The largest group of health professionals in the United States is composed of RNs, with more than 3,000,000 nurses (U.S. Department of Health and Human Services, Health Resources and Services Administration, 2010; U.S. Department of Health and Human Services, Health Resources and Services Administration, National Center for Health Work-force Analysis, 2014). Despite this widespread presence, minority and disadvantaged groups have been historically under-represented, indicating a need to enhance workforce diversity (American Association of Colleges of Nursing, 2014). Summer bridge programs are an innovation to transition prospective students from high school to college (McCurrie, 2009). The University of Cincinnati College of Nursing implemented a summer bridge program in 2013 to reduce the disparities in first-year retention between non-Hispanic White and underrepresented students. The purpose of this article is to share the preconceptions of college by underrepresented and disadvantaged nursing students, describe important elements of a summer bridge, and discuss the longitudinal impact of summer bridge programming on the transition to college.
A Call for Diversity in Nursing
Nurse leaders recognize that workforce diversity is crucial to the delivery of health care to a diverse population (American Association of Colleges of Nursing, 2015; Degazon & Mancha, 2012) and reduction of health disparities. Underrepresentation of racial and ethnic minorities, men, and individuals from socioeconomically disadvantaged backgrounds has led to the failure of the nursing profession to reflect the U.S. population. Racial and ethnic minorities comprise approximately 40% of the U.S. population but only 25% of RNs (U.S. Department of Health and Human Services, Health Resources and Services Administration, 2013). Similar gaps exist in nursing for economically disadvantaged individuals (Gardner, 2005; Seidman, 2005; Singell, 2004). The recruitment and retention of a diverse pool of nursing students is critical to diversifying the work-force. Minorities comprise only an estimated 28% of all nursing students in entry-level baccalaureate programs (American Association of Colleges of Nursing, 2014). This low number has been linked to finances (Gardner, 2005; Seidman, 2005); residence in low-income areas (Aud, Fox, & Kewal Ramani, 2010); psychological stressors, such as insecurity and isolation (Gardner, 2005; Seidman, 2005; Wong, Seago & Keane, 2008); and perceived lack of peer and faculty support, family responsibilities, and feelings of discrimination (Gardner, 2005). Low-income students tend to have fewer educational opportunities (Aud et al., 2010; Seidman, 2005) and are often first-generation college students (Pascarella, Pierson, Wolniak, & Terenzini, 2004), who can have notable struggles adjusting to the expectations of college.
Summer Bridge Programs
Programs designed to transition students from high school to college are particularly pragmatic in alleviating the barriers faced by minority students (McCurrie, 2009; Noone, Carmichael, Carmichael, & Chiba, 2007). Summer bridge programs are an effective means of providing students with the tools to help them prepare for the academic, social, and financial demands of college, allowing students to assimilate to the college environment prior to starting their freshman year (McCurrie, 2009). Nursing summer bridge programs have generally focused on introductions to breadth of knowledge requirements, while providing skills for college success, such as study skills, financial aid, and access to campus organizations (Daumer & Britson, 2004; Noone et al., 2007). Few studies have reported holistic outcomes of summer bridge programs and instead focus on metrics such as grade point average (GPA) and retention. As a result, information about the specific aspects of summer bridge programs that are deemed to be most effective to student success is lacking (Sablan, 2013).
Protection of Human Subjects
All study activities were approved by the University of Cincinnati Institutional Review Board and conducted in accordance with the Declaration of Helsinki (World Medical Association, 2013). Each participant was randomly assigned an identification number by a third party. All responses were anonymous. Identification numbers were assigned to participants to make within-subject comparisons.
Twenty-six students were selected to participate in a summer bridge as part of the Leadership 2.0: Nursing's Next Generation program between June and August 2013 and June and August 2014. Students represented diverse backgrounds. The demographic breakdown was 19% male (n = 5), 11.5% Asian (n = 3), 19% Black (n = 5), 11.5% Hispanic (n = 3), 8% multiracial (n = 2), and 50% White (n = 13). Fifty percent (n = 13) were first-generation college students, with neither parent having attended college, whereas 42% (n = 11) were economically disadvantaged (defined as being eligible for a Federal Pell Grant or as being at 200% of the poverty level). Some of the students attended schools with limited resources. One hundred percent of summer bridge students were considered either underrepresented racially or ethnically or disadvantaged (either economically or educationally). The mean ACT® score of the participants was 25 (range = 22 to 29), which is more than 3 points above the average ACT score for the state of Ohio (ACT, 2012) but below the mean of 26 for the college. The mean high school GPA was 3.55 on a 4.0 scale, ranging from 3.08 to 4.0. The college uses holistic admissions review and does not have a GPA or ACT cut-off score; however, a GPA of 3.0 and an ACT score of 23 are recommended.
Leadership 2.0 Summer Bridge Residential Program Intervention
In 2013, the University of Cincinnati College of Nursing initiated a comprehensive student-centered summer bridge residential program as one component of a 2-year program, called Leadership 2.0: Nursing's Next Generation, to increase the recruitment, academic success, and retention of students from historically underrepresented (based on race, ethnicity, and gender) and disadvantaged (socioeconomically and educationally) backgrounds. Leadership 2.0 consists of eight components that support students enrolled in the first 2 years of the baccalaureate nursing program: preadmission, summer bridge, academic success, research experience, leadership and professional development, socialization, community engagement, and diversity enrichment. Every underrepresented and disadvantaged student who had been offered admission was personally invited to apply to the program. Prospective candidates and their parents were then asked to participate in an interview. Using a holistic review process, students' academic credentials, personal qualities, interest in being a nurse, and parental support were considered for selection.
The bridge is a 6-week residential program in which students stay on campus in the summer between high school graduation and college matriculation. The program is overseen by a grant-funded program director, and includes a student manager, instructors (J.D.P.), college leadership (K.D.B., G.G.), and faculty and staff (T.J.P.) who volunteer outside their traditional roles in the college. The program allows students to become oriented to campus resources, while fostering academic success and socialization to facilitate the transition to college. Programming was organized around five main areas: academic preparation, socialization, clinical and research immersion experiences, cultural exposure, and financial support. Academics were central, with students attending classes 4 days per week in Anatomy and Physiology and Chemistry courses, which are required in the fall semester. Students also had to complete a math course, as success in chemistry has been linked to math proficiency (Sadler & Tai, 2007). All courses were taught in a contextual format, so students could apply abstract concepts to nursing. iPads® were issued to facilitate learning (George, Dumenco, Doyle, & Dollase, 2013; Rossing, Miller, Cecil, & Stamper, 2012). Daily supplemental academic programming was provided, including learning assessments, and workshops on the use of technology to enhance learning, time management, anxiety reduction, and test taking. Students attended study tables every evening, which are supervised, dedicated allocations of time and space for students to convene for the purposes of studying course content either individually or in groups. Intrusive advising (i.e., regular, intentional and proactive academic advising of students on an individual basis to prevent adverse academic events) was used, as each student was assigned a student affairs academic advisor, faculty advisor, and full-time resident advisor (referred to as a student manager).
Socialization was an underlying program thread, with the goal of establishing a sense of community in the students. This was achieved by students residing on campus in the same dorm and providing orientation to campus resources and affinity groups, visits to nearby communities, introduction to college staff, and social events (trips to the zoo, amusement park, museums). Students were exposed to clinical and research activities to raise cultural awareness and professional opportunities. The Table summarizes the activities around each summer bridge component. Programming was informed by the literature and community needs assessments. To complete the bridge, students had to maintain a “C” average for their summer courses and exhibit responsible conduct.
Design of the Summer Bridge Residential Program
A longitudinal study design, using quantitative and qualitative methods, was used to collect baseline, immediate, and post–summer bridge (time points: 0 weeks, 6 weeks, and 9 months) data. Methods included surveys, one-to-one interviews, and a focus group.
Quantitative Data Collection and Analysis
Summer bridge participants completed a 27-item, preprogram survey to assess perceptions of college readiness, determine interest in caring for the underserved, and gather baseline indicators on what summer bridge components students thought would be most beneficial. Students completed a 21-item, postprogram survey that posed similar questions included in the preprogram survey for comparison. Closed-ended questions were analyzed by the percent of participants who selected each response. For Likert scale or rank-style questions, mean rank and standard error were calculated. Mean responses pre- and postprogram were compared using the student's t test, with p ⩽ .05 indicating statistical significance. Mean GPA was calculated across demographic groups. GPA means were compared between groups, using Student's t test, with p ⩽ .05 indicating statistical significance.
Qualitative Data Collection and Analysis
Structured, one-to-one student interviews at the end of the summer bridge and a focus group 9 months later were conducted by a research team member who was not affiliated with the program to avoid influencing responses. A 9-month data collection point allowed enough time to elapse to understand the effects of the summer bridge on the first semester as part of a larger evaluation of the whole Leadership 2.0 program. Interview questions focused on participants' feelings of college preparation, challenges faced in the program, how the program influenced their passion for nursing, feelings of isolation, use of technology in learning, and the community nursing experience. Interviews and focus groups were audio-recorded and transcribed. A team-based thematic analysis of transcripts was completed (Morse & Field, 1995).
Evaluation of Summer Bridge Components: Results from Pre- and Postassessment
College Preparedness. Summer bridge participants were asked to assess how well their high school prepared them for science, technology, engineering, and math (STEM) courses. Math, chemistry, and biology are required courses that are often challenging for first-year nursing students. The postsurvey revealed that for all three subjects, students thought that the summer bridge program better prepared them for STEM courses than did their high schools, with statistically significant increased feelings of preparation in biology (mean presurvey response = 3.31 ± 0.23 versus postsurvey response = 4.46 ± 0.13; p < .01).
Financial Aid Process. Students indicated an intermediate understanding of the financial aid process (mean = 3.19 ± 0.18 on a 5-point scale ranging from 1 = not at all knowledgeable to 5 = very knowledgeable), which increased after the summer bridge (mean 3.50 ± 0.18). Regarding their success in college, students also assessed their concerns about having someone to lean on or to ask for help, finances and tuition, feeling part of a community and making friends, access to help with studies, being away from home, knowledge of the nursing profession, and use of technology. These factors were selected from evidence in the literature indicating that feelings of connectedness, cost of tuition, and academic support influence success in college (Gardner, 2005; St. John, 2002). Student concerns centered on finances, feeling like part of a community, and knowledge of the nursing profession. The summer bridge alleviated concerns related to these factors, except for finances and tuition costs (Figure 1). These results indicate that the cost of attending college is a major student concern, even when students have a good understanding of the financial aid process and have received some financial support.
Percentage of students (N = 26) who thought that the summer bridge did or did not alleviate their concerns about success in college, related to seven common barriers faced by first-time college students.
Assessment of Summer Bridge Components. The residential summer bridge program was multifaceted and included tools for academic success, socialization, and orientation to the university, college, and the nursing profession. At the beginning of the program, students were asked to rank 15 components of the summer bridge on how valuable they thought each component would be. After program completion, students ranked those same components on how valuable they actually were. Initially, students perceived that lectures, experiential learning, interactions with faculty and staff, simulation, and clinical immersion would be most valuable. Postprogram, students weighted their interactions with peers, faculty and staff, and the student manager, in addition to lectures, as most important. This demonstrates the importance of relationships and socialization to students' success in transitioning to college (Figure 2).
Relative importance of each component of the summer bridge residential program. Students (N = 26) enrolled in the summer bridge residential program ranked the order of importance from 1 (most important) to 15 (least important) of each programming component prior to the start of programming and at the end of the program. No two components could be assigned the same rank. Black bars show mean rankings of the components pre–summer bridge, and the gray bars show the mean rankings of the components post–summer bridge; error bars represent the standard error of the mean. * Indicates statistical difference between pre- and postprogram responses; p < .05.
Overall Satisfaction With the Summer Bridge. Ninety-two percent of students strongly agreed or agreed that the bridge program helped to prepare them for college, and 100% of students thought the program helped to prepare them for the undergraduate nursing degree program. In fact, 81% of students indicated that the bridge program increased their interest in becoming a nurse. Also, the bridge program provided a sense of community for 96% of students. Students were highly satisfied with the summer bridge (mean score = 4.59 ± 0.10, based on a 5-point scale ranging from 1 = not satisfied to 5 = very satisfied). Students cited course preparation, friendships, fun, staff, and exposure to college as helping to meet or exceed their expectations of the summer bridge.
One-to-One Interviews at Completion of the Summer Bridge Residential Program
After completing the summer bridge, the majority of students felt prepared for freshman year. Programming elements that students thought increased their preparation included introduction to college life, classes and curriculum, and the overall program experiences. One student commented, “Being on campus for six weeks has allowed us to get adjusted to the setting.” All students indicated that the program, particularly the curriculum, challenged them. One student stated, “I was definitely challenged by the academic portion of it because in high school, I didn't really have to study that much, so it was a big change.” Other challenges included being away from home, time management, and making new friends. All but two students reported that the program facilitated connections among students and faculty. One student commented that it “really helps [that] I know I'm coming in not being isolated [and that] there will be other people here…I know I can rely on.”
When asked whether the program increased their passion for nursing, 92% of the students answered yes. One student stated, “This program has made me realize…all the different aspects [of] nursing and all the different career options you can go into.” Many of the students were positively influenced by the program faculty and the nurses working at the site visits. Most (73%) of the students thought that the community experience influenced their desire to serve underprivileged individuals. The remaining students indicated they were overwhelmed and uncomfortable when visiting the inner-city clinic. Even when answering “maybe,” all students reported the overall experience as positive and indicated an increased desire to help people. One student summarized, “It made me realize I could get used to doing this, I like the feeling of helping other people in need.”
Long-Term Impact of the Summer Bridge Residential Program
First-year college retention for those who completed the summer bridge program was 96%, versus 92% of the nursing student body. The average GPA for Leadership 2.0 students was 3.45, with 74% of students making the Dean's List (minimum GPA = 3.4). For comparison, the mean GPA of nursing undergraduate students at the end of their first year was 3.40 for the entire student body, 3.06 for racial and ethnic minorities, and 3.00 for first-generation students. The mean GPA for under-represented and first-generation Leadership 2.0 students was 3.46 and 3.44, respectively. The gap in GPA between the total student body and underrepresented and disadvantaged students was reduced for bridge students.
In a focus group 9 months after completion of the summer bridge program, students described it as having been beneficial in their preparation and transition from high school to college, including adjusting to the college-level workload, providing a college campus experience, and increasing their time management skills. One student stated, “I think it helped with the transition from high school to college life. It would've been a very hard change without the leadership program.” Another student shared, “I learned how to study for these [college examinations] during the summer so I didn't have to go through that…failing the first exam [experience] because you don't know how to study, um, phase [during the] first semester.”
Another key theme discovered was that the students found it beneficial to build relationships prior to beginning the freshman year. Participants indicated that the program allowed them to develop relationships with faculty, staff, administration, and fellow students. Those relationships helped ease their transition into the first year of college. A student shared:
Having…the ability to meet the administration before we got started really helped…because we started off the year knowing a lot…. If we ever had any issues or problems, we knew [who] to go to.”
Another student stated:
It's not just school stuff…. If you need something…out in the community [for example], you have people who…have lived here for a while that you can go to for that stuff. It's not just… education-wise; you have…resources for outside life too.
Although summer bridge programs have existed for many years, little has been published on the efficacy of best practices for transitioning high school students from diverse and disadvantaged backgrounds into nursing programs. The Leadership 2.0 summer bridge component has distinctive elements that set it apart from other summer bridge programs, including parental involvement, community health experience, service-learning, research exposure, and contextual coursework. These students were exposed to more than traditional bedside nursing by having been provided with experiences of corporate industry, community clinics, public health sites, and research. Some of these experiences were interdisciplinary, inclusive of students from other bridge programs, notably engineering. Although this program was grant funded, several effective program elements are not large investments: use of graduate students as summer instructors, study tables, and orientation to campus resources. Leveraging community resources was important to the funding costs associated with socialization (i.e., university and school discounts, community donations).
Students viewed interactions with college faculty and staff as important prior to and throughout the summer bridge. Of note, students viewed interactions with peers and the student manager as unimportant prior to the summer bridge but as the most important component by the end of the program. The significant changes in the perceived importance of social activities pre– and post–summer bridge supports the notion that socialization is a key element of success. This is similar to other published reports showing that social integration is a positive outcome of bridge programs (Stolle-McAllister, 2011). Although a bridge program must have personnel roles defined, the composition, characteristics, and presence of leadership are critical. During focus groups, students cited friendliness, accessibility, and engagement of program personnel as being significant. These interactions helped to create the sense of community that the authors believe supported the students.
The summer bridge was designed to prepare students for college. A preprogram survey revealed that students felt prepared to move into the role of college student, despite sharing the differences between high school and college with them. The authors emphasized that although summer grades would not count toward the students' degree, the rigor would be similar to prepare them for the fall semester. Post–summer bridge, students were surprised at how challenged they had been. After the first semester, students shared that even with having information on how college differed from high school, the semester was still challenging, reinforcing the importance of having realistic experiences before grades count.
Financial concern is an overwhelming stress for underrepresented and disadvantaged students in attending and being successful in college (Paulsen & St. John, 2002). Inability to earn money for an entire summer limits some students from applying to the program. Although parents are involved in the selection process and receive financial aid counseling, the inability to reconcile the benefit from the summer bridge with the financial burden to the family prohibits some students from participating. This highlights the need to generate sustainable funding for these support programs so all eligible students can attend.
Results from the summer bridge evaluation have uncovered the following: (a) the summer bridge is important in the transition to college and first-year academic success; (b) both academic and social components of the summer bridge program were essential, with lectures, clinical and experiential learning, and socialization and interactions with people associated with the program being viewed as most important; and (c) the summer bridge is just one component of retention and academic success for underrepresented students and is part of a support package.
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Design of the Summer Bridge Residential Program
|Academic preparation||Anatomy and physiology, chemistry, and math instruction|
|Use of technology to facilitate learning (distribution of iPad® minis)|
|Orientation to on-campus resources for learning|
|Learning assessments (Myers-Briggs Type Indicator and StrengthsFinder testing)|
|Time management, anxiety reduction, and test preparation workshops|
|Introduction to college leadership, faculty, and staff|
|Orientation to student affinity groups|
|Clinical and research immersion experiences||Clinical experiences in underserved areas|
|Tour of clinical units at an urban level 1 trauma center|
|Tour of an academic clinical-based research laboratory|
|Simulation activities and tour of a smart house collaboratory (i.e., a residential unit that is an interprofessional learning platform used to test technology, creating an environment that supports independent living for older adults) at an assisted living center|
|Field trips to large corporations that conduct research|
|Cultural exposure||Tour of an underserved neighborhood, learning activities on social determinants of health|
|Field trip to cultural centers|
|Reading/discussion groups around social equality and ethics in health care|
|Financial support||Paid housing and food during the 6-week summer bridge|
|Scholarship incentive for completing the summer bridge program|
|Financial literacy workshops|