The profession of nursing is at the vanguard of transforming health care in the 21st century (Institute of Medicine, 2010). The population of the United States continues to grow, reflecting an increasing diversity of racial, ethnic, and cultural minority groups, as well as an aging population (United States Population, 2019). These emergent shifts in population patterns, together with an increase in health care spending, are impacting the health care workforce. The United States will face a serious shortage of primary care providers in the near future, which will increase existing disparities in access to primary care services for minority communities (Health Resources and Services Administration, 2013). These demographic and health care workforce changes call for a reassessment of how minority populations and individuals from disadvantaged backgrounds are able to access and receive quality health care.
A more diverse pool of health care providers has been associated with increased patient satisfaction, improved access to care for racial and ethnic minorities, and better patient-clinician communication (Health Resources and Services Administration, 2013). However, the current advanced practice RN (APRN) workforce does not reflect the growing diversity of the U.S. population. The majority of nurses in practice, particularly those with graduate degrees, are White non-Hispanic women. According to a national survey by the American Association of Nurse Practitioners (2018), only 5.4% of master's-prepared nurses are African American/Black, 4.3% are Hispanic, 4.2% are Asian, and 2.0% are from other non-Hispanic minority groups; these numbers are disproportionately lower than the numbers of minorities in these groups.
Although the development of a more diverse APRN workforce is vital to meet the growing health care needs and to address the health and health care disparities facing minority communities in the United States, there are significant barriers to nurturing an APRN workforce that represents the diversity of the nation. The lack of diverse nursing faculty can impact a nursing school's ability to create a welcoming environment and mentorship program that can attract and retain a diverse nursing student body (National League for Nursing, 2015). Another barrier is access to graduate education; in 2018, among the 64,400 qualified applicants denied admission across all levels of nursing education, 15% were at the master's level (American Association of Colleges of Nursing, 2019). Thus, applicants from disadvantaged backgrounds may find their choices are limited due to increased competition in the admissions process. A third barrier and one of the most challenging is the cost of higher education and subsequent earning potential (Loftin et al., 2012). Nurses from minority groups tend to have lower levels of education and lower earnings compared with White nurses (Carnevale et al., 2017).
This article describes and evaluates the implementation of the Scholarship for Disadvantaged Students (SDS) program, which provides disadvantaged nurse practitioner students with financial support and individualized mentoring throughout their course of study. The SDS program assists students in overcoming potential barriers to successful completion of their degrees and to participate in the workforce as nurse practitioners. The program aims to increase: 1) the number of master's-prepared nursing graduates in Family Practice and Adult Gerontology primary care, 2) enrollment and retention of full-time, master's-level, economically disadvantaged students who are members of racial and ethnic minority groups and/or male, and 3) the number of master's-level graduates working in medically underserved communities.
Implementation of the SDS program began in the summer of 2016. The University of Miami School of Nursing and Health Studies website posted information regarding master's program enrollment opportunities for students from disadvantaged backgrounds. The project director and the assistant dean for student services conducted an open house with an orientation and advising session for potential students prior to the program application deadline. Detailed, in-depth information about the school's MSN programs was provided, and attendees were given the opportunity to meet with faculty members, ask questions, and interact with current students.
To apply to the MSN program, prospective students were required to have a BSN degree from an accredited institution with a 3.0 grade point average. Applicant files were reviewed by a Scholarship Committee composed of the SDS program director, an MSN faculty member, and the directors of the Family Nurse Practitioner and Adult Gerontology Primary Nurse Practitioner tracks. SDS awardees were required to be full-time students of minority or disadvantaged backgrounds with a financial need, for whom the cost of attendance would constitute a severe financial hardship. Disadvantaged background was defined by the following criteria: 1) first-generation college student, 2) percentage of free/reduced lunch at high school attended, 3) high school graduation rate, 4) high school average Scholastic Aptitude Test (SAT) score, 5) high school average American College Testing (ACT) score, and 6) county median income. After determining whether applicants met at least one of these criteria, the committee ascertained whether students had a financial need of at least $30,000. Students selected for the SDS program received a $30,000 scholarship, which covered two thirds of the total tuition cost for the 1-year MSN program.
A key component of the SDS was its mentorship program. At the beginning of their first semester, students were matched with one of four faculty mentors; two of the mentors were African American, two were Hispanic, and three had previously participated in other scholarship programs. After students had been selected for the SDS program, they met as a group with the four faculty mentors and learned more about each other's interests. Students were permitted to rank their top three desired mentors. The program director and mentors then met to match students and mentors based on students' preferences and unique mentoring needs, including academic and clinical interests; most students were matched with their first or second choice.
The program director also met with the mentors to orient them to the program and to discuss the warning signs that students might be struggling academically or emotionally. Mentors were provided with resources to refer students to support services on campus and in the community. They also learned how to advocate for their mentees; for example, a mentor might intervene and talk with a professor if a student needed more time to complete an assignment.
Each mentor-student dyad met at least twice monthly during the first semester and at least once monthly during the second and third semesters. Students were encouraged to discuss any challenges they faced in the program, and additional meetings were scheduled at the student's request or if the mentor thought the student needed additional guidance or support. Importantly, minority faculty mentors served as role models who came from communities similar to those of the students. They talked with their mentees about professional goals, helped them apply for nurse practitioner positions or to graduate programs, and served as a personal and professional reference. This structured, intensive, year-long mentoring experience was unique to the SDS program and was not provided to students who were not in the SDS program.
An initial meeting was organized during which SDS students met with their mentors as a group. The expectations, benefits, and responsibilities of both mentors and students were discussed, as well as potential challenges to the mentor-mentee relationship, such as difficulty scheduling meetings, issues with communication, or dissatisfaction with the relationship. Examples of how mentors and students could address these issues were provided, such as scheduling a meeting early on to discuss any emerging concerns or requesting a confidential meeting with the project director.
Continual communication between the project director and MSN program faculty ensured that SDS students who were struggling academically would be brought to the project director's attention. For example, SDS students who failed to turn in an assignment, did not participate in class, or performed poorly on an exam were asked to meet with the MSN program director and faculty mentor to strategize an intervention. This could include academic tutoring by the faculty mentor, another faculty member, an instructor, or a senior student. Program directors remained especially vigilant to SDS students' needs and were prepared to intervene and assist them at any time. These supports helped identify and address barriers to success in the program, and ensured that SDS students were able to graduate and move on to careers in primary care or medically underserved areas, geographic areas not adequately served by available primary health care resources.
The process of evaluating the SDS program was approved by the Institutional Review Board. The SDS program was evaluated through implementation of a rapid cycle quality improvement strategy from the beginning of the program up to 1 year after each awardee's graduation. Every 3 months, the project director assessed Typhon data records to verify proper documentation of students' clinical placements and mentors' activities; these formative evaluations provided information on student progress and feedback regarding the degree to which the SDS program was meeting its goals. At the end of each semester, students and their mentors completed an evaluation form that was used by the project director to improve program delivery.
Program effectiveness was evaluated 1 year after graduation. Data evaluated included the percentage of awardees who 1) had passed a national certification board examination (either the American Nurses Credentialing Center or the American Association of Nurse Practitioners), 2) reported employment or postgraduate education, and 3) worked in a primary care setting, with underserved populations, or both.
A total of 45 students received an SDS during 2 consecutive years (2016–2017 and 2017–2018). Of these, 38 students were admitted to the Family Nurse Practitioner track and 7 were admitted to the Adult Gerontology track. The awardees were selected from 68 applicants (66% acceptance rate). The students' self-identified racial distribution was 58% White (n = 26), 24% Black (n = 11), 7% Asian-American (n = 3), 1% American Indian (n = 1), and 4% other (n = 2). In addition, 58% (n = 26) identified as Hispanic. Eighteen percent (n = 8) were male, and 49% (n = 22) were first-generation college students. The mean financial need was $47,659.36 based on their Free Application for Federal Student Aid.
SDS students completed at least 60% of their clinical hours providing care to patients from underserved populations. Nineteen (42%) students participated in international missions to provide care to underserved or rural communities in Latin America and the Caribbean, including Haiti and the Dominican Republic. Forty-two of the 45 SDS students (93%) successfully completed all required program components, including meetings with faculty mentors, without any delay or change in their plan of study. Of the three students who did not complete the program, one student did not pass two courses and was dismissed after the first semester, one student left the program due to illness, and one student transferred to a part-time program at the school.
SDS awardees who completed the program reported a 100% pass rate in their first attempt taking the certification board examination. One year after graduation, six awardees reported enrollment in or completion of additional graduate school education: two in a doctor of nursing practice program, two in a postmaster's certificate in psychiatric mental health nursing, one in a postmaster's certificate in an emergency nurse practitioner program, and one in a postmaster's certificate in a neonatal nurse practitioner program.
One year after graduation, 43 of 45 (96%) awardees reported working as APRNs (of the remaining two, one was unemployed and one could not be reached). Specifically, 19 (42%) were working in primary care settings, of which nine (20%) were medically underserved areas. Six (13%) were employed by federally qualified health centers, and nine (20%) were employed in critical access hospitals. Eight (18%) were employed in academic institutions, and one reported working part-time as a clinical faculty in an academic institution. Two (4%) reported serving in settings providing substance use disorder treatment.
This article describes a scholarship and mentoring program that helped 45 minority or disadvantaged MSN students from diverse backgrounds complete their graduate programs and achieve professional success after graduation (e.g., APRN board certification, employment as nurse practitioners, additional graduate work, or professional certifications). These outcomes confirm the importance of scholarships for academically qualified students from disadvantaged backgrounds who demonstrate financial need. Without assistance, these students might not have been able to attend a graduate nursing program or may have had to work during their course of study, potentially compromising their academic performance. The successful entry of these new nurse practitioners into the field represents a vital contribution because a diverse and inclusive health care force must reflect the changing demographics of the U.S. population (DeWitty, 2019; DeWitty et al., 2016).
One of the central goals of the scholarship was to foster educational experiences that would encourage graduates to pursue careers at medically underserved areas and with other underserved populations. For this reason, SDS students were preferentially matched with clinical sites providing care to underserved populations. In addition, the substantial percentage of students (40%) who participated in international mission trips merits special attention. Previous research has indicated that study-abroad experience enhances student awareness of the global community and helps develop their perspective on future practice (Ortega et al., 2016). International experience also contributes to readiness to work with underserved populations and in settings with limited resources.
This SDS program can serve as a model of an effective program that assisted two cohorts of nurse practitioner students from disadvantaged backgrounds in completing their degrees and preparing them for professional success postgraduation. The key elements of this program (i.e., scholarships, mentoring, and clinical placement in primary care or underserved areas) may be applied to support additional students in obtaining a graduate nursing education and in preparing them to contribute as part of the health care workforce, especially in medically underserved areas and in service to health disparity populations.
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