The demand for RNs in the United States is projected to grow by 15% by 2026 (U.S. Department of Labor, Bureau of Labor Statistics, 2019). This is a large and accelerated rate of growth compared with other professions. During the same period, heightened attention on preventative medicine and the demand for services brought about by an expanding aging population will impel an anticipated 31% increase in the need for advanced practice RNs (i.e., nurse practitioners [NPs]). The primary contributing factors are an aging nursing force, the shortage of qualified nursing faculty for schools of nursing, and the country's changing demographics (American Association of Colleges of Nursing, 2017).
In 2011, the Institute of Medicine issued a report titled The Future of Nursing: Leading Change, Advancing Health that offered several recommendations to address the nation's health care crisis. Recommendation four in this report specifically identified the need to increase the percentage of nurses with a baccalaureate degree to 80% by 2020. In addition, the report called for the diversification of the nursing workforce, which has been noted as an area that continues to be deficient (Stringer, 2019). According to a report by the National Academies of Sciences, Engineering, and Medicine (2016), there was roughly the same number of baccalaureate-prepared nurses practicing as nurses with associate degree licensures.
The Texas Department of State Health Services (2016) reported that of the 224,780 RNs who were practicing, only 14.8% were Hispanic and 42.5% held less than a bachelor's degree. Equally concerning is that by 2030, the state is projected to face a deficit of 59,970 RNs and 20,227 NPs. Comparatively, Hispanics are the largest underrepresented race or ethnicity, accounting for an estimated 18.3% of the U.S. population (U.S. Census Bureau, 2019b) and 39.6% of the population in Texas (U.S. Census Bureau, 2019a). The professional nursing workforce rarely resembles the patients it serves. As a result, schools of nursing must ask themselves what more can be done to graduate the diverse students they enroll to address this discrepancy.
The case study focus is a Texas school of nursing designated as a Hispanic Serving Institution. The majority of the students enrolled in the school of nursing identify as Latinx, and the institution has become one of the largest programs to prepare Hispanic nurses in the state. Table 1 provides the fall 2018 undergraduate enrollment of the school. In 2013, the school began to see a decline in the first-time pass rates on the NCLEX-RN® examination. By 2015, the school was facing the threat of probation, with graduates posting 2 consecutive years of pass rates below 80%. To combat this decline, the school immediately began studying how students were transitioning into the school's undergraduate curricula, implemented new instructional methods that included predictive examinations to identify gaps in student learning, and created a student success center to support its diverse learners academically.
Undergraduate Demographics for Fall 2018 (N = 543)
In September 2014, the school hired a director of academic enhancement who was tasked to work with the school's student dean to develop a comprehensive center that would provide support resources designed to address academic skills deficiencies identified by the students and the faculty. The School's Committee on Faculty and Student Matters was selected to serve as a faculty advisory board to help guide and implement selected support interventions. In spring 2015, the student success center leadership received approval from the University of Texas Health Science Center at San Antonio Institutional Review Board (Protocol Number: HSC20150105E) to engage in human subjects research and began a modified Delphi study that used focus group interviews to determine the barriers faced by diverse students enrolled in the undergraduate programs. This study was a replication of a study entitled, Using Data to Increase Student Success: A Focus on Diagnosis (Gonzalez, 2009). The demographics of the participants (Table 2) were representative of the enrollment in the school at the time.
Demographics of the Student Success Study Participants, 2015
After analyzing participants' responses, five themes emerged:
- Students thought improvements needed to be made to faculty instruction and in-course decisions.
- Students thought there was too much variation in the clinical experiences provided by the school.
- Students perceived there were inadequate support resources.
- Students perceived an inherent anxiety that was exacerbated by the curriculum.
- Students indicated there was an imbalance between the expectations of the school and the available time students had to complete assignments.
Further analysis of these data coupled with member checking of the themes that were identified by the researchers led to the analysis that specific interventions could be created to address student needs and positively influence the anxiety and frustrations that were voiced throughout the study. Interventions were researched through an extensive review of the literature, and narrowly tailored interventions were selected by the Student Success Center leadership and a grant writing team to address perceived barriers.
The student success center had started to develop specific interventions to enhance the student experience even before the study was concluded. The staff began seeking extramural funding to support its efforts and was awarded a U.S. Department of Education Title V grant in the fall of 2015. These funds provided the resources necessary to offer peer mentoring, supplemental instruction, personal tutoring, an undergraduate research program, and academic coaching.
With the rigors and demands of nursing education, there is a great need for personal and academic support through peer mentoring. New students in health professions are full of questions and face new challenges for the first time; they are in great need for peer support at the beginning of their academic career. Many postsecondary institutions offer peer mentoring programs for entering freshmen or first-year students to help them acclimate to the college's academic and social life (Dorsey & Baker, 2004).
Peer mentoring at the designated school of nursing is a 16-week program formatted to have second-semester students assigned to first-semester students to educate them on campus resources, academics, and co-curricular activities. Peer mentors are selected in a competitive application and interview process, and play an active role during new student orientation and throughout the first-semester transition into a professional nursing environment. Each mentor is assigned a learning community of 10 to 13 nursing students enrolled in a similar clinical course, and the selected mentors often reflect the overall demographics of the school.
The peer mentors play a critical role in new student orientation as they are trained and tasked to stimulate conversation and enhance engagement opportunities such as academic integrity case studies, group discussions, and ice breakers. Subsequently, peer mentors meet with their mentees on a continual basis and provide small and large engagement events throughout the first semester. For their efforts, mentors are paid a modest $200 stipend to compensate them for their time investment.
Students often have immediate issues that are more non-cognitive in nature or focus on the student's future. Academic coaching can be a critical intervention as students transition into college by offering strategies for increased academic success and campus engagement (Robinson & Gahagan, 2010). Academic success coaching offered by non-nurse study skills experts in the school of nursing address students' noncognitive skills that may impede positive student learning outcomes. Academic coaches use an early alert system (Starfish) to identify students who may be at-risk of failure in nursing courses. Coaches intervene early by scheduling an initial assessment, the Learning and Study Strategies Inventory, which identifies study skills that may be risk factors for academic success. Individual coaching sessions address time management, testing strategies, test anxiety, reading comprehension, and critical thinking skills.
Coaches meet with students one-on-one to create customized success plans, providing the skill enhancement and strategies necessary to be a successful nursing student.
Undergraduate research experiences have been shown to increase undergraduate success, improve preparation of the next generation of scientists, and increase the enrollment and retention of underrepresented minorities in graduate education (Graham et al., 2013; Kuh et al., 2010; Pascarella & Terenzini, 2005; Woodin et al., 2010). The Summer Undergraduate Nursing Research Immersion Experience (SUNRISE) program was developed in the school of nursing to provide opportunities for eligible underrepresented and underserved nursing students to participate in a semi-structured summer research experience. First-year undergraduate nursing students enrolled full-time in the bachelor of science in nursing program were eligible to participate in SUNRISE.
Using the knowledge integration framework developed by Linn et al. (2013), the goals of SUNRISE are to: 1) develop skills to conduct research from the origination of ideas to analysis and reflection of study results, 2) expand knowledge of the phenomena of interest, 3) understand the nature of science, and 4) develop an identity as a nurse scientist and nurse researcher. Using a mentor-based approach, scholars are provided research training that is often lacking in nursing programs.
Peer-to-peer learning is an important aspect of nursing education due to its positive effect on confidence and competence, while also decreasing anxiety among nursing students (Stone et al., 2013). Numerous studies have reported nursing students have made positive strides in various areas including problem solving, communication, critical thinking, and motor skills with peer learning (Daley et al., 2008; Horne et al., 2007; Tiwari et al., 2006). In addition, researchers have shown that a peer-based learning approach has a positive effect on confidence levels among students when tasked to problem solve or critically think when completing clinical skills (Broscious & Saunders, 2001; Daley et al., 2008; Horne et al., 2007; Loke & Chow, 2007).
The supplemental instruction (SI) program is a nationally regarded academic support program largely due to its unique design of peer-to-peer teaching and learning (Widmar, 1994). Almost 50 years later, the SI model continues to impact student success as it provides regularly scheduled, peer-facilitated, voluntary study sessions for all students in difficult courses (Hurley et al., 2006).
The SI program implemented in the school of nursing is an academic support program that provides weekly peer-facilitated study sessions. SI sessions are regularly scheduled, informal content review sessions in which nursing students compare notes, discuss readings, develop organizational tools, and predict questions. Students learn how to integrate nursing course content and study strategies while working in a collaborative environment. The sessions are facilitated by upper-level nursing students who have previously taken and mastered the course, meet with the professor from the course, review lecture notes, and model professional behavior in and out of the classroom. The SI leader selection process includes an application, resume, faculty recommendation form, and an interactive interview process. Each year, approximately 25 SI leaders support identified high-risk nursing courses including pathophysiology, pharmacology, and medical-surgical.
Researchers have long found one-to-one peer tutoring to be beneficial for all students. Loke and Chow (2007) reported that some of the positive aspects of peer tutoring included enhancement of learning skills, intellectual gains, and personal growth for nursing students. Furthermore, they found that peer tutoring brought a deeper understanding of content and the ability to organize, clarify, and apply knowledge.
Personal tutoring in the school of nursing is provided by peers in individual or small-group settings during flexible hours to support clinical course schedules. Tutors assist nursing students in improving subject knowledge, while developing academic skills and strategies to apply during high-stakes nursing examinations. Tutors are upper-division nursing students who meet academic and interpersonal skills criteria. The selection process includes an application, faculty recommendation, interview, and a 1-day training program. Annually, approximately 25 tutors are hired to support high-risk nursing courses or courses not being supported, such as Pediatrics and Psychiatric Mental Health.
Soon after implementing these narrowly tailored interventions, the school of nursing observed an immediate and positive impact on student performance. After delivery of these support resources, the first-time NCLEX-RN pass rate improved by 9.65%. Particularly interesting to the researchers was the unanticipated positive influence on all enrolled students. Although initial interventions were designed with vulnerable and under-represented students in mind, NCLEX-RN results increased for the total population. From the first year of the center to the most recent certified data on graduate performance on the examination, the pass rate has improved by 19.31% (Table 3).
NCLEX-RN® Pass Rates 2014–2018
As the nursing workforce ages and the demographics of our country continue to change, schools of nursing must keep in mind the diverse support needs of the students they serve. Specific interventions and high-impact practices designed to address the skills deficiencies faced by vulnerable student populations have been proven to enhance learning and increase degree attainment (Gonzalez, 2009; Kuh et al., 2010). Through careful monitoring of student satisfaction surveys, focus groups, graduation rates, and NCLEX-RN pass rates, schools of nursing can positively shape the nursing workforce to ensure the health care providers of tomorrow more accurately represent the patients they serve.
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Undergraduate Demographics for Fall 2018 (N = 543)
| African American||28||5.2|
Demographics of the Student Success Study Participants, 2015
|Cohort||n||Average Age, y||Female||Male||Racially/Ethnically Underrepresented||First-Generation Student||Mean GPA|
NCLEX-RN® Pass Rates 2014–2018
|Year||School of Nursing||State||National|