Significant attention has been focused on ethnic and racial disparities in health care since 1985, when the Report of the Secretary's Task Force on Black and Minority Health was released; yet, critical health disparities persist (U.S. Department of Health and Human Services, 1985). The Centers for Disease Control and Prevention reported in a special feature on racial and ethnic health disparities that health disparities in mortality, natality, health conditions, health behavior, and health care access and utilization have continued from 1999 to 2014 (U.S. Department of Health and Human Services, 2014, 2017). The complexity of incessant health disparities is amplified by the rapidly changing population percentages of various ethnic and racial groups in the United States. In 2012, 37% of the U.S. population comprised ethnic and racial minority groups (U.S. Census Bureau, 2012), by 2018 this number increased to 40% (U.S. Census Bureau, 2018). Ethnic and racial minority groups are expected to represent 50% of the U.S. population by 2044 (Colby & Ortman, 2015). Clearly, there will be a majority-minority nation consisting of no majority ethnic or racial groups. The White American group will be the minority (U.S. Census Bureau, 2012).
With the projected U.S. population demographic shifts, the nursing workforce must be prepared to provide culturally sensitive and appropriate care to a wide range of ethnic and racial groups that have been confronted with health disparities for decades. It is crucial that health care providers, including nurses, be better prepared to address the health care needs of diverse populations. Evidence supports that patient–provider race concordance may improve desirable outcomes for minorities due to increased mutual respect, trust, communication, and satisfaction. Health care providers must be further prepared to focus health care systems quality and research on improving the health for a diverse population (Meghani et al., 2009).
In 2016, 30% of baccalaureate and graduate nursing students were from ethnic and racial minority groups (American Association of Colleges of Nursing, 2017). Although traditional mentoring and recruitment programs have contributed to an increasing number of ethnic and racial minority nursing students, current trends will not be sufficient to meet future diverse patient needs. Nontraditional and innovative strategies must be implemented to minimize this gap. The targeted group of students for the Summer Professional Immersion in Nursing Program (SPIN) were attending universities without nursing programs, were pursuing non-nursing degrees, and/or had minimal exposure to nursing programs at their home institutions. Often, underrepresented minority students may express doubts about the possibility of becoming a nurse within a “reasonable” length of time. These students may also anticipate encountering institutional barriers along with other personal or environmental barriers that may impede the academic success of ethnic minority undergraduate and graduate students (Bagley, 2019; Isik et al., 2018; Toretsky et al., 2018; Williams et al., 2017). Having exposure to programs such as SPIN provides an awareness of available academic and professional resources and better prepares students for pursuing nursing careers.
Increasing interest in nursing as a profession among bright and talented individuals from ethnic and racial minority groups is critical to the future health of the U.S. population (U.S. Department of Health & Human Services, 2014). Summer enrichment, or “pipeline programs,” have demonstrated beneficial effects when interested prospective students are provided deliberate and systematic exposure to the nursing profession. Pipeline programs have been found to enhance interest, commitment, and preparation for the professional school application process and academic rigor is recognized as one of the most promising methods to increase diversity in the health care workforce (Dapremont, 2013; Duffus et al., 2014; Smith et al., 2009; Snyder et al., 2018). The purpose of this article is to describe and evaluate the effectiveness of a pilot program designed to expose ethnic and racial minority participants to a summer immersion nursing experience. The program was also designed to foster interest in the nursing profession and prepare participants for the application and matriculation process into top tier nursing programs.
SPIN was a 4-week, summer, Monday through Friday, immersion program to expose participants to various nursing roles, simulated nursing experiences, and real-life clinical observation rotations in acute and primary care sites. SPIN's primary purpose was to expose undergraduate minority students to nursing-related experiences and activities to gain interest in a nursing career and advance critical thinking methods that can improve their ability to apply the nursing process. Students were provided with observational experiences that offered insight into the nursing roles and responsibilities of patient care. Through these experiences, students were able to further develop their level of understanding and learning as it pertains to nursing.
The theoretical underpinning of the program is the self-efficacy theory (Bandura, 1977). Self-efficacy theory postulates that individuals must believe they can accomplish a task in order to complete it. A basic premise of SPIN is that if provided the necessary information, the participants would be able to successfully select a career of their choice, preferably nursing. The SPIN faculty team consisted of two co-investigators and two program managers. The program managers coordinated and facilitated the SPIN daily activities. Three ethnic or racial minority nursing students served as student mentors. Thirteen faculty members, two staff members, and seven clinical nurse educators participated in discussions with the participants throughout the program. The program began with 1 week of interactive classroom and clinical simulation sessions. Classroom discussion sessions included topics concerning general health care subject matter in the lean quality improvement model, motivational interviewing, community health, and health disparities, along with nursing-specific themes such as an introduction to the nursing process, nursing research priorities, evidence-based practice, and nurse leadership and management. These discussions were led by nursing and other university faculty who were experts in their fields. Two clinical simulation sessions were created and facilitated by simulation nurses. Students were initially taught vital sign techniques on patient manikins to allow life-like interactions. The students were then given the opportunity to extend their learning by identifying abnormal signs and symptoms exhibited by the patient manikins. Debriefing occurred after each experiential learning activity, and the learners were able to reflect, review, and discuss the activity to improve upon new skills learned and build confidence before entering the clinical environment for the first time (International Nursing Association for Clinical Simulation and Learning, 2016). Student exposure to these topics and simulations were integral in familiarizing them with information they would see and hear during observational rotations in the hospital and were critical to the foundation of establishing a career in nursing.
Weeks two through four consisted of four 8-hour observation days in an inpatient clinical setting followed by 1 day of clinical sharing, debriefing, and enhancement sessions. The daily clinical activities were completed during rotations that were based on the specialty interests (e.g., nurse-midwifery, neurology, pediatrics) of the participants and took place in inpatient settings. The clinical activities were observation only, but an assigned nurse in each clinical area was responsible for selecting experiences that met the program and participant objectives. Additional interactions with nurses experienced in leadership, research, and informatics were interspersed throughout the program on designated professional development days. The professional development experiences included exposure to a wide array of nursing roles through informal presentations from bachelor's-, master's-, and doctoral-prepared nurses. Additionally, experiences included application guidance via a flipped classroom model and simulated nursing experiences in a laboratory setting. Table 1 provides a sample schedule of presentation topics and hospital setting units for the first week of SPIN.
Classroom Lecture Topics and Observational Experience Units
Design and Participants
A pre–post design was instituted to collect the survey data from the target population of undergraduate, ethnic, and racial minority students interested in pursuing a career in nursing after graduation. Inclusion criteria were: (a) undergraduate student; (b) enrolled full time in one of three universities/consortiums invited to participate in a summer immersion program; (c) identified with at least one of the following ethnic or racial minority groups: African American/Black, Hispanic/Latin American, Native American/Alaskan Native, Native Hawaiian/Other Pacific Islander; and (d) expressed an interest in participating. Approval for SPIN was granted by the university institutional review board and office of research to conduct research involving human subjects.
Participants were recruited by soliciting eligible students via electronic advertisements sent to campus organizational groups and faculty mentors at the selected undergraduate campuses. An application process was used, and an informed consent was obtained prior to starting the program. Monetary compensation was offered to incentivize study participation and supplement living expenses during the 4-week immersion program. There were eight participants enrolled in one of three universities/consortiums that did not offer nursing as an undergraduate major of study with all being located in the southeastern region of the United States.
Survey data were collected by using REDCap® (Harris et al., 2009), a secure web application and data management tool, and Mind Garden, Inc. ( https://www.mindgarden.com/), which allowed a safe, secure storage of raw data until data collection was completed. The Mind Garden, Inc. online publication, manual, and license to reproduce the Career Decision-Making Self-Efficacy (CDSE) scale were used to guide data collection. REDCap was used to collect demographic data from each participant, and Mind Garden provided an online, secure tool to collect CDSE data. The CDSE scale measures how well individuals perceive their ability to complete tasks and perform behaviors necessary to making significant career decisions (Betz & Taylor, 2012; Taylor & Betz, 1983). The demographic data were collected at the beginning of the program, and the CDSE data were collected at two distinct time points: the first and the last day of the program.
The CDSE scale measures how well individuals think they can successfully complete tasks necessary to making career decisions (Betz & Taylor, 2012; Taylor & Betz, 1983). In the current pilot study, the CDSE was used to assess the participants' levels of self-efficacy in making a career decision. It was believed that the classroom, simulations, and observation experiences would positively influence the participants' ability to make career decisions. The CDSE—based on two formulations of modern psychology, Self-Efficacy and Career Maturity Theory as cited by Taylor and Betz (1983)—has 50 items evenly divided among five subscales: self-appraisal, occupational information, goal selection, planning, and problem solving. The scores on this scale range from 1.0 (no confidence at all) to 5.0 (complete confidence), with higher scores indicating more confidence for successful career decision making. Self-appraisal measures how confident an individual is in accurately identifying and evaluating personal assets and liabilities; occupational information measures how confident an individual is in knowledge of what workers in different occupations do; goal selection measures how confident individuals are in personal ability to match the occupation for which the person is best suited; planning measures how confident an individual is in the ability to start and progress in a given career; and problem solving measures how confident an individual is in the ability to choose the best solutions to resolve personal career problems (Betz & Taylor, 2012; Taylor & Betz, 1983).
The CDSE has theoretical and construct validity and the tool has overall good to excellent internal consistency with Cronbach's alpha scores (excellent reliability for α > .9, good reliability for α > .8, acceptable reliability for α > .7). Based on three samples of college students, other studies have reported Cronbach's alpha scores as high as .95 for the five-level continuum of the total CDSE score and scores ranging from .78 to .87 for the five subscales (Betz et al., 2005). In this study, the internal consistency of all 100 items between the CDSE pretest and CDSE posttest assessments was determined using Cronbach's alpha reliability analyses. It was demonstrated with a Cronbach's alpha coefficient of .95 that the pre- and posttest CDSE 100 items had shared covariance and likely measure the same underlying construct of perceived risk among study respondents.
Nonparametric statistics were initially used to compare descriptive characteristics of the students and CDSE scores. Non-parametric testing was appropriate due to the small sample size of SPIN students and because the distribution of the outcome cannot be assumed to be approximately normally distributed. In addition, a comparative analysis of pre- and post-SPIN program scores was conducted to decide if the differences between the participant scores represent reliable changes and if they were significantly relevant (Mata et al., 2018). Generally, change point analysis may be performed in either parametric and non-parametric settings (Matteson & James, 2014). Comparative analysis for this study was performed using a reliable change index, which has been historically applied when determining whether improvement after a therapeutic/developmental intervention was real or due to measurement error (Jacobson, 1991).
Eight applicants were selected, and all consented to participate in this program. Participants were female with a median age of 20 (interquartile range [IQR] = 19–20) years. All participants self-identified as an ethnic or racial minority, with the majority indicating Black or African American (n = 6; 75%) and two (25%) indicating an identification of biracial, including White or Caucasian and Hispanic or Latin American. The participants identified as sophomore (n = 4; 50%), junior (n = 3; 38%), or senior (n = 1; 12%) undergraduate students, and participants attended either Fisk University (n = 2; 25%) or Vanderbilt University (n = 6; 75%). Participants self-reported a median grade point average of 3.37 (IQR = 3.26–3.52).
All participants completed the CDSE pretest. Seven completed the CDSE posttest. The pre- to postchange was 0.38, indicating a meaningful significant difference. The participants' aggregate score of CDSE post-SPIN (Table 2) ranged from 4.1 to 4.7 (possible range = 1.0 to 5.0). An analysis of the group's CDSE subscale items identified several areas of career decision making suggested for improvement are listed in Table 3.
Aggregate Median Scores of Career Decision Self-Efficacy (CDSE) Posttest Subscales (N = 7)
Areas of Career Decision Making Suggested for Improvement
Despite the increased self-efficacy level of career decision making at the second data collection point, a few limitations of this pilot study should be noted. The small sample size limits the generalizability of the findings. In addition, the sample was primarily homogeneous, consisting of college students with similar ages. Because the targeted participants were undergraduate college students, it is anticipated that these individuals would have a higher level of self-efficacy toward career development. Similar aged students who were not enrolled in college may have resulted in different findings.
Another limitation relevant to the sample size is the number of CDSE items and validity issues. Given that this is a pilot study with a small sample size, the statistical significance of the findings must be carefully interpreted. Because of the small sample size, there is a possibility that the statistical significance may be attributable to other extraneous factors; however, the increased ability to make career decisions implies SPIN augmented this relationship. This study's design was only quantitative, which eliminated the asset of incorporating qualitative methods that would have further enhanced the knowledge of career decision making of future nursing students.
The SPIN program is an example of a professional immersion program which may positively affect the number of ethnic and racial minority students selecting nursing as a profession. From the use of a reliability index, the SPIN program, which consisted of expert-led presentations, simulations, mentoring experiences and shadowing of inpatient nurses, seemed to have positively influenced self-efficacy toward pursuing a desired career in nursing among undergraduate, underrepresented ethic and racial minority students. The shadowing of nurses in clinical settings for extended periods of time is believed to be a unique attribute of SPIN and heightens its outcomes. Partnering with universities that have large populations of ethnic and racial minority students and collaborating with an academic medical center enhanced the efficacy of this program. Replicating SPIN at a larger scale and following participants longitudinally would provide increased design rigor to support SPIN's effectiveness in exposing ethnic and racial minority participants to the nursing profession and increasing confidence in career decision making.
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Classroom Lecture Topics and Observational Experience Units
|Week 1||SPIN Program
Overview & Expectations
Tour of University
Baseline survey||“A Day in the Life-Adult Neurology”
“What is Motivational Interviewing?”
“Lean Methodology in Health Care”
Simulation Lab Activity
“A Day in the Life-Acute Medicine”
Tour of hospital and outpatient clinics||“A Day in the Life-Adult Cath Lab”
“Psychiatric Mental Health Advanced Practice Nursing”
Tour of Center for Experiential Learning and Assessment
“Nursing Student: Financial Services”
“Public Health Disparities in HIV/AIDS”
“Nursing Research Intro”
“Global Health and Climate Justice: The Role of Nurses”
“A Day in the Life Cardiovascular ICU”||“A Day in the Life-Pediatric ED”
“Community Nursing and Health Disparities”
“Pediatric Nursing Research”
“The Nurturing Woman”
“Nursing Leadership and Management”
“A Day in the Life-Pediatric Hem/Oncology”
“Disparities in Childbearing and Breastfeeding”
Reflection- Quick Write “Modern Nursing”||“Skin Disorders”
Teambuilding “Name That Hospital Item” Game
Reflection-Discussion: “A Day in the Life”
Orientation for Observational Experiences:
Cardiac Catheterization Lab
Surgical Intensive Care Unit
Orthopedic Trauma Unit
Cardiovascular Intensive Care Unit
Cardiac Stepdown Unit
Urology & Surgical Care Unit
Medical Intensive Care Unit
Palliative Care Unit
Adult Inpatient Medicine Unit
Pediatric Emergency Department
Pediatric Hematology/Oncology Unit
Aggregate Median Scores of Career Decision Self-Efficacy (CDSE) Posttest Subscales (N = 7)
|CDSE Subscale||Subscale Scorea|
Areas of Career Decision Making Suggested for Improvement
|Career Decision Self-Efficacy Subscale||Subscale Item|
|Self-appraisal||Determine whether you would rather work primarily with people or with information.|
|Define the type of lifestyle you would like to live in.|
|Occupational information||Find out the employment trends for an occupation in the next decade.|
|Find information about graduate or professional schools.|
|Goal selection||Choose a major or career that will suit your abilities.|
|Choose a major or career that will fit your interests.|
|Choose the major you want even though the job market is declining with opportunities in this field.|
|Planning||Plan course work outside of you major that will help you in your future career.|
|Decide whether or not you will need to attend graduate or professional school to achieve your career goals.|
|Successfully manage the job interview process.|
|Problem solving||Go back to school to get a graduate degree after being out of school 5 to 10 years.|
|Identify some reasonable major or career alternatives if you are unable to get your first choice.|
|Apply again to graduate school after being rejected the first time.|
|Move to another city to get the kind of job you really would like.|