Schools of nursing are increasing admissions of diverse students to meet the needs of the communities they serve to address health disparities (Health Resources and Services Administration, 2017). These students face numerous financial, academic, and socialization challenges and may not have the direction or guidance from family to navigate the unfamiliar college environment (Boehmer, 2014). Research has shown these students need additional support to achieve college success (Gilchrist & Rector, 2013; Latham, Singh, & Ringl, 2016).
Building on this research, the National Education Association (NEA) suggests racial equity advocacy training to foster social justice and inclusion in educational environments (NEA, 2019). The NEA has a threefold recommendation. The first recommendation is to assist educators in developing a better understanding of culture, beginning with their own culture, sense of privilege, interpretations of others, and how they react when faced with noninclusive behavior, such as micro-aggressions. The second recommendation is to create support resources for students that encourage self-reflection and self-care. The third recommendation is to advocate for ongoing equity and inclusion to extend the training to others. For nursing, this could involve training for those involved in clinical education and subsequent employment to help create ongoing, meaningful health care environment change for the nursing profession in which nurses are equipped with the knowledge and skills to guide them in their decisions and actions as they care for culturally diverse clients.
Using NEA Recommendations for Nursing Education
This article describes how one school of nursing (SON) used a three-pronged strategic approach to follow the NEA recommendations for nursing education. The first strategy involved cultural diversity and equity training with faculty, staff, and administrators to optimize relationships with students. The program defined cultural diversity and equity competence as the ability to engage others of different backgrounds, assumptions, beliefs, values, and behaviors with cultural awareness, understanding, and interpersonal skill (Hogan, 2013; NEA, 2019).
The second strategy was to institute student resources that included student peer mentoring, self-reflection journaling, and self-care for both mentors and mentees. Studies suggest student peer mentoring is a resource that significantly increases retention and success for nursing students (Igbo & Sule, 2019; Latham et al., 2016). In the university context, peer mentoring involves experienced university students spending time with less experienced students, providing social, psychological, and other support by means of direction, guidance, empathy, and insight into the university culture and ideas on how to fit into that culture and use appropriate resources (Latham et al., 2016).
The third strategy was to gain student perspectives about the adequacy of student resources and students' sense of a fair, inclusive environment. Evaluation of student resources, social justice, and equitable education approaches were conducted each semester using a shared governance process that incorporated student input based on self-reflective mentoring journals and students' personal experiences. Faculty and administrators then advocated for change based on student input. Student input was achieved through faculty meetings with student mentors and mentees to obtain student ideas to improve the educational environment to meet their challenges.
Student peer mentors used innovative approaches to provide ongoing mentee support and to transform the educational environment through a shared governance process (Latham et al., 2016). Boswell, Opton, and Owen (2017) reviewed shared governance literature and found that although it is a widely used concept, it is not always labeled; however, the sharing of ideas through a formalized process continues to be incorporated and supported in numerous academic settings. The SON shared governance was based on a definition encompassing organizational structures that support collaboration and open communication, empowerment, and shared decision making to foster positive work and learning environments (Boswell et al., 2017; Latham et al., 2016; Luescher-Mamashela, 2013).
To sustain these three strategies, a model was designed that incorporated student leadership into both peer mentoring and shared governance practices for implementing students' innovative strategies to address ongoing challenges. Building student leadership into the program would allow alumni to incorporate this focus on positive, culturally sensitive, and respectful practices within their future work environments that will promote positive student clinical experiences and employment, the final component of NEA's recommendations.
The SON's multiyear experience with the three-pronged strategic approach revealed the value of the program. Cultural diversity and equity training of faculty, staff, and administrators; peer mentoring with student self-reflection; and student-administrator shared governance led to advocacy for student perspectives and changes in instruction, advisement, and student relations with SON faculty and staff.
Method of Implementing NEA Strategies
First Strategy: Faculty, Staff, and Administrator Education
Over a 2-year period, the Four Skills Model was adapted to a multiphase cultural diversity and inclusion-training schedule for the SON (Hogan, 2013). The training objective was to assist SON faculty with integrating cultural diversity content and enhanced teaching-learning methodologies throughout the curriculum. The larger goal of the cultural knowledge and skills training was to create an inclusive student-learning environment with improved faculty-student communication and relations to dispel student stress and decrease feelings of alienation in the academic setting.
The Four Skills Model. The Four Skills Model is grounded in anthropological fieldwork concepts of culture, contextualization, cultural interpretation, holistic perspective, emic and etic perspectives, self-reflection, and nonjudgmental orientation. Table 1 provides conceptual definitions of the Four Skills Model and an example of each concept. People are products of culture and socialization, with personal beliefs, values and tastes that run deep as part of everyone's personality. Practicing self-reflection and a nonjudgmental orientation advances our ability to reduce explicit biases as well as our deeper, unconscious implicit biases that impede understanding diversity and can result in discriminatory treatment (Hardy & Hulen, 2016; Hogan, 2013; Hyatt & Mullin, 2019; Kondo, 2019; Woodson, 2019). The following section describes the components of the training process implemented for the SON. The training process embodies respect for cultural diversity at its core because it promotes a lifelong, collaborative, inclusive learning process that addresses multilevel power differences and institutional accountability (Baker & Beagan, 2014). The training process of SON faculty, staff, and administrators used a holistic, comprehensive approach that allowed individuals to reflect on their personal culture as it interrelates with cultural diversity at different levels (such as the organization culture of SON and the hospital or clinic in which students intern).
Definition of Major Concepts in Cultural Skills Development
Components of the Cultural Diversity and Equity Model. The following describes the components of the training process implemented for the SON that incorporated cultural mindedness and culturally centered communication skills.
- Cultural-minded people in any given situation attend to the demeanor and behavior of the people with whom they interact (Vindrola-Perdros, 2016). People are sensitive to organizational structure and relational processes, including the power differences embedded in the organization's roles and hierarchies. The first conceptual tool for developing cultural mindedness is understanding culture as multidimensional using the Aspects of Culture, which includes 12 categories that can be applied to any situation to identify cultural dynamics. The aspects of culture include history/traditions, social status factors, social group interaction patterns (intragroup and intergroup), values, language and communication (verbal and nonverbal), family life processes, healing beliefs and practices, religion, art and expressive forms, diet and foods, recreation, and clothing (Hogan, 2013).
- The second conceptual tool promoting cultural mindedness is understanding culture as multilevel. The Aspects of Culture tool aided in recognizing cultural complexity and identifying cultural dimensions that are actively operating at different levels: the personal cultural level, subcultural level, mainstream U.S. cultural level, and the organization/institutional level (Hogan, 2013).
- The third conceptual tool for developing cultural mindedness is recognizing the Six Barriers to respectful interpersonal and social group interactions (both intra- and intergroup). The Six Barriers include verbal language, nonverbal language, judgment, stress, preconceptions/stereotypes/discrimination, and organization/institutional barriers. Practicing recognition of the Six Barriers entails multilevel thinking because the barriers exist at the personal, interpersonal, and organization-wide levels (Hogan, 2013).
Operationalizing cultural mindedness in terms of three conceptual tools in this way allows for critical multicultural analysis based on the recognition that all systems of beliefs and practices are heterogeneous, are dynamic (in continuous transformation), and are always influenced by organization hierarchies and power relations (Vindrola-Perdros, 2016). Sensitive communication skills foster cultural understanding and practice at the personal and interpersonal levels. Culturally centered communication comprises personal competency behaviors that promote relational capacity for dialogue (Hogan, 2013). The behaviors that underlie the dialogue process can advance cultural understanding and respectful practice because both involve continuous self-reflection of social place in life (positionality) and self-discovery when interacting with others. Work with faculty, staff, students, and others needs to incorporate cultural differences to bridge the cultural gap to achieve mutual understanding and authentic relationships across differences.
The dialogue process is central to cultural understanding and inclusive practice because it is the basis for gaining emic or insider information to combine with etic or outsider information, and for collaborative proactive problem solving, conflict intervention, and action planning for implementing organization-wide cultural understanding and practice. Dialogue is an inherently respectful form of speaking that helps nurses to discover the cultural factors influencing patient behaviors and decisions as well as to assist nurses from imposing their cultural beliefs and values on patients (Hogan, 2013).
During this training, faculty, staff, and administrators discussed strategies for embedding the cultural mindedness and culturally centered communication skills they were learning into SON curriculum, as well as creating a coordinated approach to provide the cultural knowledge and skills content in student peer mentoring.
Cultural work with faculty, administrators, and staff. The cultural diversity and equity training process is adaptable to various time formats based on the needs of the organization. This training was conducted in 30-minute increments twice each semester over 2 years during SON faculty and staff meetings.
The training process was as important as the theoretical content because the goal was to change the SON's organizational culture to one of inclusion of all forms of diversity through the practice of self-reflection and action. For example, the personal experiences of faculty, administrators, and staff provide valuable resources when analyzed in relation to the cultural conceptual tools through dialogue. Using case examples drawn from health care settings, SON faculty, administrators, and staff engaged in dialogue about relevant cultural dynamics presented in the cases and practiced cultural mindedness and culturally centered communication skills through the action of dialogue (Hogan, 2013). This process was empowering because SON faculty, staff, and administrators were actively involved in conceptualizing and directing the culture change of inclusion in the SON.
The interactive cultural knowledge and skills training process combined cognitive and experiential learning activities in a four-step sequence: presentation, demonstration, practice, and debrief (the PDPD training process) (Hogan, 2013). During the first 1.5 years of training, the focus of each presentation included demonstrating the cultural mindedness conceptual tools. Practice and debriefing then were added to the training sessions in the second year in preparation for collaborative action planning by participants. Collaborative action planning based on dialogue was a foundational process for the SON's organizational culture change goal of developing an inclusive culture for all forms of human diversity through developing ground-level-up strategies for change (Bonilla, 2014; Hogan, 2013). Table 2 provides an outline of the cultural knowledge and skills training.
Two-Year Cultural Training Process for Faculty, Staff, and Administrators
Finally, in addition to cultural understanding and skills training, a list of films, documentaries, books, and other references were given to faculty, staff, and administrators that included both emic and etic perspectives on critical diversity dilemmas and issues. The resources promoted understanding of culturally relevant pedagogy, another element of the SON's organization change process, to one of inclusion of diversity (Bailey, 2018; Ladson-Billings, 2014; Paris & Alim, 2014).
This training augmented student support programs, especially in the development of the Peer Mentoring Program, as faculty and staff were sensitized to the importance of student perspectives as key players in the pursuit of a culture of inclusion for the SON. The next step was to address the need for ongoing recruitment, instruction, and support of students to be mentors and mentees, and to embed the entire process into the SON.
Second Strategy: Student Peer Mentoring
The faculty designed a structured pathway to build on and extend student expertise and leadership to sustain an ongoing Nursing Peer Mentoring Program. During new student orientation and throughout the beginning classes in the SON, faculty and staff informed students about the Peer Mentoring Program and provided information on how to obtain a mentor if they wished to participate. In addition, previous mentors and mentees shared information about the program in classes, during meetings, and at informal gatherings.
Initial and Enhanced Student Peer Mentor Role. Student peer mentoring was taken to a new level to allow more student growth in the peer mentor role from one-on-one mentoring to group mentoring and oversight of other mentors and evaluation of the Nursing Peer Mentor Program. Initially, student peer mentors performed a complementary, informal support role to peers that involved sharing mentors' own experiences and knowledge gained from their previous experience with the student role on campus. However, during the past 5 years, a separate class was augmented with support from academic and professional staff. Collaboration between students and faculty augmented student participation and fostered additional student involvement and leadership responsibilities.
The new structured Peer Mentor Program enhanced the student peer mentor role. Peer mentors were able to progress from supervised and semi-supervised work to less closely supervised mentoring assignments as they progressed in their role within the SON Peer Mentor Program. Some highly qualified student mentors (under the supervision of a mentor faculty facilitator) assumed responsibility for supervising other mentors, convened and held mentor support groups, and had the option to become more involved with data analysis of the mentor journals and measures of student outcomes.
Process of Becoming a Mentor in the Enhanced Peer Mentor Structure. Student mentors must complete an application and meet certain criteria to be appointed to and continue in peer mentoring beyond their mentoring course. First, students must be enrolled and successful in their program, with good academic standing. Second, peer mentors must complete an orientation to mentoring and a peer mentoring course during which they demonstrate good listening skills, resourcefulness, and the ability to actively facilitate problem solving by the mentee and maintain confidentiality.
Finally, peer mentors must have ongoing evidence of positive evaluations from mentees and supervising faculty while in that role. Because peer mentoring expertise represents a set of skills and attitudes acquired through training and experience, preparation for and practice of peer mentoring is the core of the Peer Mentor Program. The SON provides training to ensure that peer mentor students are adequately prepared for their responsibilities. Peer mentors undergo education and training on the process of mentoring based on previous work (Latham, Hogan, & Ringl, 2008; Latham, Ringl, & Hogan, 2011, 2013; Latham et al., 2016).
Peer mentors also receive support and guidance to address the unique needs of their mentees. Faculty-sponsored peer support groups and feedback are conducted in class and via a designated website to assure the peer mentors were able to support and encourage their mentee students without adding undue stress to their already complex role as a nursing student. An oversight person, the Mentor Faculty Facilitator, was required to meet with peer mentors prior to each semester to provide a thorough overview of the expectations, examples of the various levels of mentoring work, and the students' role for that semester including evaluation work.
Establishing a Culture of Peer Mentoring. To foster sustainability of peer mentoring and to address student requests for more involvement, a three-tiered peer mentor structure was developed that incorporated many of the student mentor suggestions. The Enhanced Nursing Peer Mentor Program developed three levels of student peer mentors to allow students to have ongoing input into the program and assist with sustainability, including Peer Mentoring Assistant, Associate, and Fellow. An established minimum amount of participation is required for each level, and students do not automatically progress to the next level. In some cases, students may not choose the next level in subsequent semesters due to the increased complexity of work. Table 3 provides a description of each peer mentor level.
New Structure for Student Peer Mentoring Leadership
The new structure has exceptions to the above peer mentor role qualifications that may, in individual cases, be based on criteria such as outstanding mentoring expertise, commensurate work experience, and demonstrated contributions to the Peer Mentor Program. Such exceptions are documented in student appointment to the next level. This model allows students to have ongoing input into mentoring, including providing assistance to evaluation of the outcomes of student input and SON responsiveness to inclusion.
Supervision and Evaluation. To enhance the peer mentoring experience of mentees, all peer mentors are assigned to a Mentor Faculty Facilitator, who provides ongoing supervision of mentoring during the peer mentor appointment. At the outset, the Mentor Faculty Facilitator provides a description of the duties expected of the peer mentor in the upcoming semester that is dependent on the level of the peer mentor responsibilities. The Monthly Mentor Faculty Facilitator holds meetings with the peer mentors to assess mentoring activities.
All peer mentor appointments are forwarded to the SON Student Success Center to be kept on file. Following submission of a student log of hours and activities, the Mentor Faculty Facilitator verifies peer mentor contributions and obtains a mentee evaluation of the mentor. By the end of the semester, additional feedback is provided as a follow-up consultation with the peer mentor during their appointment. All first-time Mentoring Assistants are required to have at least one formative evaluation of their contract by the Mentor Faculty Facilitator. Peer mentors are formally recognized for their performance during recognition forums set up by the SON each year as part of the SON Honors and Awards Program.
The Peer Mentor Program revealed ongoing student challenges. To address these challenges, peer mentors were given opportunities to lend their perspective on how best to handle these complex student issues through Shared Governance meetings with other mentors, faculty, and administrators. By incorporating the student's voice, these meetings enhanced students' skills and educational experience. These meetings allowed students to practice their communication and leadership skills as they discussed challenges faced by students and suggested innovative approaches not only to assist their peers but also to strengthen the climate of support in the SON.
Third Strategy: Student Shared Governance to Optimize the Nursing Educational Environment
The Peer Mentor Program required each mentor to communicate monthly with their mentees and journal about their meetings in a semistructured format (Latham et al., 2016). These journal reflections after the mentor-mentee meetings provided insightful and relevant information about the challenges faced by diverse students (Latham et al., 2016). The journal information was analyzed and presented by students at the end of each semester in Shared Governance meetings that were also attended by select faculty and administrators. These Shared Governance meetings gave the peer mentors an opportunity to share nursing students' experiences and perceptions about the nursing program. To prepare for these meetings, the student peer mentors reviewed journal submissions. Content analysis was used to identify themes, and the mentors added context to the themes as well as sharing their own need for support and guidance to best help mentees and future nursing students.
The Shared Governance meetings became a critical part of the Enhanced Peer Mentor Program. Previous research by the authors supported the value of shared governance to help nurses improve their problem solving skills and teach nurses how to communicate issues and challenges to administration as well as how to create a more sympathetic and understanding culture (Latham et al., 2016). It is important to incorporate caring and cultural sensitivity into the shared governance structure to assure better outcomes for students and ultimately for patients (Akright & Crabtree, 2019; Boswell et al, 2017).
Participation in Shared Governance meetings also has been shown to increase students' level of self-efficacy, decision making, and professionalism (Akright & Crabtree, 2019; Latham et al., 2016; Luescher-Mamashela, 2013). In addition, reflective journaling helped mentors refine their critical thinking and communication skills (Benner, Sutphen, Leonard, & Day, 2010). Most importantly, student participation in Shared Governance meetings with SON administrators gave students a voice and enabled them to improve the educational environment.
Shared Governance meetings used an open communication format that supported the sharing of information and perspectives and also developed understanding and trust (Latham et al., 2016). This is especially important to underrepresented students who may not believe they have a voice (Luescher-Mamashela, 2013).
Cultural Skills Training Outcomes
Training workshops were conducted for SON administrators, faculty, and staff over several academic years. As depicted in Table 1, following the workshops, administrators, faculty, and staff were engaged in the action planning process. During the final module, faculty identified SON diversity issues and created action plans to address student issues to promote inclusive processes, including incidents of student clinical challenges related to racial bias. For example, one case involved an action plan for intervening in the case of a nursing intern in a hospital who was openly criticized by a patient because of her dark skin color. The nursing intern was so offended she told her nursing supervisor that she was considering leaving nursing. Nurse faculty and staff devised an action plan for providing immediate resources and support for nurses and nursing students of color who experience maltreatment by patients.
The training also facilitated the development of structural changes to address inclusion throughout the SON. The SON uses more equitable student admission procedures that consider a student's background. Nursing faculty recently instituted new annual multidisciplinary Diversity Support Team conferences for students and faculty to address student-focused diversity topics and methods for inclusive practice. The Peer Mentoring Program and Shared Governance improvements in the SON were based on students' perspectives and suggested changes.
Peer Mentoring and Shared Governance Outcomes
The mentee themes identified in the journals by mentors, as well as the mentors' perspectives and program concerns, were used in Shared Governance meetings to initiate change, strengthen the climate of support, and improve the quality of the nursing student program experience. Initially, when the SON introduced Peer Mentoring and Shared Governance, social support from other students and friends was found to be very important (Latham et al,. 2011). The anxiety experienced by these students when parents were unable to provide advice or even understand the pressure of college work created significant stress (Boehmer, 2014). Many of these diverse, first-generation college students experience unique challenges that family members are unfamiliar with and not able to address, so oftentimes friends become the major source of social support (Bailey, 2018; Boehmer, 2014).
Stress and Anxiety. Stress and anxiety related to academic performance, school/life/work balance, and financial concerns were a major theme in the shared governance meetings and are ongoing issues with many nursing students. Suggested solutions included pairing prelicensure entry-level nursing students together with senior prelicensure students to address the new students' stress as well as to provide support with clinical experiences, examinations, and competency testing.
The Peer Mentoring Program assisted in devising a new, interactive orientation approach at the beginning of the program that assisted in decreasing students' fear of the unknown. Course requirements including study time and assignment expectations were shared to introduce students to the reality of college work as well as to the resources available to help them. To improve the connection between students and the program, suggestions included expanding the use of social media to provide advice, encouragement, and announcements moderated by different mentors throughout the semester.
Other recommendations to help reduce stress in the skills lab included a mandatory orientation to labs and competency check expectations. Unique stress reduction techniques included new ways to boost student morale and combat burnout, including a midterm focus on time management skills, mindfulness workshops, and the launching of SON energy foods and handouts called “We Care about You” prior to major examinations. The handouts included student packets that contained Kleenex, hand sanitizer, pens and pencils, and a stress ball.
Lifestyle Habits. Another significant theme identified from journals was difficulty maintaining a healthy lifestyle. Sufficient nutrition, exercise, stress management, and sleep are typical concerns for a college population. However, an urgent need to address these issues was identified from the initial input from students (Latham et al., 2016). A new Nurse Coach faculty position was established to institute mindfulness, stress-reduction sessions, and ways to avoid procrastination. Information and classes about healthy lifestyles were added to the Peer Mentor Program and incorporated into new student orientation. The orientation information included program requirements and support resources, especially related to stress reduction and the need for maintaining a healthy diet and exercise regimen.
Another major theme of the Shared Governance meetings was the value and benefits of the Peer Mentoring Program and the need for it to be sustained within the SON. The Peer Mentoring Program helped new students succeed in the nursing program, and mentor and mentee satisfaction with the program was high (Latham et al., 2016). Mentors and mentees documented improvement in academic-personal life balance and reduced stress. They emphasized the value of the nonthreatening peer supportive environment to help them get through their frustrating days and to succeed (Latham et al., 2016).
Mentors also discussed the value of the mentoring program to enhance their resume and the honor of formal recognition as a peer mentor, as well as the sense of fulfillment, satisfaction, and personal growth they experienced as a peer mentor. Other student recommendations addressed more marketing to expand the peer mentoring by making it more visible and prestigious. Changes included providing graduation cords for mentors, and a student-nominated award for the “Latham Award for the MVP: Most Valuable Support Person” was added to the graduation ceremony, named for the faculty member who initiated mentoring in the SON.
Finally, the Peer Mentoring Program and related Shared Governance meetings resulted in student perspectives that were, at times, not what the faculty expected or wanted to hear. However, these perspectives can be extremely enlightening, especially after faculty have had education on multiculturalism, cultural mindedness, and empowering pedagogies that helped them to be more open to the opinions and viewpoints of diverse others.
Conclusion and Implications
There are three important education principles reflected in this organizational culture change research. First, it was discovered that faculty, staff, and administrators wanted to expand their self-awareness, understanding, and skill set of multiculturalism and culturally relevant pedagogies through cultural knowledge and skills training and an action planning process. There were requests for ongoing sessions each year.
Second, SON faculty staff and administrators reported being empowered to initiate change in their teaching methods, and they reported the benefits of continued participation. The Student Peer Mentor and Shared Governance data suggest SON students also were empowered to use their voice to help others through peer mentoring to solve issues and use school and university support resources as needed.
Third, when changes were made as a result of the Shared Governance program, students, staff, and faculty became more accountable and engaged because they could see the tangible benefits resulting from the ideas and suggestions that students shared and discussed that were then promoted and implemented by faculty (Akright & Crabtree, 2019; Bailey, 2018; Hyatt & Mullins, 2019). When students share their views in an environment that respects student diversity and different cultural and generational perspectives, the goal of transforming the nursing educational experience to one of inclusion is feasible.
Other nursing programs could increase involvement with ongoing cultural diversity and equity training, with the expectation that it will lead to changes in teaching methodologies as well as in policies and procedures, such as support services and admission policies. Future work then could be considered with clinical partners who may benefit from more transparency in employee relations and employee-student relations. Faculty with expertise in cultural diversity and equity training could assist clinical partners, along with metrics to measure the change in the support culture (Latham et al., 2008).