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Abstract
Preparing a richly diverse nursing student population is essential to improving health outcomes for the nation and achieving a robust supply of health-care providers who better reflect the society we serve. As the U.S. population becomes more diverse, cultural competence is necessary among health-care professionals in order to practice with cultural humility. Cultural humility refers to a commitment and active engagement in a lifelong learning process that allows individuals to better meet the complex health-care needs of patients, communities, and colleagues. The design of an effective recruitment strategy should be driven by the mission of the educational institution and aligned to reflect the targeted population of potential students. Recruitment efforts and activities should be designed to improve the ability to attract a diverse population and more firmly establish a continuing pipeline of possible students. This article presents strategies such as building relationships and partnerships with 2-year community colleges with upper division nursing programs, and employing technology solutions to enhance recruitment and admissions of a diverse pool of applicants. Technology solutions can help manage large applicant pools, help staff coordinate a communication campaign so there is frequent contact with prospects, and capture notes throughout the recruitment process that can be utilized in a holistic admission strategy. Recruitment is the first step; to address retention, students must be welcomed into an inclusive learning environment where they can successfully advance, in order to achieve the goal of a more diverse nursing workforce.
The U.S. federal government projects that by 2050, racially and ethnically diverse persons will comprise 53% of the population (U.S. Census Bureau, 2019). As the population becomes more diverse, cultural competence/cultural humility among health-care professionals becomes essential to meeting complex health-care needs. Cultural humility refers to a commitment and active engagement in a lifelong learning process that allows individuals to better meet the complex health-care needs of patients, communities, and colleagues (Tervalon & Murray-Garcia, 1998). The U.S. Bureau of Labor Statistics, U.S. Department of Labor (2019) projected that by 2029, employment of registered nurses will increase by 7% from the current workforce of 3,096,700, a faster rate of increase than the average for all occupations. (This projection was made prior to the COVID-19 pandemic). Preparing a future workforce comprising students who better reflect the patients they serve is essential to improving health outcomes for the nation through a robust supply of health-care providers who better reflect the broader society.
According to data from the American Association of Colleges of Nursing (AACN, 2019), from 2010 to 2018, enrollment of students who have historically been underrepresented in higher education (e.g., those from low socioeconomic and/or racially or ethnically underrepresented groups) in baccalaureate nursing programs increased from 26.8% (39,601) to 34.2% (72,781), and the number of underrepresented baccalaureate graduates increased from 26.3% in 2009 to 32.2% (22,657) in 2018. While progress has been made in increasing the diversity of the nursing workforce, more is needed to meet diversity goals and achieve the recommendation of the Institute of Medicine report, The Future of Nursing: Leading Change, Advancing Health (Institute of Medicine, 2010) that the nursing workforce be representative of communities that we serve.
Woods-Giscombea et al. (2020) examined student perspectives on the influence of family, friends, and other supportive peers on nursing as a career choice, and effective recruitment strategies to enhance diversity in schools of nursing. They reported that students' perceptions involved two major thematic areas: misconceptions about nursing, and closing the gap between majority populations and historically underrepresented populations; the latter theme had two sub-themes: facilitating support and encouragement and marketing nursing to younger groups. Respondents reported that nursing is often portrayed through the lens of “doctor's assistant” or carrying out orders. The authors indicated that more emphasis should be placed on the independence of the nursing role, including the importance of the independent professional judgment and critical thinking necessary to be a successful nurse. Students may underestimate the rigor of prerequisite courses, putting them at a disadvantage if they decide to pursue nursing in college. These researchers suggested that if nursing is categorized as a Science, Technology, Engineering, and Mathematics (STEM) field grounded in science and evidence-based practice, more students interested in STEM may consider nursing as a career option. Categorizing nursing as a STEM field opens additional revenue streams through extramural funding and federal grant programs that could be utilized to recruit and retain students. They recommended providing prospective students information to overcome myths and stereotypes about nursing, incorporating family members and friends into the recruitment process, highlighting nursing as a STEM profession, and engaging in outreach to educate elementary, middle, and high school students about the nursing profession. Greater understanding of the broad scope of practice of nurses may appeal to a broader population of prospective students who might otherwise never consider this profession.
RECRUITMENT STRATEGIES
The design of effective recruitment strategies should be driven by the mission of the educational institution and the targeted student population. Recruitment activities and efforts of a nursing school are key to attracting a diverse student population. A good place to begin is with an assessment and evaluation of current efforts, and then a plan to incorporate new efforts (e.g., a targeted recruitment and special admissions focus for students from geographic areas that may be important for the institution to serve based on its mission, but underrepresented within the institution's student body).
The goals of recruitment efforts should be identified by asking three key questions:
Are recruitment activities designed to engage the diverse students you wish to attract?
What are the reasons students apply to and enroll in your school?
How can you sustain a steady stream of applicants from populations underrepresented in your program?
If your current recruitment efforts align to reflect the targeted population of potential students, consider what future recruitment efforts you can add that would improve your ability to attract an ongoing pipeline of diverse students. For example, transfer articulation agreements with diverse institutions that maintain the required coursework and admissions requirements for your program can provide an automatic threshold by which students can gain admission. When these agreements reside on both institutions' websites, they are a marketing tool that is always available for prospective students.
College applicants commonly use the Internet as a primary resource to explore educational opportunities. As a credible source of information, the university website can be leveraged to attract potential applicants and answer their questions. To actively engage your online audience, you need to post informative descriptions of your program and the nursing profession. Technology solutions such as customer relationship management tools can connect prospective students with ongoing recruitment and help manage the application process. Timely response to student inquiry is a vital element for ensuring that underrepresented potential applicants are provided the tools needed to navigate their new educational environments.
Conducting a Website Audit
Take a look at your school of nursing's current website. Is important program information easily accessible and visible? Does the website convey all necessary information about the program, including prerequisites, program length, academic expectations, and faculty contact information? Most schools have offices of information technology to support comprehensive websites; Web design and support staff at the institutional level can be an invaluable resource for developing the message you want to deliver as well as enhancing your site for organic search engine optimization (SEO). Ineffective web-based recruitment has information that is difficult to navigate, does not include testimonials from and images of diverse student populations, and/or uses language to which prospective students cannot relate. Currently enrolled diverse students can provide feedback about their own admissions experience and about the recruitment materials on your website. Many underrepresented students may not have guidance or support in completing the application form; posting an example of a successfully completed application is helpful.
Keeping Your Content Current
If your program's website has been stagnant for a few months, consider drafting new content that reflects the target population. Simple changes to the messages and photographs depicting your program and curriculum (emphasizing unique aspects, including those that may be of interest to underrepresented students), with a plan for regular updates, will stimulate interest and enhance SEO. Many underrepresented students may not have easy access to a computer or laptop for receiving and responding to information; your content must be easily visualized on mobile devices. Web campaigns can be conducted that target specific geographic regions where you hope to attract more diverse populations. Here are some promising strategies to share with your Web team.
Upload Student Snapshots With Compelling Quotes
Website visitors like to hear from sources like themselves, so diversify your pool of online ambassadors. Student testimonials are a win-win tactic. Students' success can be rewarded with a website feature, thus humanizing the nursing program for online viewers.
Answer Important Questions Using a Stylized Blog Post
Beyond the initial program Q&A, students may have other, less formal questions. How hard is the program? What clinical opportunities will students have to work within their community or to study abroad? How will health-care reform impact their professional career? To generate blog ideas, ask current students what they wished they had known prior to selecting a nursing program, or draw from your own nursing experiences. Many historically underrepresented prospective students will be the first in their family to attend college, and often do not have mentors from whom they can obtain information about the nursing profession and/or the collegiate experience. Schools of nursing must communicate widely, using multiple media forms to inform and attract new students.
Spotlight Program Graduates Who Have Transitioned to Leadership Positions
Interested applicants want to know their return on investment for completing a nursing degree. Leverage relationships with program graduates who have put their practice to use. A simple Q&A or picture with a quote can reinforce the benefits of obtaining a nursing degree. Presenting opportunities for professional fulfillment in nursing at all levels of the educational spectrum of nursing is an important topic to address in the recruitment of all students, because most are considering career paths they see as gratifying, prestigious, and flexible (Carter et al., 2015). Narrowly tailoring this message to specific populations by having it delivered by graduates who originate from historically underrepresented backgrounds will enhance diverse student enrollment.
Highlight a Recent Program Success or Community Initiative
Did students recently volunteer at a blood drive, or check people's vital signs at a community health clinic? Play back these touching moments through your website. Heartfelt stories show your program's commitment to both its students and its community, and can motivate potential applicants to consider a career in nursing. When these types of community initiatives focus on social justice efforts to demonstrate nursing's commitment to addressing health-care disparities, they can be particularly attractive to students who have lived with those inequities throughout their lives.
SPECIAL CONSIDERATIONS
First-Generation Students
Challenges frequently encountered by first-generation college students include financial issues, inadequate academic preparation before enrollment into nursing, lack of support from family, few role models or mentors, and experiences with discrimination (Loftin et al., 2012). Students may not have the requisite pre-entry academic preparation such as a strong science and math background. In the publication The Playbook: A Guide to Assisting Institutions of Higher Education in Evaluating Race- and Ethnicity-Neutral Policies in Support of the Mission-Related Diversity Goals (Coleman et al., 2014), the authors offered insights on the recruitment and retention of first-generation college students. Recommendations include engaging early with first-generation students during middle and high school to help ensure their later success in college. Specific guidance may focus on enrolling in a rigorous course schedule (including advanced placement or honors courses), planning an appropriate standardized testing schedule, and learning the fundamentals of college costs and financing options. As a complement to student-facing efforts, nursing faculty and staff should receive training on the unique value, experiences, and challenges that first-generation students bring to campus (Carthon et al., 2014, 2015).
Low Socioeconomic Status Students
Recruiting a more diverse applicant pool will often lead to the enrollment of more students who are from low socioeconomic status (SES) backgrounds. As the cost of college degrees increases concurrently with fewer state and federal dollars being invested in higher education, student indebtedness continues to increase—a college education may now be viewed as a private good rather than a benefit to the society at large. In 2019, the average debt incurred by undergraduate graduates was $25,000, while graduate students incurred approximately $45,000 in loan debt (Cilluffo, 2019). To reduce student debt, schools of nursing must develop close relationships with their financial aid offices so early outreach and financial literacy education can be provided. These relationships will cultivate an environment in which students can make more sophisticated borrowing decisions, can budget their funds more accurately so there is less reliance on loan debt, and additional forms of nonloan aid can be identified for students.
Students of Color
Through the diversification of the recruitment pool and the use of holistic admissions strategies, schools of nursing can increase the yield of matriculating students who have historically been underrepresented on college campuses (e.g., African American, Latinx, multiracial individuals, etc.). Holistic admission is defined as “a flexible, individualized way of assessing an applicant's capabilities by which balanced consideration is given to experiences, attributes, and academic metrics” (Addams et al., 2010, p.10). The inclusion of a more diverse student enrollment precipitates the need to create spaces where these students can express themselves within a safe environment outside the academic arena and can seek mentoring from faculty of color (Smith, 2013; Vélez-McEvoy, 2010). To ensure the faculty–student engagement mentor program is as effective as possible, nurse educators must embrace and value an inclusive learning environment, and schools of nursing must concurrently recruit for a diverse teaching force to enhance the availability of nursing faculty who resemble the students they support (Adeniran & Smith-Glasgow, 2010). Additionally, diverse national professional organizations (e.g., National Association of Hispanic Nurses, National Black Nurses Association) often have student chapters that should be fostered to create these safe spaces where students can feel nurtured and supported, and their voices heard. Supporting students through enhanced cultural understanding and holistic comprehensive care has proven to positively influence academic success for underrepresented nursing students (Wilkie, 2020).
RETENTION STRATEGIES
Any effort to recruit new populations of students without identifying and addressing these new learners' educational needs will likely not yield a diverse group of nursing graduates and will defeat the purpose of the recruitment efforts (Bristol et al., 2020). Diefenbeck and Klemm (2020) described the outcomes of a multipronged recruitment process, which utilized evidence-based interventions to address systemic barriers, with the overarching goals of increasing recruitment access and retention success for historically underrepresented students and socioeconomically disadvantaged students in a sustainable fashion that could be generalizable to other nursing schools. Indirect financial support was provided by grant funds in the form of free individual and group tutoring, enhanced advisement services, and other programmatic support and opportunities. These authors attributed the successful student outcomes (i.e., retention rates, graduation rates, licensure pass rates, etc.) to the role of the Retention Specialist, who used a cohort approach that fostered a critical mass of historically underrepresented and socioeconomically disadvantaged students to promote a sense of community and belonging which is vital for persistence in higher education. Dapremont (2013) reported in the analysis of recruitment and retention strategies that when combinations of multiple strategies including academic support, mentoring, student financial support, and community partnerships were used in minority nursing student populations, there was increased minority retention.
Schools of nursing have the moral responsibility to ensure that the appropriate scholastic and psychosocial support is provided for all admitted students to succeed academically in the program. Many schools are investing in Student Success Centers as a mechanism to deliver individualized and narrowly tailored support programs for their students. Schools must first study their students to determine what obstacles/challenges might exist that are preventing students from achieving higher levels of success (metrics can include first-year retention, graduation, and licensure examination pass rates), and then design interventions based on those findings (Byrd & Meling, 2020). Interventions might include supplemental instruction, peer mentoring, individualized tutoring, academic coaching, or the implementation of high impact practices like undergraduate research or residential learning communities (Kuh, 2012).
CONCLUSION
Schools of nursing are increasingly aware of their unique role in attracting and preparing a more diverse student population to serve our increasingly more diverse society. By employing a narrowly tailored and strategically implemented multipronged approach to recruitment efforts, historically underrepresented students will increasingly enroll in nursing education. Finally, concurrent efforts to provide for the educational needs of new student populations must be identified and implemented to ensure all students have the best possible opportunity to achieve our collective goals of making health care a more representative assembly of the patients served.
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Disclosure
The authors have no relevant financial interest or affiliations with any commercial interests related to the subjects discussed within this article.
Funding
The author(s) received no specific grant or financial support for the research, authorship, and/or publication of this article.
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