Appendix J

Educating a Diverse Workforce Minority Students: Recruitment, Retention & Graduation

Janet S. Rami, Ph.D., R.N.
Dean School of Nursing
Southern University And A&M College-Baton Rouge
Baton Rouge, Louisiana

Introduction

Southern University School of Nursing (SUSON) was established in 1986 in a Historically Black College University (HBCU). Southern University and A&M College at Baton Rouge (SUBR) was an open admissions institution until the year 2000 and therefore the only requirement for admission to the university was a high school diploma. In establishing the BSN program at SUBR, it was clear that potential students could represent disadvantaged backgrounds. In addition, the university had no prior history of education of health professionals.

The founding nurse faculty viewed the situation as a unique opportunity to develop a nursing education program to educate at risk students and produce potentially successful African American, baccalaureate prepared registered nurses. This early faculty group was aware of the national data on lack of success of students from disadvantaged backgrounds in nursing education but believed that if majority students could succeed in nursing then minority students could do the same. SUSON's story is about how we designed a program to validate our thesis, which is best, expressed through a statement by Harry Wong.

Our Thesis

"The greatest effect on student achievement is not race, not poverty­it is the effectiveness of the teacher and the learning environment."

Retention And Graduation

The retention and graduation strategies used by SUSON are designed to speak to goals of national health agendas. The National Advisory Council on Nurse Education and Practice (NACNEP) recommends increasing the racial/ethnic diversity of the nurse workforce as an essential step in addressing the shortage. This group recommends a national effort between government, public and private sectors and educational institutions as a necessary measure to ensure an appropriate nurse workforce for the nation. Recommendations presented by NACNEP to enhance efforts to increase the recruitment, retention, and graduation of minority students are:

• Increase minority students' and their advisors/counselors' understanding of the academic requirements necessary to facilitate access to a professional nursing program.
• Increase the overall number and percentage of baccalaureate- prepared minority nurses in the basic nurse workforce. At least two-thirds should hold baccalaureates or higher degrees by the year 2010.

The American Association of Colleges of Nursing (AACN) suggests that nursing students of today do not "mirror the nation's population". According to AACN, baccalaureate-nursing students are 91% female, and 73.5% represent non-minority backgrounds. In comparison the nations population is 51% female and 33% represent minority groups. Healthy People 2010 addresses nursing workforce issues in its 2000 companion document, The Key Ingredient of the National Prevention Agenda: Workforce Development. This document suggest that the health workforce is the "heart" of the national public health system that provides for the health of individuals, families, and communities. Objective 1-8 of this workforce document states, "increase the proportion of all degrees awarded to members of under-represented racial and ethnic groups in the health professions, allied and associated health profession fields, and the nursing field". Healthy People 2010 also provides a set of belief statements to support its objective 1-8. They suggest that communities care about this objective because:

• Minority Americans working in health care can help end disparities in health status.
• A diverse health workforce is important in assuring the delivery of culturally competent health care and preventive services.
• Minority health professionals can serve as role models in our diverse communities.
• Minorities are an increasing proportion of the U.S. population.
• Minority Americans are five times more likely to treat other under-represented minorities in underserved areas

Healthy People 2010 strategies to increase minority representation in the health professions include the following:

• Promote health professions in high schools with high minority populations.
• Establish local programs to prepare undergraduate minority students for admission to and success in health professions schools.
• Provide internships and field experiences for under-represented minority students to gain exposure to health professions and practice settings.
• Offer students preparatory programs to increase minority admissions to health professions schools.

Background

Southern University and A&M College, established in 1880 under a constitutional mandate to educate "persons of color", currently has a multi-cultural student and faculty population of nearly 10,000 and 450, respectively. The students, faculty, and staff of SUBR support nine colleges/schools which grant 66 undergraduate and 25 graduate degrees, including doctoral degrees in Special Education, Public Policy, Environmental Toxicology, Science Mathematics, and Nursing.

Southern University School of Nursing (SUSON) was granted initial approval by the Louisiana State Board of Nursing in 1985 and admitted the first baccalaureate level students to upper division courses in the fall of 1986. The School of Nursing currently offers three degrees: the bachelor of science in nursing (BSN), the master of science in nursing with a specialty in family health nursing (MSN) and role options as administrator, educator or family nurse practitioner, and the doctor of philosophy with a major in nursing (PhD). The school houses two academic departments (graduate and undergraduate), the Office of Nursing Research, The Learning Resource Center, and The Nurse Managed Clinics. The school has four funded Endowed Professorships through The Baton Rouge Area Foundation, The Louisiana Board of Regents and three area health care agencies (Our Lady of the Lake, Woman¹s¹ Hospital, and The Baton Rouge General). The BSN and MSN programs are approved by the Louisiana State Board of Nursing, and accredited by the National League for Nursing Accrediting Commission (NLNAC), and the Commission on Collegiate Nursing Education (CCNE).

The Setting: Louisiana Perspective

In Health Care State Rankings for 2000, Louisiana ranked 49th, second worst in the nation in health indicators. According to this report, Louisiana ranked 1st in the nation in diabetes death rate (38.7 deaths per 100,000 population) and 2nd in the percent of births by cesarean section (25.4% of live births). Louisiana¹s performance related to prenatal care is dismal, with Louisiana ranking 1st in the percentage of low birth weight babies (10.1% of live births), 6th in the rate of neonatal deaths (6.2 neonatal deaths per 1,000 live births), and 5th in the rate of infant mortality (9.1 infant deaths per 1,000 live births). A major explanation for Louisiana¹s poor health status is the lack of access to routine and preventive health care.

As of January 2001, the US Bureau of Health Care Delivery and Assistance recognizes 66 primary care shortage areas in Louisiana (each of the 64 parishes has a shortage designation): 26 geographic areas, 20 population groups, 14 sub-areas, and 6 facilities. Of the 26 whole-parish designations, 24 are non-metropolitan parishes. In lieu of primary care practitioners, many people seek care at hospital emergency rooms. In 1998 Louisiana ranked 15th highest nationally in the number of emergency outpatient visits to community hospitals. The Louisiana State Department of Public Health makes the following recommendation to solve its poor health ranking.

"Louisiana must continue aggressively to attack the health professional shortage problem to meet the existing health needs of its residents. Lack of access to appropriate care in their communities is resulting in many ill persons becoming patients at state hospitals".

Decline in Louisiana Nurse Grads

Louisiana Nursing Supply and Demand Commission's, 2002 Annual Report provides eleven recommendations to address the Louisiana Nursing shortage including recommendations to "Enhance the image of health care careers" and " Develop a recruitment plan for screening an adequate number of future health care professionals". A third recommendation was to develop partnerships to assist in the cost of educating health professionals. Louisiana State Nurses Association in a March 2002 Report documented the decline in the number of new RN graduates from Louisiana schools. The following Table 1shows that the decline in RN graduates for Louisiana was more dramatic between 2000 and 2001 than in previous years. This could indicate that the RN workforce shortage is just beginning in Louisiana. The Louisiana Board of Regents provides data on number of BSN graduates by University, and shows that the decline in graduates was more dramatic in HBCUs than in majority schools. Table 2 shows that the African American population of Louisiana represents about 30% and according to the Louisiana Board of Nursing, African Americans represented 12.3 % of RNs in Louisiana in 2001.

Table 1: Decline in New Nurse Grads in Louisiana

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Table 2: RN Population in LA

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SUSON's Diversity Profile 2002

SUBR enrollment in undergraduate courses in 2001 consisted of 85% Louisiana residents and 34% were residents of East Baton Rouge Parish in Louisiana. Of the 796 lower-division and upper-division nursing students enrolled at SUBR in 1999-2000, 511 were from disadvantaged backgrounds and of these 308 were from economically disadvantaged backgrounds. Tables 3, 4, and 5 profile the SUSON student and show the ACT scores for BSN students compared to state and national means. More than 80% of those currently enrolled in upper division nursing courses are from environmentally or financially disadvantaged backgrounds.

Table 3: Profile of Graduates BSN 1988-2002

Table 4: Profile of Admits

Table 5: Mean ACT & GPA Scores

SUSON's Outcomes

Two key outcomes are used by SUSON to evaluate effectiveness in addressing minority student retention and graduation. These include 1) Are you graduating sufficient numbers? and 2) Are graduates successful on NCLEX-RN? Tables 6 and 7 show that SUSON has graduated the expected number of graduates compared to total RN graduates in Louisiana even when 80% of our student population represents disadvantaged backgrounds. In 1999, for example the 13 schools in Louisiana graduating BSN students produced 995 grads. SUSON would be expected under normal circumstances to produce 1/13 of the total or 77 graduates. During 1999 SUSON actually produced 80 graduates, exceeding the expected number. Since 1986 there has been a 164% increase in African American RNs in Louisiana from 1,771 to 4, 687. During the last decade SUSON could be the largest producer of African American BSN RNs in the nation. Table 7 shows the NCLEX-RN pass rates for SUSON first time writers. The NCLEX-RN pass rates for SUSON grads has been above the national average for 11 of the last 13 years even when 80% of our grads represent disadvantaged backgrounds.

Table 6: SUSON and RN Population in LA

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Table 7: SUSON NCLEX­RN Pass Rates for First Time Writers

Our Success Strategies

The success of SUSON's educational enterprise is based on four major factors, the curriculum, the faculty, the students, and the environment in which they interact. We strive for a curriculum that is logically organized, internally consistent and appropriate to the science of nursing and liberal arts education. The curriculum includes Essential Content as described by AACN.

Success of students from disadvantaged backgrounds requires competent teachers. Faculty retreats, consultants and development activities are utilized to enhance teacher effectiveness and for team building. SUSON faculty adhere to the major concepts presented by Harry K. Wong, which follows:.

• The three characteristics of an effective teacher are: 1) has good classroom management skills, 2) teaches for mastery, 3) has positive expectations for student success.
• Expectations of your students will greatly influence their achievement in your class and in their lives.
• Treat students as though they already are what they can be, and you help them to be capable of becoming what they will be.
• Use criterion-referenced tests to evaluate the performance of the students.
• Mastery learning plus tutorial instruction results in higher achievement than students taught in a conventional manner.

SUSON's student selection process is based on continuous evaluation of success variables of our graduates and findings from research on minority student success in higher education. The goal of the admissions process is to eliminate barriers and focus on raduation and entry into practice rather than retention alone. SUSON's Admission Criteria (BSN) includes completion of pre-requisite courses with at least C grades, have ACT scores on file, and have a CUM GPA of at least 2.60. The following principles guide our admissions process.

• ACT and SAT scores are not best predictors for minority students
• Selection using multiple variables more predictive than a single variable process
• Elimination based on single variable should be avoided
• Prior success is best predictor of future success

The evaluation of our student selection process shows that ACT scores for our graduates are not significantly related to success on NCLEX-RN. ACT composite scores for SUSON graduates range from 08 to 30 with a mean of 17. SUSON's data on ACT scores and NCLEX-RN is unique in that the opened admissions process of the university allowed for students to enter with low scores. The result is a wide range of ACT scores included in the correlation procedure. Table 8 shows the results of the correlation procedure and a probability of greater than .05.

Table 8: Correlations Between NCLEX­RN Success & ACT for SUSON Minority BSN Grads

SUSON strives for an educational environment that is caring. The school's philosophy and conceptual framework focus on assisting individuals to maximize their potential and is guided by theoretical frameworks including Orem's Self-care Deficit Theory, Caring as described by Watson, and Family Theory. The concept of caring for example helps to develop graduates who are critical thinkers and decision makers, have self-understanding, personal awareness, and appreciation of various cultures and environments. This type environment requires commitment from administrators, faculty, students and staff. Resources that support assessment, tutorials, testing and re-testing, mentoring, and faculty development are critical to a successful environment. Student financial support and appropriate technology are essential. Success with students from disadvantaged backgrounds is resource intensive and external funding is a major component of SUSON's success. Our funding sources include Division of Nursing (DN), Bureau of Health Professions (BHPr), Health Resources and Services Administration (HRSA), Department of Health and Human Services (DHHS) under Southern University Retention Efforts in Nursing (5 D19 NU40048-02) 1990 to 1995; Scholarships for Disadvantaged Students (SDS) 1995-present; Nursing Capitation Grant Program-Louisiana Department of Health and Hospitals; and currently the university.

The educational environment that supports students from disadvantaged backgrounds includes a strong evaluation program. Retention rates are examined at mid-semester, and at the end of the course for all nursing courses. Sound test development strategies are utilized including a review panel, and item analysis. Evaluation results are communicated and examined, and program changes are supported by empirical data.

Summary

The educational enterprise developed by SUSON for students from disadvantaged backgrounds graduated its first class in 1988 and by the end of 2003 produced over 800 BSN graduates. The NCLEX-RN pass rates for SUSON grads has been above the national average for 11 of the last 13 years even when 80% of our grads represent disadvantaged backgrounds. Employers rated SUSON graduates above average on all eight graduate outcomes. Since 1986 there has been a 164% increase in African American RNs in Louisiana from 1,771 to 4, 687. During the last decade SUSON could be the largest producer of African American BSN RNs in the nation.

SUSON's success with students from disadvantaged backgrounds is due to, first elimination of barriers to admission, especially the ACT score. The most important factor in our success we believe is effective teaching. SUSON faculty teach for mastery and have positive expectations for student success. An environment that is supportive and an evaluation program that highlights success and examines failures is a significant component in our success story. SUSON's future success with students from disadvantaged backgrounds is dependent on our ability to secure external funding for the retention program. The rewards include faculty satisfaction, confidence of minority students, positive recruitment, and a positive image within community. SUSON's ultimate contribution is its positive impact on increasing the overall number and percentage of baccalaureate- prepared minority nurses in the state and national workforce.

References

National Advisory Council on Nurse Education and Practice (2001) A National Agenda for Nursing Workforce Racial/Ethnic Diversity: Executive Summary.

Moore, W. E., Rami, J. S., & Robinson, J. B. (1991). An immersion model for skills enhancement at historically black colleges and universities. The National Alliance of Black School Educators, Inc.

Rami, J. S. (2002). The Enterprise that Dillard University Graduates Built. The ABNF Journal, 13(4), 84-85.

Rami, J. S., Brown, S. (1999). Making Health Care Accessible: A Framework for Medically Underserved Rural and Inner-City Populations. Harvard Journal of African American Public Policy, Volume V, 33-44.

Rami, J. (1997). Successful recruitment and retention programs: The Southern University School of Nursing Story. Proceedings of Nurse Leadership 97 Invitational Congress. Caring for the Emerging Majority: A Blueprint in Action. (79-80). U.S. Department of Health & Human Services, Health Resources & Services Administration, Bureau of Health Professions, Division of Nursing.

Rami, J. S. & Hansberry, A. H. (1994). Educating minority students for the health professions: Taking a "quantum leap" to meet the challenge. Education, 115 (1), 80-86.

Rami, J. S. (1993). Nursing education: An agenda for health care reform in Louisiana. In Report to the White House Health Care Reform Task Force: Proceedings of the State of Louisiana Governor¹s Health Care Issues Forum. Office of the Governor, Baton Rouge, LA.

Rami, J. (1992). Predicting nursing student's success on NCLEX-RN. The ABNF Journal, 3(3), 67-71.

Wong, H., & Wong, R. T. (1998) The First Days of School. California: Harry K. Wong Publications, Inc.

U.S. Department of Health and Human Services. (2000 ) Healthy People 2010. 2nd ed. Washington, DC: U.S. Government Printing Office.

United States Department of Health and Human Services
Health Resources and Services Administration
Bureau of Health Professions
Division of Nursing
5600 Fishers Lane
Rockville, Maryland 20857-0001
www.hrsa.gov