification numbers were assigned, and participants referred to themselves by their number throughout the entire focus group interview. Participant identification numbers were used solely for identifying transcript narratives across individuals; personal identifiers were not collected. Both focus groups lasted for approximately 2.5 hours. Interviews were audiorecorded and transcribed by a professional transcriptionist.

Analysis

Applied thematic analysis (Guest, MacQueen, & Namey, 2012) was used to inductively organize and describe implicit and explicit concepts in the interview data. The analytic team consisted of five members (three PhD-prepared faculty [C.W.-G., P.J.R., S.M.K.] and two PhD students [C.W.O., K.M.S.). Of the faculty members, all three had research expertise in health disparities, social justice, and recruitment of underrepresented students for nursing and graduate programs; two were from historically underrepresented ethnic minority groups, and one was a first-generation college student. Both PhD students also had experience and knowledge in these areas and were from historically underrepresented groups in nursing (one was male and the other was of an underrepresented ethnic minority). In addition, these PhD students served as two of the four focus group interviewers.

The analytic team members first read the focus group transcripts to become familiar with the data. They then worked through the following steps in sequence: (a) independently assigned preliminary codes to the data, (b) discussed the patterns identified in the data and shared thoughts about the preliminary codes, and (c) confirmed codes and identified and named overarching themes. After the first complete draft of the final report was written, two PhD students (K.V.G., S.H.), who were from underrepresented ethnic minority groups and served as focus group interviewers, reviewed the report, which was modified based on their feedback. Those methods were utilized during the analysis to promote trustworthiness and rigor.

Results

The current article focuses on the findings from the following interview questions:

  • What was your experience of the admissions process?
  • What types of support did you receive?
  • What barriers did you encounter in the admissions process?

Six major topics, or themes, were identified related to the institutional climate and the application and admissions processes. Students vocalized the importance of having (a) navigators in the offices of admissions and student affairs to provide encouragement, support, and information during the application process; (b) tailored programming for underrepresented students; (c) financial aid guidance; (d) timely feedback about the admissions decision; (e) a Web site that is clear and easily navigated; and (f) negotiation and acculturation to know the right things to do and say during the application and admissions process.

Theme 1: Admissions Navigators

Participants indicated that the application process was daunting and that the application and admissions staff members served as navigators, which helped to ease their feelings of intimidation by providing individualized feedback regarding the specific components of the application and admissions requirements. The participants shared that navigators outlined the entire application process, reviewed transcripts to clarify what prerequisites were needed, and provided other tips. The students valued their ability to speak directly with an admissions counselor face-to-face or via telephone for personally tailored guidance. One participant indicated:

Everything was laid out step-by-step. If you had any questions...they gave you feedback on what you needed. They did the unofficial transcript evaluation to help you prepare to apply.

Participants also noted the importance of the accessibility of the navigators and receiving tailored information to ascertain whether it was realistic to consider applying to the program and whether the program would be a good fit for them. One participant stated:

During the summer, I walked into the office here to ask some questions and—with my background—I was asking them if I would be a good candidate. They were receptive to my visit and that was really important for me [in] deciding to go ahead and apply to this school.

Students also shared that a polite and generous demeanor of the navigators made a difference, particularly because students may have had doubt about their fit, and one student stated: “It may have been just a usual day for them, but it was really important that they received me at the office there cordially.” Another student shared: “The receptionist in the student affairs [office] who answers the phone was really courteous and really informative. If they [the student affairs office staff] didn’t know the answer, they were able to find an answer for me.”

The open-door policy of the admissions office and the staff’s approachability and responsiveness to questions and concerns seemed to be particularly important for these students. One student indicated:

They didn’t say, “Well, we’re having an information session, so please sign up and come back later.” They took me in the office. They sat down with me one-on-one [and] answered my questions; they took the time. That was important because I was busy trying to figure out which way I would go. I wanted immediate answers at the time and that’s what I got.

For underrepresented students, the welcoming climate may have alleviated questions and concerns about the program’s commitment to equity and diversity.

Because of the competitiveness of the nursing school admissions process, many students are not admitted the first time they apply. This fact is particularly important for underrepresented, disadvantaged, or male students to know, as they may become discouraged or interpret the admission denial as rejection due to their race, ethnicity, socioeconomic background, or gender. Knowing the specific admissions criteria that needed improvement was beneficial for these students, as it helped them to understand how to become more competitive and improve the possibility of admission into the program.

Focus group participants shared that when their applications were not accepted, it was tremendously valuable to have an encouraging navigator within the nursing program to provide feedback about the areas of their application that needed to be strengthened, as well as to provide reassuring comments that inspired them to reapply. One participant described a particular navigator who provided reassurance:

She was very encouraging. She listened to what I had to say, and by the time I finished and we hung up, I felt real good about looking forward to the next year and applying again. That was nice.

Participants noted that it was particularly helpful to receive specific, individualized information about how to improve their application. They valued their degree of engagement with admissions office staff and administrators, as indicated by one participant:

I did get feedback in the mail [as to] why I did not get accepted. I did call the university, and I was told, “If you have any questions, feel free to go ahead and just speak directly to the admissions director.” I called her, and she gave me the straight, on-point [information] what they want to see in the essay, what they’re looking for. She asked me questions about who I am. She asked me just a lotta [sic] questions. She says, “I want you to include that in your essay.”

Students also shared that other staff members, such as an undergraduate academic advisor and the director of the office for multicultural affairs, helped them to stay inspired, instead of giving up on nursing school. Students valued the variety of communication pathways that were available to them to receive tailored feedback and support, including e-mail, live chat, in-person information sessions, and telephone conversations. The students emphasized that the ability to connect with a navigator in the office of admissions and student affairs should be more prominent on the Web site, particularly for students who are out of state and unable to set up in-person meetings for guidance on the application process.

Theme 2: Tailored Programming for Underrepresented Students

The importance of tailored programming that can assist underrepresented students in navigating the application and admissions process was a key theme identified in the focus group sessions. Programs such as CaBB provided activities designed specifically to help underrepresented, disadvantaged, or male applicants feel more engaged and welcomed in the school of nursing. In addition to seminars that delivered tips on essay writing, obtaining research experience in nursing, and graduate education and career options in nursing, sessions were also offered that specifically addressed stereotypes, diversity, and inclusion in nursing and key issues related to men in the nursing profession. This type of programming is aligned with the goals of the Sullivan Commission (2004) and the aims of the CaBB program at the school of nursing. Students noted that the information and prenursing sessions offered by CaBB were helpful in making the application process easier. One participant shared:

The CaBB...I went to a lot of the info[rmation] sessions or the pre-nursing ones. That helped me a lot, although I really didn’t have a lot of anxiety about the application. I like stuff laid out, so it laid out for me what I would need transcript-wise and all that stuff.

The focus group participants who found this type of programming valuable mentioned the importance of being able to access the information and sessions. However, out-of-state students were not able to access the tailored mentoring provided by the CaBB program; therefore, they did not find the programming helpful.

Interactions with students who had been accepted to the program also served as a source of encouragement and peer-to-peer mentoring. One student offered an example:

The pre-nursing CaBB sessions, those helped me out a lot.... If I’m talking to other students, especially males and stuff, I tell them, “Hey, if you got questions about the application, you’ll learn more by attending those sessions than I can really tell you.” I give them information, but I really tell them to come to the CaBB sessions [be]cause it’s a great way to just get your foot in the door and just find out what you need to know. That helped me out a lot.

Tailored programming appeared to enhance the students’ enthusiasm and confidence about applying to the nursing program by increasing their insight regarding how to navigate through the application process.

The importance and value of a navigator was mentioned in relation to the theme of tailored programming as well. One focus group member noted the particular helpfulness of a faculty member whose role as a cultural coach through the office of multicultural affairs in the nursing school is to support under-represented students: “[She] helps with minorities here, and she helps us find our way when we’re lost.” Having a specific navigator within the tailored programming is key for underrepresented students to feel a sense of connection to the program and not get “lost” during the application and admissions process.

Theme 3: Financial Aid Information

Participants expressed the need to “know the financial aid process and available resources.” Students shared the need to understand the whole financial aid process. One student stated:

I had to do a complete Excel® spreadsheet analysis to make sure I understood all the fees associated, the out-of-state tuition, and the difference if I got in-state or out-of-state status; it did take some time to figure it out.

Students also discussed the desire to have an in-house financial aid resource person and provided an example of a private school nursing program that has such an in-house person. Focus group participants also discussed “not having enough resources to answer financial aid questions” and not understanding the complexity of the FAFSA® (Free Application for Federal Student Aid) or how to calculate the actual cost of attending nursing school. One participant stated, “It would’ve been nice when I was doing my research, looking on the Web site, that there would be a whole section about financial aid.”

Lack of financial aid in the form of grants and scholarships was also a major concern discussed by the focus group participants. Several participants indicated that they received “financial aid, but for scholarships, I’m not eligible until the fall semester and it would have been nice to know that.” Others perceived that loans were the only financial aid offered.

Theme 4: Timely Feedback About the Admissions Decision

Focus group participants communicated that the anxiety they experienced related to the “quick turnaround” or the short notice they were given to make major life changes in preparation for attending nursing school or for making plans to reapply. One participant shared:

I think it’s a pretty quick turnaround time between mid-October, finding out you’re...accepted to started in January. I know for people moving from across the country that can be pretty daunting to get all of your things in order, in addition to all of the compliance things that you’re having to do, also finding living and...I don’t know if...the deadline could be bumped up at all.

Another participant disclosed the challenges that she faced related to the quick turnaround and the negotiation with the nursing program’s faculty and staff to ease the potential burden of having to make rapid decisions about attending nursing school:

The issue was that we had already planned to move to another state. I was in Arizona and...we were gonna [sic] move to Colorado. I had 2 days to decide whether or not I was going to accept or not. It was nice that I called and I said, “Could I have a few more days? I just need to sort this out and make sure I can afford this school and everything, and the long-distance and everything.” It was nice to call and they said, “Yeah, no problem. We’ll give you a few more days to decide.”

One participant expanded the discussion about quick turnaround to include a scenario where their application to nursing school was not accepted and that relatively immediate plans needed to be made to improve the likelihood of receiving a positive admission decision in the future:

I was just kind of…I don’t know…I felt stuck, like I didn’t really know what to do for basically the whole semester [while waiting to receive feedback about the submitted application]. Until the very end, the day before summer classes started, that’s when I found out that I didn’t get in. Then I basically had a day to decide if I was gonna [sic] sign up the summer class and pay for it.

Theme 5: A More Helpful Web Site

The focus group participants discussed the importance of the nursing program’s Web site and how it could be used as a tool to make the application process less daunting. Several participants mentioned their difficulties navigating the Web site to obtain the resources they needed during the application and admissions process. Participants shared how their interface with the Web site further complicated an already challenging process of applying to nursing school. One individual stated:

I just feel like you had to search a lot to find the things that you needed. Nothing was in a clear...nothing was in one place. You had to go to different spots to find different information. The Web site could be clearer and could have everything where you need it to be instead of having to search through many different pages to get the stuff you need. It’s frustrating when you’re already frustrated about the program because it’s hard to get in there, so it just adds frustration.

One student identified the Web site as a potential way to identify a navigator, or point person, to provide support during the application process. However, this student expressed difficulty navigating the Web site to identify such individuals:

I feel like maybe the Web site could reflect…if you have any questions or if you need to speak to someone, this is the person to speak to, instead of trying to go through a bunch of pages and figure it out for myself.

Another student shared that the large amount of information on the Web site could have been organized more succinctly:

The whole application was difficult, and I feel like the Web site is not accessible, and it’s hard to find things. That was my one issue with the [application]…there [were] five pages of instructions on how to apply. It was a little overwhelming.

Although some participants described their experience using the Web site as difficult or challenging, others described their experiences as “easy,” “smooth,” “laid out step-by-step,” and “without any hiccups.” One out-of-state applicant shared positive feedback about his ability to use the Web site to access information that had been transmitted in-person via “informative chats” to local applicants:

I wasn’t able to make any of the chats, but they kept transcripts that…archived transcripts…so I was able to go online and read through their conversations of the past. Questions that I didn’t know I had were actually asked in them, so that was good.

Another statement suggested that the nursing program should enhance the Web site by going beyond providing transcripts of the information sessions to providing actual webinars for out-of-state or international applicants:

For those who are out of state and can’t come here, it would probably be a good idea to have an online information session so whenever they do have the ones that people come to, have them record it.... I don’t know whether or not it would help in any way, but just so they can see how that works would probably be a good idea for those who’s [sic] out of the state, country, whatever.

Theme 6: Negotiation and Acculturation

In addition to the more tangible or readily identifiable features of the application and admissions processes that students highlighted during the focus groups, select narratives indicated a latent, less direct, or higher order theme. These narratives were discussed extensively within the team during the data analysis. The narratives within this theme suggested that students were acutely aware of the potential advantages that acculturation had for completing a successful application and for being admitted to the program. Two subtexts informed the acculturation theme: Knowing the Right Thing to Say, and Knowing How to Play the Game. In the context of these findings, acculturation was defined as “a dynamic and multidimensional process of adaptation that occurs when distinct cultures come into sustained contact” (Organista, Marin, & Chun, 2010, p. 105).

Specifically, focus group participants had a heightened sense of concern related to the use of language and word selection in their application essays. This concern is reflected in the following narrative of an international student:

I didn’t get accepted, and so I called them, and I asked them, “What did I do wrong? Can you give me something that I can use for next time?” They basically told me that my essay wasn’t structured the way that it’s supposed to be; that I should seek help from a writing center. I felt like they [the admission office staff] helped me out there, but then again, I was wondering…I gave my paper to everyone, and they said it was good. Is it because of my culture or maybe the way I write is not the same as how most people write here? That was in the back of my mind. Maybe they were not accepting of the way I expressed myself. Then the next time that I did apply, I gave it to someone who could look at it, and then it was fine. I applied again, and they helped me change it to sound more like an American, and then it was fine.

Of note, when the above comment was made during the focus group session, several other students affirmed agreement with the statement (i.e., vocalizing “um hmmm,” “yes”), indicating this is not an isolated experience or concern. Others expressed a similar concern, as indicated in one participant’s statement:

For me, it was English is my second language, so I’m always…when I’m writing, I’m like, “Is this the right way you say it?” Fortunately, I don’t have an accent, but when it comes down to writing, I think that’s where I’m very hesitant.

The relief expressed over not having an accent further suggested that although students may not necessarily want to conceal their ethnic identity, they are concerned about drawing attention to it when communicating with others. The focus group narratives suggest that students were highly attuned to knowing the “right” things to say in the “right” way. In other words, they were concerned that their use of grammar conformed to academic standards in the United States and that the essay content of their application conformed to cultural expectations across all levels (i.e., national, academic, institutional).

A second subtext related to acculturation was a focus on Knowing How to Play the Game, which reflected knowing the culture or unspoken rules of the application and admissions process. This included the participants’ perceptions related to having access to individuals or being known by key individuals and having a sufficient understanding of nuances of admission probabilities across undergraduate program options to gain a favorable admissions outcome. As reflected in the following statement, a number of students perceived that knowing individuals within the program was an advantage: “If you knew people in the program, you had insight into what you needed to do, but if you didn’t, you didn’t know what you were getting yourself into.” Another student discussed her experience in more detail:

I met a former student [from the institution to which the student was applying], but [in] a different major, and she really encouraged me to apply. She actually helped me with the process. She actually worked for the admissions office at one point; not nursing, but in another office. That just really helped me a lot because he or she talked to me about what they really look for in admissions, what they expect, and that just opened up a different window for me. She helped me and I think that’s what really made a difference. Knowing her, who worked in admissions, and talking to someone who was really aware of what the school looked for and just someone who was able to edit my essays really helped a lot. I was able to get in the second time.

Other students adopted strategies to become known to key admissions application personnel. One participant stated:

I called her [admissions staff] at least twice. I called to ask questions, and I called just to get her to remember my name if it was all possible and made up a question to ask. I felt like that helped a lot.

Another participant stated:

Sometimes when I would e-mail the counselor, I wouldn’t really ask her stuff pertinent to the essays. It was just I guess to get my name out there and just to keep that contact with her.

Although some of the focus group participants had the perception that maintaining personal and frequent contact with the admissions office staff would be helpful, it is important to note that office staff members do not actually vote on who will be ultimately accepted into the program.

Finally, students also shared their perceptions of how they successfully navigated the process by understanding admission probabilities across programs. In the following excerpt, a student described her experience with not being admitted to the accelerated BSN program on the first application attempt. Using a strategy that focused on applying to a different program with a higher acceptance rate, rather than improving the application, the student stated:

Fortunately, all of that was already included in the first essay, so I resubmitted the same essay for the [traditional] BSN program. Didn’t change anything, and I was wait listed, and then 3 days later got my acceptance letter.

Discussion

The participants shared information about their experience of the application and admissions process that is most relevant to underrepresented students. They identified factors that provided support, as well as perceived barriers. Participants communicated the importance of identifying and using the support of designated navigators who could assist during the application and admissions process. They also spoke about being exposed to programs tailored for underrepresented applicants. The students highlighted that tailored programming for the diverse population of students pursuing nursing degrees is a key component to the recruitment and retention of underrepresented students. The students also mentioned the assistance they received from the office of multicultural affairs’ cultural coaching program. The focus group participants confirmed that programs, such as CaBB, that offer information and prenursing sessions are important, as well as is peer-to-peer mentoring and an individualized faculty or staff navigator committed to the needs of underrepresented applicants.

In addition, the focus group discussions addressed the importance of nursing programs directly providing more information and resources about financial aid to applicants who are under-represented, disadvantaged, or male (particularly those who are disadvantaged). Inadequate financial support is a major barrier for recruiting and retaining some underrepresented students to nursing school. Many underrepresented students need to work full time, often while carrying full academic loads. Many students are forced to cut back to part-time status or drop out of school temporarily or permanently. The thought of supporting themselves throughout nursing school can be intimidating; having early access to financial information is critical. Underrepresented students may view loans as a deterrent from attending nursing school because they are reluctant to incur large debt. The reduction in grant and scholarship-based aid may make it difficult for disadvantaged students to attend nursing school. Participants expressed a desire to have onsite (in the nursing school) assistance with navigating the financial aid process, as well as more access to scholarships and grants, rather than student loans. Although the logistics related to having such in-house financial aid resources are often closely tied to university policy, nursing programs committed to increasing diversity must find ways to provide financial aid assistance to students when they are making admission decisions. Programs such as CaBB could provide workshops about navigating the financial aid process and provide resource information to help remove some of the barriers articulated by focus group participants.

In a related theme, participants addressed the issue of the quick turnaround of the application and admissions process and the requirements for students to quickly make challenging life transitions (e.g., identify financial aid, relocate households). Many schools of nursing have a time line for application submission, review, and decision communication, which is based on the academic calendar, availability of faculty and staff, and institutional demands. However, underrepresented nursing students are more likely than others to experience home lives that involve obligation to others, as well as less flexibility regarding the financial, work, or living arrangements that are needed to accommodate the demands of nursing school (Nnedu, 2009; Noone, 2008). This may hamper their ability or willingness to use nursing school as a means to achieve professional aspirations and provide more long-term financial stability to their families and communities. Nursing programs aiming to attract underrepresented students may benefit from considering the elements involved in the transition of attending nursing school. Supportive programming, such as that provided by the CaBB program, could be developed to help applicants prepare their lives for this waiting period and help them to develop strategies for managing uncertainty during this time.

The Web site of a nursing program is an essential component of the institutional climate. Web-based resources are currently relied upon to attract and inform potential nursing students. For most applicants, the Web site is the first point of contact and could influence an individual’s confidence about moving forward with applying to a program. Participants’ comments about the Web site provided important insight into what may not be a traditional focus for attracting underrepresented students. Some participants articulated feelings of frustration and discouragement related to navigating the Web site. They emphasized their desire to use the Web site to identify the key staff involved in the application and admissions process.

In addition, they communicated the potential of the Web site to be a valuable tool for applicants who are unable to attend the information sessions or other in-person meetings. This may be particularly important for students who do not have the opportunity for face-to-face contact with one of the navigators or those less familiar with the fact that navigators are available to provide individualized support during the application and admissions process. Previous research has demonstrated the potential benefits of diversity cues on recruitment Web sites (Walker, Feild, Bernerth, & Becton, 2012). The inclusion of pictures of individuals from diverse backgrounds and the publication of the school’s goals related to diversity were associated with attentive processing and higher recall of Web site information among both Black and White students (Walker et al., 2012). In addition, it may be beneficial to create an electronic link on the admissions section of the nursing program’s Web site so that potential applicants can connect with the office of multicultural affairs to learn about the services they provide. Investigators may further examine how nursing programs’ Web sites can be used most effectively to reflect their values regarding diversity and inclusiveness.

Underrepresented students may be able to provide valuable information to help design Web sites to be most attractive to underrepresented applicants. During the application process, the information and personnel resources that students need should be transparent, reproducible, and accessible. Future research can be geared toward understanding the role that technology plays in helping students to obtain admissions-related information regarding nursing programs. Often, prenursing students are deciding between majors; therefore, having a Web site that is easy to navigate is effective in helping students explore various health-related professions. Using social media is a potential method to facilitate online discussion and awareness of common admission-related questions. Using the school of nursing public relations staff to share social media information about application deadlines, job outlook, and events happening at the school of nursing may help facilitate students’ decision about applying to the program.

Many of the students in the current study shared the importance of knowing someone in the school of nursing during the admissions process. It may be helpful for the school to provide statements from previous applicants on their Web site under the topic “Things I Wish I Had Known Before Applying.” Admissions faculty and staff could also share their recommendations for developing and submitting a successful application on this site. Both students and faculty and staff can provide insight about the institutional culture and climate, as well as effective ways to apply to the program. Virtual tours of the school of nursing building may be a way to attract out-of-town students who are unable to tour the site before deciding to apply. Through the use of technology, the information-access gap between those students who live nearby and those who live out of town could be narrowed.

Findings from the latent themes of Negotiation, Playing the Game, and Acculturation suggest that underrepresented students have concerns around fitting into the national, academic, and institutional culture enough to gain admission to the program. Therefore, they apply a number of strategies to optimize their opportunities. These findings corroborate the previous research that revealed the pressures that students from diverse backgrounds experience to become socialized to the dominant culture to survive the process of applying to and successfully completing nursing school (Love, 2010). In addition, these findings provide insight into how the “playing field” in the “game” of program admission is not level, especially for underrepresented students, who may be less acculturated or socially connected to individuals attending the university or program to which they are applying. For institutions that are historically composed of students who are predominantly White, from middle class backgrounds with college-educated parents, or female, it is important to raise awareness among faculty and staff about overt and subtle issues related to acculturation and socialization to the dominant culture and the impact it may have on the experiences of underrepresented students. In addition, it is important to consider how social networking opportunities are essential for increasing racial, ethnic, socioeconomic, and gender diversity within nursing. For example, the CaBB program provides workshops and seminars to facilitate discussion of the broad issues related to bias and discrimination, as well as practical issues, including writing admission essays that create a lasting impression on the admissions committee. These workshops can serve to ease students’ concerns about barriers related to culture and language and emphasize the value and potential contribution of their unique experiences and perspectives to the institution and the nursing profession.

It is worth noting how future studies could be improved to identify optimal programming and resources to enhance the application and admissions process of underrepresented students. In the current study, focus groups were integrated to include participants from a variety of the targeted underrepresented groups together in two groups. It may be beneficial to plan distinct focus groups that include specific underrepresented groups in each group (e.g., a focus group with men only, a focus group with each racial/ethnic group separately, a focus group with only first-generation college-students). This strategy may provide more information about the nuanced needs, desires, and experiences of each group, or it may confirm the commonality of themes across groups. Future research may also include follow-up focus groups with the participants to member check the findings and to identify applicant-oriented details about how to more specifically and optimally tailor programming and resources.

Conclusions and Lessons Learned

The findings of the current study provide guidance for developing programming, strengthening collaborations, and enhancing the institutional climate for underrepresented applicants to nursing school. A continued close relationship between programs and offices, such as the office of student affairs, the CaBB program, and the office of multicultural affairs, at schools of nursing can help to address the issues discussed by the focus group participants. Each of these entities has already taken strides to promote diversity, inclusion, and accessibility. The office of multicultural affairs promotes equity, inclusion, and diversity and also provides continuing education for faculty to enhance their understanding of the issues faced by underrepresented students. Attendance at specific continuing education sessions is incorporated in the faculty evaluation and salary process. This is important because faculty members comprise the admissions committees, and awareness of implicit biases can influence consciously and subconsciously the discussion about the essays and applicants.

Future initiatives should also include workshops and programs for faculty and staff so they can be more aware of the perspectives and realities presented by the underrepresented students who participated in the focus groups, their own unconscious behaviors that may bias or create barriers for underrepresented students, and specific modifications they can make as faculty or staff to enhance the institutional climate. As suggested by the Sullivan Commission (2004) and the Nursing in 3D Initiative (Phillips & Malone, 2014), the creation of an institutional climate for diversity and inclusion involves strategy, effort, and (most importantly) teamwork. The ultimate aim is to facilitate a socially, culturally, and psychologically welcoming climate for diversity, which will not only enhance the overall environment of the nursing program but also will strengthen the nursing profession at large.

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Focus Group Participants’ (N = 22) Demographic Characteristics

Characteristicn
Gender
  Male7
  Female15
Age (yrs)
  21 to 2510
  26 to 308
  31 to 352
  36 to 391
  40 to 451
Race/ethnicity
  Black11
  Asian1
  White4
  Hispanic6
First-generation college student
  No7
  Yes15

10.3928/01484834-20150417-03

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