|Texas Journal of Rural Health 2003; 21(3): 27-38||Table of Contents|
Partnerships in Developing a Diverse RN Workforce on the
South Plains of Texas
In an attempt to address the nursing shortage on the South Plains of West Texas, a unique partnership was formed between the Texas Tech University Health Sciences Center School of Nursing (TTUHSC SON) and the South Plains WorkSource (SPWS). The goal of this union was to increase rural and minority community awareness of nursing as a profession and to enhance university efforts to recruit, retain, and graduate disadvantaged and rural students (DARS). The project used a simple model (Bessent, 1997) to guide enhanced efforts and strategies developed to meet DARS program objectives. The model emphasizes the strategy of community awareness and partnerships to enhance the overall process of recruitment, retention, and graduation of DARS. This article describes these major project strategies and evaluates their effectiveness in enhancing recruitment and retention of disadvantaged and rural students.
Key words: nursing, recruitment, rural West Texas, TTUHSC SON, SPWS. (Texas Journal of Rural Health 2003; 21(3): 27-38)
The Nursing Shortage and Declining Enrollments
A critical shortage of nurses grips the nation, with estimates of 13% of registered nursing positions remaining unfilled in hospitals (American Nurses Association, 2000). Current projections reveal a growing shortage with an estimated 800,000 registered nurses (RNs) missing from the bedside by 2020 (Buerhaus, Staiger, & Auerbach, 2000). Although nursing is a profession with a long history of cyclic shortages, this shortage proved to be different as an aging nursing workforce begins to retire over the next 10-20 years. One factor in the aging of the nursing workforce is that younger birth cohorts, those born after 1955, are smaller in population size as well as significantly less likely to choose nursing as a career (Buerhaus et al., 2000). This has resulted in schools of nursing experiencing significant declines in nursing school enrollments, accompanied by significant reductions in budgets which negatively impacted recruitment efforts. Overall, nursing school enrollments dropped by 23% between 1995 and 2000 (Carpenter, 2000). Since many young nurses are attracted to the excitement of a critical care setting, hospitals in particular have been hit hard by this decline in younger nurses entering the workforce. The declining size of graduating classes of professional nurses has resulted in a shrinking supply of RNs wanting to work in hospital settings (Buerhaus et al., 2000). The shrinking workforce is complicated by two factors: an overall smaller number of younger individuals are available to enter the workforce and there are expanded career opportunities for women outside of nursing. Women currently make up 90% of the professional nursing workforce (Bednash, 2000).
Complicating the problem further is a failure of the nursing profession to recruit and educate a diverse workforce, one which reflects the demographics of our nation and communities. A culturally diverse workforce is essential to meeting the health care needs of communities and in reducing the health disparities that exist among the population. Hispanics comprise a growing segment of the United States population and a major concern is the paucity of nurses that are Hispanic. Only 2% of United States RNs are Hispanic, while in Texas approximately 7% of nurses are Hispanic. A national report entitled, "A National Agenda for Nursing Workforce-Racial/Ethnic Diversity," called for the education of minority and rural communities regarding nursing as a career and for increased recruitment and graduation of disadvantaged and rural students into the profession of nursing (Health Resources Service Administration, 2000).
Numerous efforts are presently underway to recruit more students into nursing. Twenty-one of the nation's leading nursing and health care organizations has formed a coalition, Nurses for a Healthier Tomorrow, in an attempt to provide long-term help (Sigma Theta Tau International, 2000). According to the coalition, highly visible patient and professional complaints about managed care in the early 1990s have discouraged young people from entering the nursing profession. The first phase of the coalition's work reveals that students from second through tenth grades are confused about the education involved to become a nurse, are unsure of job security and career advancement possibilities, and voice a lack of compelling reasons to become a nurse. Another significant initiative includes the Campaign for Nursing's Future, a multi-year nationwide effort to enhance the image of the profession and the recruitment of nurses sponsored by the Johnson & Johnson Family of Companies in 2003.
In addition to strategies being developed at the national level, the state of Texas took the initiative to begin addressing the nursing shortage with the passage of legislation during the 2001 session. One component of this legislation focused specifically on recruiting qualified applicants to enroll in RN educational programs, retaining them once enrolled, and graduating them by establishing a competitive grant program under the auspices of the Texas Higher Education Coordinating Board. Texas Tech University Health Sciences Center School of Nursing (TTUHSC SON) applied for and received funding to focus specifically on increasing rural and minority community awareness of nursing as a profession and enhancing efforts to recruit, retain, and graduate disadvantaged and rural students (DARS).
Rural West Texas and Partnerships
TTUHSC serves the 108 county of West Texas, including 98 counties designated as rural. This project focused specifically on the 15 county region of the South Plains (SP), consisting of 9 rural counties, 5 frontier counties, and 1 suburban county. With the exception of Lubbock County, whose population has increased over the last 20 years, the surrounding 14 counties that make up the SP area are confronted with the challenges that most rural counties in West Texas face. Rural residents have greater health care needs than urban residents because they are generally poorer, older, and less insured. In addition, 2000 census data indicated that the Hispanic population of West Texas grew at an astounding rate of 28.5%, comprising almost 42% of the West Texas population (United States Census Bureau, 2001).
Enhancing TTUHSC SON's efforts to recruit, retain, and graduate DARS became vitally important as a result of the nursing shortage, knowing that many students return to serve their rural communities upon graduation. To catalyze this process, in 2001 TTUHSC SON formed a partnership with the South Plains WorkSource (SPWS), a state supported entity under the auspices of the Texas Workforce Commission. SPWS's mission includes increasing awareness of opportunities and training requirements for individuals to access long-term career opportunities and has an infrastructure for career counseling within the 15 SP counties. Together, a grant proposal was submitted to the Texas Higher Education Coordinating Board (THECB) and funding was received in January 2002 with a focus on enhancing awareness of nursing as a profession, and recruitment, retention, and graduation of DARS.
Project Planning and Evaluation
Planning and evaluation for the project utilized a timeless process described by Suchman (1967). This process focuses on key processes of:
Value formation occurred as the state of Texas recognized the value of nurses in providing quality health care and thus the impact of a nursing shortage on the quality of health care to Texas citizens resulting in the passage of the 2001 legislation. Goal setting and goal measuring were identified by the project team in preparing the grant application.
Project planning was guided by adapting a simple, generalized framework developed by Bessent (1997) to exhibit Exemplary Strategies to Recruit, Retain, and Graduate Minority Students in Schools of Nursing. The model is shown in Figure 1a and highlights the basic elements for goal activity necessary to achieve the project goal. Figure 1b shows a simplified version of the Bessent model. The model was adapted for the grant with increased emphasis on leveraging community awareness and partnerships to facilitate the progress.
The adapted model, Figure 2, effectively captures the intertwining of elements and processes required to develop the DARS project. Community awareness is increased through leveraging partnerships and in turn enhances recruiting opportunities. Recruitment benefits from offering a strong student support/retention program based on awareness of DARS student community background. Retention activities support graduation where the student's community awareness can lead the graduate to support activities and partnerships that can in turn re-enforce and renew the overall process.
Identification of goal activities was initiated with the project proposal utilizing the Bessent model. The project had three major objectives:
A project of this scope also required building an organization with assigned roles and responsibilities. An organization chart for the DARS project is given in Figure 3.
Operationalizing the Project and Assessing Effectiveness
Partnerships: Partnerships were integral to the success of this project by providing additional avenues and resources to improve community awareness of nursing and reach out to capture DARS candidates. The main objective of collaborative partnerships was to increase awareness about nursing as a career option for DARS and to provide students and parents in rural communities current information about nursing as a career choice, including the educational tracts available to enter nursing in the South Plains area of West Texas. Under the auspices of the DARS project, the SON devoted resources to pro-actively foster and manage partnerships. The SON purposefully identified partners who could contribute to focusing on the nursing profession and the potential for each partner to contribute to project goals was carefully analyzed. Resources and energies were directed to those partners that were believed to have the greatest benefit and access to disadvantaged and rural individuals who could become successful nursing students with the school.
The initial and key partnership with South Plains WorkSource provided a credible existing set of aggregate sites with which to begin sharing nursing career options. The initial partnership with the South Plains WorkSource evolved into a more comprehensive model of addressing the nursing shortage on the South Plains with the creation of a larger, more encompassing partnership of all professional schools of nursing in the 15 county area of West Texas. The South Plains Nursing Education Community Coalition in collaboration with the South Plains WorkSource submitted a competitive grant proposal to the United States Department of Labor and was awarded $2.9 million to further address the nursing shortage, particularly addressing the recruitment and retention of disadvantaged and rural students in West Texas. The coalition built upon the momentum generated by the DARS project and the Bessent model.
Community partnerships were also extended beyond the South Plains WorkSource. Another key partnership was the Community Workforce Partnership, where the SON gained access to the resources and strengths of many community groups, both public and private. This included the regional education service center for public schools, a community college, two private universities, and three Chambers of Commerce, including the Hispanic and African-American chambers. Cultural liaisons with the Hispanic and African-American Chambers of Commerce were key to the success of the project by involving the SON at the grass roots level via association membership and participation in community activities.
Partners were specifically groomed to understand the value nursing brings to the community and to their own individual entities. Methodologies used to create "nursing value" with partners included such strategies as sponsoring partner programmatic activities (i.e., such as banquets and health fairs) and providing scholarship and summer camp opportunities to partner members. The activity found to be most effective was active participation by the SON in partner organizations, which included joining the Hispanic Chamber of Commerce and Raiders Rojos's (Hispanic alumni organization). The potential partnering organizations responded positively to the pro-active SON outreach and assisted the SON in achieving the DARS project objectives. Positive examples of partnership outcomes include:
An additional focus was improved collaboration between departments within TTUHSC. An example of this is a summer academy collaboratively developed between TTUHSC SON and the TTUHSC Office of Rural and Community Health to promote interest and basic study in the health related fields. A partnership was also created with the South Plains AHEC to enhance an awareness of nursing as a profession.
Community Awareness and Recruiting
By definition, the DARS population presents a demographic challenge for increasing community awareness and recruiting new nursing professionals. To cost effectively facilitate rural community contact with recruiting sites and systematically develop improved practices, a SON Nurse Educator/Recruiter position was created. This strategy served dual grant objectives. Responsibilities of the position included increasing community awareness of nursing as a profession as well as foster SON recruiting of DARS. In the absence of a devoted Nurse Educator/Recruiter, it would have been necessary to otherwise recruit and co-ordinate the activities of multiple volunteers to contact target populations in multiple areas with prepared materials.
The project leaders determined a full time Nurse Educator/Recruiter position was needed to coordinate and enhance community awareness in collaboration with recruiting efforts. The Nurse Educator/Recruiter was a TTUHSC graduate student in the critical care nurse practitioner tract. The project team was pleased when an experienced male nursing student applied for the position, because he brought a wealth of nursing experiences to each discussion with prospective students from the rural communities and exemplified the need for a diverse profession, including more men, parental responsibilities and rural roots.
Target populations for increasing community awareness and recruiting contacts through WorkSource partnership, in order of priority, consisted of:
Table 1 provides an overview of the numbers and types of organizations who participated in project activities in the South Plains area.
Both formal and informal networkings were identified as key strategies in promoting awareness of the nursing profession and the TTUHSC SON. Both networking strategies were given a trial of six months to determine their effectiveness in the community.
Formal strategies involved attending career days and setting appointment times to access key personnel in community schools such as principals, counselors, and school nurses.
Informal networking was based on drop-in visits at schools, the community hospital, chambers of commerce and libraries. Contact consisted of face-to-face meetings with all available personnel with printed materials provided in person.
Clearly informal strategies proved to be the preferred strategy over formal recruitment activities, especially when dealing with rural communities. Rural school personnel were appreciative of the direct personal contact. The time spent on a site was longer and more persons were greeted and educated when an impromptu meeting occurred. The effectiveness of the informal strategies (short trips to specific sights with no fixed appointments) quickly evolved into the preferred methodology for disseminating information to rural communities. More effective recruitment and education occurred with smaller groups of 15 or less. Formal strategies with career days and scheduled meetings were also continued throughout the South Plains area, however, the less structured, informal activities proved more efficient and cost effective.
Through the community awareness/recruiting program, contact was made with thousands of individuals in the target population. In the first 9 months for example, 1000 persons were contacted in groups of 15 or more, and 800 persons were contacted as individually and in smaller groups. Contacts increased exponentially over time.
Significant increases were seen in the recruitment of minority and rural students to the TTUHSC SON, as indicated by overall increased admissions of 39.7% from academic year (AY) 2001 (pre-grant) to AY 2003 (see Table 2). Although, improvements were made in increasing the number of Hispanic individuals admitted to the SON, this particular ethnic group remains an important challenge considering that Hispanics compose 42% of the West Texas population.
Retention and Graduation
In an effort by the university to further examine issues of recruiting and retention for all schools, a university-wide assessment was performed. The DARS program faculty participated in the TTUHSC assessment to identify and document motivators, facilitators and barriers that affect disadvantaged and rural students from participation in a university level education. Identified motivators were consistent with the theme of entering nursing in order to make a difference, necessitating leaving their community to pursue the educational requirements. The barriers reported were fear of being inadequately prepared to succeed, lack of eligibility for financial/scholarship support, and concern over abandoning family farm/business responsibilities. Additional barriers were lack of vision and self-confidence. The prime facilitator identified was personal contact with recruiters and other educated role models. The experience of this study led directly to the search for a supporting model and was the incentive to pursue a grant to build on the motivators identified and to reduce barriers and perceptions for rural students.
Retention efforts enhance the recruiting potential, indicating TTUHSC SON's commitment to assist disadvantaged nurses in overcoming perceived barriers in pursuing a nursing career. The retention efforts also increase the probability of reaching the ultimate goal of graduation. Strategies for retention began with the identification of students at risk currently in the SON. All students entering the school fill out a survey that aids in identifying students who are disadvantaged. Disadvantaged student status may include ethnicity, financial need, and being a first generation college graduate, working student, and/or parent, as well as having rural educational background. Students interested in a nursing career and who were identified as meeting disadvantaged criteria were offered an opportunity to participate in a special retention program aimed at DARS. These students participated in monthly seminars, tutoring, and other mentoring activities. Retention efforts by the SON were enhanced with the addition of a second retention counselor being employed to specifically work with students identified as being disadvantaged. This component of the project was funded by a second, smaller grant funded by THECB, which augmented the larger grant. Overall the majority of project participants were retained and graduated from the SON. National licensure exam pass rates exceeded state and national averages for baccalaureate graduates, as indicated by a range of 92% to 98% pass rate for the classes graduating during the project period.
Examples of strengthened retention activities included monthly seminars focused on learning styles and the development of test taking strategies, as well as stress relief techniques, financial advisement, and community resource utilization. Faculty played an active roll in the mentor program with activities scheduled on and off campus. Seminar attendance improved as relationships between and among faculty and students were strengthened. Alumni surveys have been distributed but not yet reviewed for the most recent graduating class. It is hoped that the new graduates will spread a positive word about nursing as a career, the study of nursing, and the benefits of nursing as a profession whether the new graduate practices outside the South Plains or stays in West Texas.
A significant increase in the availability of scholarships provided DARS with better financial stability and more opportunities to focus on their education versus earning an income. Through the many new partnerships, both public and private, the SON increased scholarship awards from $46,730 in 2001 to $576,366 in 2003. This would not have been possible without the support of the community in recognizing the value nursing brings to quality health care delivery.
The goal of this partnership was to increase rural and minority community awareness of nursing as a profession and to enhance university efforts to recruit, retain, and graduate disadvantaged and rural students (DARS). The efforts to attain this goal have been highly successful with increased visibility in the communities and increased partnerships impacting rural and disadvantaged communities. Project outcomes data overwhelmingly support the Bessent Model as a positive guide to enhancing recruitment, retention, and graduation of disadvantaged and rural students. This model could be applied to other health professions facing shortages. Overall, the SON experienced a 28% growth in enrollments with significant improvements in the recruitment, retention, and graduation of DARS. This compares to an increase of enrollments at nursing schools across the nation of only 8% during a similar time-frame (American Association of Colleges of Nursing, 2003). TTUHSC SON hopes that by increasing the numbers of disadvantaged and rural students becoming nurses, there will be a positive impact on reductions in health disparities as many of these nurses return to disadvantaged and rural settings to practice.
The authors wish to extend their appreciation to the Texas Higher Education Coordinating Board Nursing Innovation Grant Program for funding the research presented in this article.
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