Journal of Nursing Education

Major Article 

Interventions to Support Diversity in Nursing Education

Kimberly McNally, MS, RN; Sharon Elizabeth Metcalfe, EdD, RN; Ramona Whichello, DNP, RN, NEA-BC

Abstract

Background:

Despite increased awareness of the importance of cultural competence in the reduction of health care disparities, the nursing profession does not reflect the patient demographics of the United States. The purpose of this article is to report the results of a comprehensive review of the experiences of nontraditional nursing students in undergraduate nursing programs and the interventions used by nursing programs to increase their success.

Method:

Data from 13 studies were extracted, summarized, and synthesized. This review was organized using concepts from Jeffreys' nursing undergraduate retention and success model.

Results:

Nontraditional nursing students faced unique challenges when pursuing undergraduate nursing education.

Conclusion:

This review highlighted the need for continued efforts to support nontraditional students that pursue nursing education. Future research is necessary to identify and prioritize interventions that enhance nontraditional students' experiences and improve student outcomes. [J Nurs Educ. 2019;58(11):641–646.]

Abstract

Background:

Despite increased awareness of the importance of cultural competence in the reduction of health care disparities, the nursing profession does not reflect the patient demographics of the United States. The purpose of this article is to report the results of a comprehensive review of the experiences of nontraditional nursing students in undergraduate nursing programs and the interventions used by nursing programs to increase their success.

Method:

Data from 13 studies were extracted, summarized, and synthesized. This review was organized using concepts from Jeffreys' nursing undergraduate retention and success model.

Results:

Nontraditional nursing students faced unique challenges when pursuing undergraduate nursing education.

Conclusion:

This review highlighted the need for continued efforts to support nontraditional students that pursue nursing education. Future research is necessary to identify and prioritize interventions that enhance nontraditional students' experiences and improve student outcomes. [J Nurs Educ. 2019;58(11):641–646.]

The demographics of the United States are changing. Estimates predict that by 2044, minority groups will account for more than half the population (U.S. Census Bureau, 2015). Data projections have significant implications for the delivery of health care in this country. Nurse educators need to consider how to propel the nursing profession into the future where the needs of diverse patient populations are well met. The purpose of this article is to examine the current status of nontraditional students in nursing programs and the need to seek out evidence-based interventions to support diverse students.

The concept of diversity refers to the individual, population, and societal characteristics. Characteristics include, but are not limited to race, ethnicity, sexual orientation, gender, age, socioeconomic class, and geographic location (American Association of Colleges of Nursing, 2015). Support of minorities in nursing education has been identified as a way to increase the quality of culturally competent patient care by promoting the diversity of the nursing workforce (American Association of Colleges of Nursing, 2015). Recognition of the role of diversity in health care is critical. Nurses should explore ways to support and retain nontraditional students.

Background

Despite increased awareness of the importance of culturally competent care, disparities in access to quality health care continue to persist. Differences in access to care, lack of appropriate medical insurance, and poverty can occur as a result of race, ethnicity, religion, and socioeconomic status (National League for Nursing, n.d.). It has been nearly a decade since the Institute of Medicine (IOM, 2010a) released the report Future Directions for the National Healthcare Quality and Disparities Reports. Yet, the literature continues to indicate that disparities exist in various areas of health care (Narayan & Scafide, 2017; Nipp et al., 2018; Washington et al., 2017). In fact, there has not been a significant reduction in disparities for any racial or ethnic minority groups (Agency for Healthcare Research and Quality, 2017). This is a strong indication that more must be done to raise the equity of health care in the United States.

Nursing compromises one of the largest groups of health care workers in the United States. In a 2010 report, the IOM recommended that the diversity of the nursing workforce be increased to meet the needs of minority populations (IOM, 2010b). In 2015, the IOM followed up on the 2010 report with a brief to address the progress toward reaching the goal set forth. The progress report showed more diversity in the nursing profession, but it reiterated the need for continued efforts (IOM, 2015). In the same year, the current status of the nursing workforce was assessed. A survey conducted by the National Council of State Boards of Nursing (2015) and The Forum of State Nursing Workforce Centers found that nurses from minority backgrounds represent 19.5% of the RN workforce. The number, while improving, does not match the demographics of the current U.S. population.

Support of nontraditional students can enhance the diversity of the health care workforce. Nontraditional students are defined as those who are over the age of 24, speak English as a second language (ESL), are a member of an ethnic minority, are a member of a gender minority, or work full time (National Center for Education Statistics, n.d.) The American Association of Colleges of Nursing (2015) issued a statement titled Diversity, Inclusion and Equity in Nursing Education, in which they recognized the need for nursing education to become more inclusive in order to reflect the changing demographics of the United States. The future of nursing depends on the dedication of nursing faculty to develop ways to increase the diversity and success of students.

Minority students face additional challenges when attending higher education institutions, compared with nonminority students. However, the life experiences of diverse students can enrich the quality of the nursing profession. ESL students can help meet the need for bilingual health care workers (Englund, 2018). However, Kaddoura, Flint, Van Dyke, Yang, and Chiang (2017) found that ESL was associated with lower pass rates on the NCLEX-RN® and poorer performance in nursing school, compared with students who reported English as their native language. Therefore, nursing school faculty should continue seeking evidence-based interventions to promote an inclusive environment (Alicea-Planas, 2017). A thorough evaluation of the current research will assist nursing programs to graduate nurses who more closely resemble the demographics of the patient population.

Framework

The framework selected to guide this review was Jeffreys's (2012) nontraditional undergraduate retention and success (NURS) model. The NURS model is a discipline-specific, positive framework that allows for the consideration of multidimensional factors. Nursing students are viewed holistically. Nurse educators seek to understand what factors increase student retention instead of asking why students fail or drop out. A comprehensive review of current literature was conducted and organized according to factors defined by the NURS model.

Method

This review was limited to articles that reported on interventions and strategies to support the success of diverse students in undergraduate, prelicensure nursing programs. The integrative review process was based on the literature search strategies proposed by Whittemore and Knafl (2005). Use of the search strategies was incorporated to limit personal bias and prevent an inadequate search of the existing literature.

This integrated review includes articles from peer-reviewed journals. A comprehensive search of the literature was performed to locate articles published between the years 2016 to 2018. The online databases used in the search were SocINDEX™, CINAHL® Plus, Education Source, Health Source®: Nursing/Academic Edition, MEDLINE® Complete, ERIC™, and PsycINFO®. The search included a combination of the terms nursing students, gender, minority, nontraditional, retention, NCLEX, and ethnicity. The search produced 341 articles. Titles and abstracts were reviewed to exclude articles that did not fit the purpose of this literature review. Articles included in the review were required to include interventions or strategies that supported nontraditional nursing students. Articles were excluded if the subjects were graduate students or did not meet the NURS model's definition of a nontraditional students. Dissertations, theses, expert opinions, and commentaries were excluded because of inconsistent scholarly review. Review articles were also excluded because the focus of the literature review was individual articles. A total of 13 articles met the inclusion criteria and were selected for this review. Key themes included Cultural Values and Beliefs, Academic Factors, Professional Integration, and Environmental Factors.

Literature Review

Cultural Values and Beliefs

Students enter nursing school with learned beliefs, values, and behaviors that reflect their cultural group or groups. Culture can be associated with many variables, including ethnicity, gender, or profession (Jeffreys, 2012). Cultural values and beliefs influence student behaviors and interactions within nursing programs and the nursing profession. Multiple researchers attempted to understand the cultural experiences of underrepresented students in nursing schools. The fear of stereotypes appeared in several research studies. The fear of stereotypes led to negative experiences for both male students and ethnic minorities (Alicea-Planas, 2017; Carnevale & Priode, 2018; Kiekkas et al., 2016; Young-Brice, Dreifuerst, & Buseh, 2018).

The unconscious biases of nursing faculty and peers related to nontraditional students' cultural values and beliefs can negatively affect the experiences of nursing students (Alicea-Planas, 2017). Male students reported being excluded on labor and delivery wards, as well as in other areas of health care (Carnevale & Priode, 2018). At times, the exclusion was covert, but students reported episodes of blatant exclusion. Male students perceived gender bias in examinations because the wording consistently referenced the nurse using a feminine pronoun. Male nursing students perceived higher expectations when compared with their female peers and had to defend their career choice to peers. Male nursing school students felt less stereotyped by younger, recently graduated nurses than by older, seasoned nurses. This may be attributed to generational perspectives on gender roles (Carnevale & Priode, 2018). Gender bias also influenced the grading process. Gender bias was found to negatively affect the scores of male students on written examination evaluations in an undergraduate nursing program, compared with female peers (Kiekkas et al., 2016).

Given the potential difficulties nontraditional students may face in nursing programs, several studies focused on supportive interventions. A study selected for this review evaluated a technique that is used in many cultures. Young-Brice and Thomas Dreifuerst (2018) examined the effects of mindfulness in minority undergraduate nursing students. Students reported positive effects from the implementation of mindfulness techniques into the nursing curriculum. Mindfulness techniques included controlled breathing, self-focusing, and journaling. A lack of mindfulness was associated with disengagement and “going through the motions” in a robotic state. Students found participating in spiritual or religious activities to be a supportive factor as well (Ferrell & DeCrane, 2016). Mindfulness techniques may support retention of nontraditional students. In addition, cultural competence may be strengthened with the use of diversity coordinators. A study on the program Advancing Health Equity Through Student Empowerment and Success (HealthE STEPS) used diversity coordinators to provide individualized case management to nontraditional students (Noone, Wros, Cortez, Najjar, & Magdaleno, 2016). Students had positive perceptions and felt that diversity coordinators showed an institutional commitment to ethnic minorities. Students wanted to see a more diverse student body and nursing faculty (Alicea-Planas, 2017). Students reported that the cultural environment of the institution and program influenced their progression in the nursing program (Ferrell & DeCrane, 2016; Noone et al., 2016). Faculty may need to conduct program assessments to help identify areas where unconscious bias exists, such as on examinations. Interventions that support and embrace different cultures may decrease the fear of stereotypes.

Academic Factors

Understanding the contribution of academic factors to nursing student retention provides another opportunity for faculty to contribute to the success of nontraditional students. The NURS model recognized the importance of academic support for non-traditional nursing students, and therefore it was pertinent to examine the literature for academic interventions used to support nursing students.

Academic interventions to support diversity in nursing programs have been beneficial to nontraditional students. Culturally competent curriculum and learning activities found in two studies lead to an improvement in the delivery of care to medically underserved, minority communities. The curriculum included scenarios focused on how social determinants connect to health care outcomes (Ferrell & DeCrane, 2016; Noone et al., 2016). King, Porr, and Gaudine (2017) suggested that use of standardized patients helped ESL students to achieve success. Use of standardized patients enhanced psychological safety and improved comfort communication, psychomotor skill development, and language acquisition. The use of male standardized patients allowed female nursing students from cultures that give care according to gender a safer environment to interact with males (King et al., 2017).

The use of tutoring services was present in several articles. Personal and group tutoring for entrance examinations for the nursing program were used (Kowlowitz et al., 2018; Metcalfe & Neubrander, 2016). The research suggests that accessible, tailored tutoring services can be helpful for nontraditional students. Similarly, tutoring services were offered for first-year courses that were determined to be the most challenging for students (pathophysiology and pharmacology). Sessions offered face to face and online were found to be effective. Students who received tailored tutoring services reported positive perceptions of the nursing profession, personal satisfaction, and plans to attend graduate school (Kowlowitz et al., 2018). Kowlowitz et al. (2018) conducted a student needs assessment. The most frequently identified barrier by students was the lack of study time. Researchers sought clarification for a “lack of study time.” Students felt too many other demands already existed on their time to meet the demand of a full-time course load (Kowlowitz et al., 2018). Tailored tutoring services may help meet his need.

Although it may seem obvious, academic support can help nontraditional students succeed in nursing programs. Tutoring services were found to be useful for students (Ferrell & DeCrane, 2016; Kowlowitz et al., 2018; Metcalfe & Neubrander, 2016). ESL students benefited from targeted curriculum support (King et al., 2017). This suggests that nursing faculty should consider early, targeted academic interventions to support non-traditional students.

Professional Integration

Professional integration is achieved through formal and informal interactions with members of the nursing profession (Jeffreys, 2012). Nursing school faculty, peers, and professional networks often serve as student's first contacts in the nursing profession. Mentorships, memberships in professional organizations, participation in nursing events, integrated nursing student test enhancement services (NCLEX preparation), and socialization with friends in class or in nursing neighborhoods are considered professional integration in the NURS model framework (Jeffreys, 2012). Professional integration techniques were well represented in the current literature,

Successfully passing the NCLEX is necessary to transition from a nursing student to an RN. Jeffreys, Hodges, and Trueman (2017) explored the relationship between Kaplan educational modules and the students' results on the Kaplan Readiness Exam. The Readiness Exam is used to predict the potential for success of the student on the NCLEX. The study population was undergraduate baccalaureate students at a historically black college in North Carolina. Fifteen students were included in the sample, and all the participants were candidates for graduation (Jeffreys et al., 2017).

Subjects of the study were given a pretest that was scored followed by a review course that focused on critical thinking and clinical judgment. After the review was completed, the students were given a posttest. Data results between the pretest and posttest were compared. The posttest results indicated that eight of the 15 students improved their scores, one had no change, and six had lower scores. The authors suggested that the review was overall helpful as the cohort did go on to have a 100% pass rate on the NCLEX (Jeffreys et al., 2017). Many nursing programs have embedded NCLEX preparation into the curriculum. Nursing faculty should continue to critically evaluate the effectiveness of integrated preparation courses for nontraditional students.

Ferrell and DeCrane (2016) conducted a study to examine thematic concepts of academic success as perceived by current nursing students. Responses were analyzed for concepts that created thematic categories. The investigators uncovered four categories: institutional commitment, feedback, involvement, and support. Students placed high value on faculty and support staff in their success. Students reported more positive perceptions when they felt faculty supported the success of minority groups. Students also identified the importance of involvement and wanted to see more minority activities and social groups on campus (Ferrell & DeCrane, 2016).

Kowlowitz et al. (2018) explored the influence of seminars, career information, and structured support groups on underrepresented ethnic minority (UREM) prenursing students. The program lasted over a 3-year time frame, and the results of the evaluation were positive. UREM students who participated in the program had higher nursing school acceptance rates (87.5%) compared with nonparticipating students' admission rates (16.7%). In addition to numerical data, perceptions reflected positive experiences by the students (Kowlowitz et al., 2018).

Living-learning communities provide a way for students to become immersed in the culture of the nursing profession. Bauer and Kiger (2017) conducted a qualitative study on living-learning communities and the perception of undergraduate nursing students. Living-learning communities are composed of individuals with shared interests and passions and are believed to increase knowledge by fostering a unique language and social norms of a particular group. A sample cohort of first-generation college students was selected. Students who resided in the nursing living-learning community were perceived as serious and more motivated to focus on schoolwork. The resident assistant was a nursing student and served as a mentor. Resident assistants facilitated excitement for future classes and clinicals. Mutual support among students fostered persistence and promoted self-determination. Students reported the mentorships that developed in the living-learning communities were more genuine than when formal mentors were assigned (Bauer & Kiger, 2017). Living-learning communities may serve as a supportive factor for first-generation college students.

Noone et al. (2016) examined the use of a professional integration program called HealthE STEPS. The program was designed to address health care disparities by providing support to UREM students, with a specific focus on Hispanic students. HealthE STEPS was composed of academic socialization, financial resources, community and professional networking, campus culture assessments, and curriculum development seminars. HealthE STEPS engaged in community outreach and professional networking with groups such as The National Association of Hispanic Nurses (Noone et al., 2016). In addition to a 97% pass rate, a large percent of program graduates were employed in a medically underserved community after graduation. Professional integration strategies aimed at diverse students continue to show positive results.

Metcalfe and Neubrander (2016) examined the results of a diversity program at a university in western North Carolina. The NN-CAT Diversity Mentoring Program was a nursing pipeline program that was developed to promote academic success for ethnically diverse and rural students. Interventions included personalized intensive mentoring, structured testing support, collaborative sharing with students, and annual social and award receptions (Metcalfe & Neubrander, 2016). A major component of the NN-CAT Nurse Mentoring Program was the provision of a nursing mentor to guide the students. Mentors received extensive training prior to serving as a mentor and received ongoing monthly training during mentor meetings. A unique feature of the NN-CAT program was the Annual Mentoring and Student Reception. The annual reception included students, families, mentors, and an ethnically diverse guest speaker (Metcalfe & Neubrander, 2016). The program proved to be successful overall. An increased number of UREM students were able to matriculate into the nursing program and successfully graduate. The use of mentors and other professional integration strategies may decrease barriers to the success of nontraditional students.

Williams, Bourgault, Valenti, Howie, and Mathur (2018) conducted a secondary data analysis of survey results from a program entitled New Careers in Nursing scholarship program for non-White nursing students. Researchers wanted to examine factors that predicted first-time pass rates, satisfaction with the nursing program, and intent to pursue graduate education. The study demographics were mainly female, African American, and economically disadvantaged and had a mean age of 28.5 years. Five variables were examined and included student satisfaction, financial concerns, quality of faculty advising, quality of nonfaculty teaching, and faculty gender representation. Satisfaction with nonteaching faculty made it five times more likely that the students would pass the NCLEX on the first try. Conversely, students who were more satisfied with faculty advising were less likely to pass the NCLEX on their first attempt, compared with those who were not satisfied (Williams et al., 2018). The results indicate nonteaching faculty may play a significant role in student success. Many variables played a role in student satisfaction. Student participation in a prematriculation program was positively associated with satisfaction. In addition, students who were satisfied with the program's faculty gender representation and response to nontraditional students were more satisfied with the nursing program overall. Likewise, students who perceived academic and social support were twice as likely to be satisfied with the program (Williams et al., 2018). Similar variables appear to play a role in the students' decisions to pursue graduate education. Students who were preintroduced to nursing school were far more likely to intend to pursue graduate education. Self-support skills were also associated with an intent to pursue advanced nursing education. Students who received mentorship services and were satisfied with New Careers in Nursing scholarship program were more likely to intend to pursue graduate education (Williams et al., 2018). The study suggests that students' satisfaction and perceptions influence persistence and future professional goals.

Tab (2016) examined the RUN 2 Nursing program and the influence of the program on the retention of rural and disadvantaged students. The program included peer tutoring, faculty mentoring, NCLEX preparation for licensure, leadership and professional training, diversity training, and workshops on study and time management skills. The eligibility criteria for mentors included a voluntary commitment to mentor-assigned minority students, the ability to work with students from diverse backgrounds, the ability to meet at least three times or more with assigned mentees, and the ability to complete a faculty–mentee survey form to measure outcomes of the mentoring relationship. The RUN 2 nursing program had a positive impact on students. The program retained 93% of participants and yielded a 93% NCLEX pass rate. In addition, the minority students involved in the RUN 2 nursing program formed the first Black Students Nursing Association to provide informal mentoring to minority prenursing and nursing students (Tab, 2016).

Professional integration interventions appear to support diversity in nursing education. Mentorships that are considerate of a student's cultural background had positive effects on the students (Noone et al., 2016). Nursing is a caring profession, and purposeful interventions should help diverse students feel welcome. Steps should be taken to ensure a positive experience, beginning with nursing school faculty.

Environmental Factors

Environmental factors lie outside the academic sphere but can still significantly affect a student's progress within a nursing program. Environmental factors include financial status, family support (financial and emotional), family responsibilities, childcare arrangements, family crisis, employment, work, transportation, and friends (Jeffreys, 2012). The majority of articles included in this review offered some type of financial support.

Financial barriers create hardships for many college students. Nontraditional students may need to work full time while going to school, which can negatively affect academic performance. Working and full-time school enrollment left nursing students with little time to study (Kowlowitz et al., 2018). Financial aid, scholarships, and stipends for tuition and other educational expenses were included in five of the articles chosen for this review (Ferrell & DeCrane, 2016; Kowlowitz et al., 2018; Metcalfe & Neubrander, 2016; Noone et al., 2016; Tab, 2016). Scholarships were provided to assist students with financial needs including cost of tuition, books, transportation to clinical sites, and other expenses (Tab, 2016). One program included workshops to assist students to build their scholarship portfolios, manage their debt, and improve their financial literacy (Noone et al., 2016). In addition to providing financial support, nursing programs must also make accessibility to financial resources more manageable for students.

The process of paying for college and applying for financial aid and scholarships can be daunting. Students expressed stress related to finding financial support (Ferrell & DeCrane, 2016). Minority students not only wanted more aid for low-income students but also wanted assistance with finding and applying for scholarships (Ferrell & DeCrane, 2016). The financial aid process was perceived as a barrier to success. The process to apply for financial aid and scholarships was seen as complicated. Students expressed the need for a full-time staff member to be available to assist students. The literature supports the provision of financial support to nontraditional students as a way to improve success and retention.

Discussion

This integrative review provides an overview of the current state of nursing literature on the experiences of nontraditional, undergraduate students. The negative impact of stereotypes was highlighted in five of the included studies (Alicea-Planas, 2017; Carnevale & Priode, 2018; Kiekkas et al., 2016; Young-Brice et al., 2018). The fear of stereotypes led to behavior changes in some students, which included avoidance of school activities and nonparticipation in class. Nontraditional students benefited when cultural values and beliefs were recognized and incorporated into nursing programs (King et al., 2017; Noone et al., 2016). Students found culturally congruent mentors to be beneficial to progression in a nursing program (Metcalfe & Neubrander, 2016; Noone et al., 2016; Tab, 2016). Nursing faculty and staff support of students was identified as a supportive factor (Ferrell & DeCrane, 2016). Professional integration strategies appear to reduce feelings of isolation in nontraditional nursing students. The provision of financial resources and support is well represented in the literature about nontraditional students (Ferrell & DeCrane, 2016; Kowlowitz, et al., 2018; Metcalfe & Neubrander, 2016; Noone et al., 2016; Tab, 2016). The inclusion of a financial component in an intervention strategy tailored to increase the diversity of nursing students is well supported in the literature. Nursing has become a holistic profession. Nursing school faculty should strive to implement educational support interventions that are based on a culturally inclusive perspective.

Conclusion and Recommendations

The nursing workforce is composed of individual nurses, and the profession is strengthened by the success of diverse students. The goal for nurse educators should be to create a pathway for the retention and success of nontraditional students. The pathway should include interventions that address environmental, academic, professional, and cultural factors. Financial support allows nontraditional students the opportunity to spend more time studying and engaging in professional integration activities. Nurse educators need to reflect on the overall culture of the program to ensure an inclusive environment for all students. Efforts should be made to recruit and support diverse students that reflect the demographics of the patient populations in the United States. Finally, there was a lack of research aimed at older students (> 24 years) and nursing students with dependents. A better understanding of the barriers faced by a variety of nontraditional students may lead to more tailored support interventions.

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Authors

Ms. McNally is Graduate Student, Dr. Metcalfe is Associate Professor, and Dr. Whichello is Director, Nurse Educator Program, Western Carolina University, Cullowhee, North Carolina.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Kimberly McNally, MS, RN, 4943 Brown Drive, Kailua, HI 96734; e-mail: Kim.a.mcnally@gmail.com.

Received: April 09, 2019
Accepted: August 06, 2019

10.3928/01484834-20191021-05

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