BEGINNING WITH THE END IN MIND: CULTIVATING MINORITY NURSE LEADERS BRIGIT MARIA CARTER, PHD, RN, CCRN*, DOROTHY L. POWELL, EDD, RN, FAAN†, ANNE L. DEROUIN, DNP, RN, CPNP*, AND JULIE CUSATIS‡ In response to the need for increased racial and ethnic diversity in the nursing profession, the Duke University School of Nursing (DUSON) established the Making a Difference in Nursing II (MADIN II) Program. The aim of the MADIN II Program is to improve the diversity of the nursing workforce by expanding nursing education opportunities for economically disadvantaged underrepresented minority (URM) students to prepare for, enroll in, and graduate from the DUSON's Accelerated Bachelors of Science in Nursing program. Adapted from the highly successful Meyerhoff Scholarship Program model, the program is to cultivate URM nursing graduates with advanced knowledge and leadership skills who can address health disparities and positively influence health care issues currently plaguing underrepresented populations. The article discusses the MADIN II framework consisting of four unique components: recruitment of students, the Summer Socialization Nursing Preentry Program, the Continued Connectivity Program, and the Succeed to Excellence Program, providing a framework for other academic programs interested in cultivating a pipeline of minority nurse leaders. (Index words: Diversity; Underrepresented minority students; Scholars; Undergraduate nursing students; Leadership) J Prof Nurs 31:95–103, 2015. © 2015 Elsevier Inc. All rights reserved.
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MERICANS LIVE IN an increasingly diverse society. Individuals of minority race/ethnicity comprised 31% of the U.S. population in 2000 and 37% in 2012, and this percentage is projected to exceed 50% by 2043 (American Association of Colleges of Nursing, 2013; Humes, Jones, & Ramirez, 2011). However, the composition of the nation's health care workforce has not kept pace with these demographic changes (Health Resources and Services Administration, 2006; Sullivan Commission, 2004). For example, in 2008, members of racial/ethnic minorities comprised 34.4% of the U.S. population but only 16.8% of the
*Assistant Professor, Duke University School of Nursing. †Associate Dean for Global and Community Health Initiatives, Duke University School of Nursing. ‡Making a Difference in Nursing Program Coordinator, Duke University School of Nursing. Address correspondence to Dr. Carter: Assistant Professor, Duke University School of Nursing. E-mail: [email protected] (B.M. Carter), [email protected] (D.L. Powell), [email protected] (A.L. Derouin), [email protected] (J. Cusatis) 8755-7223
registered nurse workforce (Health Resources and Services Administration, 2010). Underrepresentation of racial and ethnic minorities in the health professions can significantly impact both access to care and the quality of care received. The Sullivan Commission reported that the lack of resemblance between the U.S. health care workforce and the diverse populations they serve is leaving “too many Americans feeling excluded by a system that seems distant and uncaring” (Sullivan Commission, 2004, p. 1). Health care providers who share a common background with the person(s) to whom they provide care may be more aware of and sensitive to their patients' beliefs, values, and cultures (Coffman, Rosenoff, & Grumbach, 2001). There is also evidence that individuals are more comfortable interacting with and are more likely to feel empowered by health professionals of the same racial or ethnic background (Health Resources and Services Administration, 2006). Other benefits of patient/provider concordance include longer health care visits, better interpersonal care, and higher levels of positive affect and satisfaction among patients (Cooper et al., 2003; Health Resources and Services Administration, 2006). In addition, minority health professionals are more likely
Journal of Professional Nursing, Vol 31, No. 2 (March/April), 2015: pp 95–103 © 2015 Elsevier Inc. All rights reserved.
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to practice in medically underserved areas and provide health care to minority populations (Health Resources and Services Administration, 2006). In response to the need to increase racial and ethnic diversity in the nursing profession, the Duke University School of Nursing (DUSON) established the Making a Difference in Nursing (MADIN) Program. A proposal to the Duke Endowment campaigned for a program that would cultivate an enhanced interest in nursing careers and begin addressing underrepresentation of minorities in health care, most specifically nursing. This program would build an infrastructure to increase interest in nursing careers through a summer internship program for a competitively selected group of minority students who were recruited from historically Black colleges and universities (HBCUs). MADIN became a reality in the summer of 2009 with the a group of eight minority rising juniors and senior collegelevel (nonnursing disciplines) students who participated in a coordinated program of career exploration and forecasting, mentoring, role investigation, and scientific inquiry in nursing. Weekly seminars were conducted to expose the MADIN students to a wide variety of nursing careers followed by shadow experiences. Students were also able to participate in Graduate Record Examination (GRE) review courses, career development initiatives, and a scholarly research project. Out of the eight students who participated, one has completed an Master of Science in Nursing (MSN) program, three have completed a Bachelor of Science in Nursing (BSN) nursing program, and one has been accepted into an Accelerated Bachelors of Science in Nursing (ABSN) program. The MADIN program was continued in 2010 with a group of five minority students of which three of the students were accepted into a nursing program. Because of the success of the MADIN program, an The Health Resources and Services Administration (HRSA) grant was submitted for MADIN II that would address improving equitable health outcomes among diverse populations and those most at-risk for health disparities by cultivating nursing leaders from underrepresented minority (URM) groups with a passion to promote transformative and substance evidenced-based change. The aim of the MADIN II Program is to improve the diversity of the nursing workforce by expanding nursing education opportunities for economically disadvantaged URM students to prepare for, enroll in, and graduate from the school's ABSN program. The MADIN II Program, a federally funded Health Resources and Services Administration Workforce Diversity initiative, is committed to developing the next generation of minority nurse leaders by academically, experientially, and socially preparing scholars for the highest levels of nursing service, research, education, and practice. Rooted in the Stephen Covey mantra “Begin with the end in mind” (Covey, 2004), MADIN II is committed to providing not only support for completion of the ABSN program but also the guidance needed to encourage minority students to pursue doctoral study in nursing [Doctor of Philosophy (PhD) or Doctor of Nursing Practice (DNP)]. The ultimate goal of the program is to cultivate URM nursing graduates with advanced knowl-
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edge and leadership skills who can address health disparities and positively influence health care issues currently plaguing underrepresented populations.
The MADIN II Model The structure of the MADIN II model was adapted from the highly successful Meyerhoff Scholarship Program model at the University of Maryland, Baltimore County (UMBC). The Meyerhoff Program was established in 1988 to prepare African American male undergraduate students to become leading research scientists in math, science, and engineering at the PhD level (Maton, Sto. Domingo, Stolle-McAllister, Zimmerman, & Hrabowski, 2009). Over time, the program evolved to become more gender and racially inclusive and was “opened to people of all backgrounds committed to increasing the representation of minorities in science and engineering” (University of Maryland, 2013). Since its inception, the Meyerhoff Program has enrolled over 1200 scholars and graduated 800 alumni, with nearly 300 students currently enrolled in graduate and professional programs. Key principles of the Meyerhoff Scholars Program (Maton, Pollard, McDougall Weise, & Hrabowski, 2012; StolleMcAllister, Sto. Domingo, & Carrillo, 2011) were used to develop MADIN II Program strategies such as (a) targeted recruitment; (b) scholarships, stipends, and other financial assistance; (c) a 6-week summer bridge program, which includes a scholarly research project; (d) social and academic support including study groups and academic mentoring; (e) personal advisement, counseling, and tutoring; (f) administrative involvement and school of nursing community support; and (g) familylike atmosphere. The MADIN II framework consists of four unique components: recruitment, the Summer Socialization Nursing Preentry Program (SSNPP), the Continued Connectivity Program (CCP), and the Succeed to Excellence Program (SEP). Similar to the Meyerhoff Program model, this is a comprehensive program that provides URM students with social, financial, and academic support systems. Each of the four components has distinctive purpose and goals and is integral to the students' successful matriculation in and progression through the ABSN program. These four components have been vital to ensuring the successful achievement of the ultimate MADIN II goal: promoting the development of URM professional nurses who seek advanced education while aiming to improve health disparities.
Recruiting Targeted recruitment was essential to successful achievement of the program outcomes. MADIN II recruited highachieving/high-potential URM students with strong analytical and problem-solving skills who also met the standard admission requirements for the Duke ABSN program and had a desired trajectory to pursue advanced level education. Applicants also expressed an interest in providing health care to vulnerable groups following graduation. We primarily recruited students to the
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MADIN II Program by collaborating with faculty and counselors among the science departments at targeted minority-serving universities and/or majority universities known to have a critical mass of minority students in the sciences. Universities with nursing programs were not included among the pipeline recruitment sources to avoid competition with campus-based nursing programs. Seven minority serving institutions of higher education and institutions with a documented record of strong academic programs and enrolling a substantial population of URMs were cultivated as our “pipeline institutions” for recruitment and development of symbiotic relationships. Key persons within each institution's offices of student affairs or science departments were identified and provided information about MADIN II and the opportunities available in nursing. They in turn identified students within their academic programs who were interested in pursuing a career in nursing. The pipeline recruitment sources included HBCUs in the southern United States (Bennett College for Women in North Carolina, Jackson State University in Mississippi, Spelman College for Women in Georgia, and Xavier University of Louisiana) and other institutions that have diverse enrollment within the sciences such as UMBC Meyerhoff Scholars Program, Florida International University, and University of Texas at San Antonio. Institutions with large populations of Hispanic/Latino, Native Americans, and Asian Pacific Islanders were also approached. Table 1 reflects applicant pools yielded from recruitment visits. During the first year of recruitment, the ABSN program recruiter was able to incorporate information about MADIN II into ABSN program recruitment and make targeted visits on behalf of the program. The recruiter was well-versed in the components of MADIN II and attended team meetings regularly. During the second year, because of transitions in the school's office of admission and student services, targeted visits to the selected pipeline schools were made by the MADIN II Project Director and
Academic Coordinator instead of ABSN program recruiter. When available, first-year MADIN II scholars would participate in these events and speak with students about the program from their perspective. Additional approaches toward recruitment included PowerPoint presentations, table-top presentations, and one-on-one interaction with interested applicants. In addition to making personal visits, we also sent print materials to advisors and student recruitment events. The recruitment process also included Web site promotions and feature stories about MADIN II students in the Duke University Magazine and Duke School of Nursing Alumni publications. To increase the likelihood that successful graduates of the SSNPP (described in the next section) would elect to enter the Duke University ABSN program, we proposed early admission for students admitted to MADIN II. This proposal was supported by the ABSN Admissions Committee, and the admission status was clarified to include the following stipulations: satisfaction of all ABSN admission requirements and demonstrated outstanding performance during SSNPP, as evidenced by two letters of reference from SSNPP faculty. This collaboration between MADIN II and the ABSN Admissions Committee in 2011 moved us swiftly toward realization of a larger pool of URM applicants and MADIN II-qualified candidates. The collaborative approach remained in place for the subsequent recruitment cycles. Over time, the MADIN II recruitment process was integrated into the comprehensive recruitment strategies of the DUSON ABSN program. This broadened our recruitment pipeline and the richness of the recruitment pool by engaging URM student applicants to Duke who had not previously been aware of or considered the MADIN II Program as an option for their nursing education. During the recruitment phase, MADIN II applicants now experience two levels of record review (on-campus or Skype-facilitated faculty interviews): one by the ABSN Admissions Committee and one by the MADIN II Selection Committee. Students
Table 1. MADIN II Demographics Cohort 2011 Total applicant pool SSNPP Total number offered admission Total number entered program Characteristics of SSNPP participants Mean age (years) Race/Ethnicity Black Hispanic/White Hispanic/Black American Indian Male First generation college Resident of medically underserved community Total number completed SSNPP ABSN program Total number matriculated Total number graduated
Cohort 2012
Cohort 2013
21
42
42
10 10
11 7
10 7
24.3
22.6
25.6
8 2 0 0 2 7 6 10
4 1 1 1 1 4 4 7
5 1 1 0 0 5 Unknown 7
5 4
7 N/A
4 N/A
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are now simultaneously considered for the MADIN II Program and the ABSN program; however, acceptance/denial into one program does not affect the other.
Summer Socialization Nursing Preentry Program The SSNPP is a 6-week curriculum designed to cultivate an enhanced interest in professional nursing, leadership, and scholarship. The students live and study together in on-campus apartments while attending daily learning activities and social/team-building events and participating in community service. The objectives of SSNPP are to (a) develop a basic understanding of professional nursing practice; (b) identify, study, and present a nursing problem through literature review; (c) develop a personal career trajectory plan; and (d) cultivate leadership and team-building skills and an attitude for success. To continue into the next component of the program, MADIN II scholars must successfully complete and graduate from MADIN II SSNPP. The students have a rigorous weekly schedule (see Table 2 for sample week), which includes an introductory professional nursing course (an ABSN first-semester credit course); guided pathophysiology readings to enhance understanding of the ABSN first-semester pathophysiology course; seminars
on nursing science, nursing practice, and nursing leadership; precepted shadowing experiences in various nursing academic, research, and practice roles; simulated experiences in nursing practice and decision making in the Center for Nursing Discovery; and weekly team-building activities. In addition, under the guidance of a faculty mentor, each MADIN II scholar is introduced to various parts of the nursing research process and mentored in the development of a scholarly research project. Similar to the Research Enrichment and Apprenticeship Program (Goeppinger, Miles, Weaver, Campbell, & Roland, 2009), a model designed to facilitate minority research career development, the incorporation of guided faculty research projects is important to enhance the undergraduate students' interest in research while simultaneously providing them with future mentors and knowledge of the research process. Typical scholarly projects include (a) review of the research mentor's data to create a poster presentation, (b) literature review with summary of findings, and (c) participation in research activities (e.g., data collection, site visits, etc.). The scholarly project provides an avenue for mentorship of the MADIN II scholars by nursing faculty and strengthens the scholars' professional and scientific writing skills. These mentoring
Table 2. MADIN II Scholars 2013 SSNPP Weekly Agenda Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
June 23 Church (Optional) Call if you would like to attend
June 24 8:00 AM
June 25
June 26
June 27
June 28
June 29
Mentored Shadowing (Hospital)
9:00 AM
Class Introduction to Professional Nursing
Class Intro to Biological and Physical Manifestations of Disease
10:00 AM Nursing Resource Seminar Using your Resources
WRIGHTSVILLE BEACH DAY TRIP
Socialization to Nursing Chief Nursing and Patient Care Services Officer
11:00 AM
12:00 Noon LUNCH 1:00 PM Socialization to Nursing Office of Institutional Equity
2:00 PM Socialization to Nursing Director, Diversity, Equity & Inclusion Office of Institutional Equity
LUNCH
LUNCH Debrief of Shadow Experiences
LUNCH
Nursing Resource Seminar Professional Writing Skills
Nursing Resource Seminar Successful Budgeting During the ABSN Program
Center for Nursing Discovery Nursing Skills
LUNCH Nursing Resource Seminar Understanding and Managing Stress
3:00 PM Introduction to Professional Nursing Independent Study
Sunday Dinner 4-6pm
MORAL MONDAY (Voluntary participation only) 4:00 PM
Socialization to Nursing “Diversity in Nursing; How will you contribute”
Introduction to Professional Nursing Self-Study
5:00 PM Dinner
Pick up at TBD Dinner and American Dance Festival at DPAC Dinner at 6pm DPAC at 8pm
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relationships typically continue after the MADIN II scholar enters the ABSN program. Scholars attend a three-part seminar (2 hours per session) on professional writing skills and also have access to an editor for their final project papers. The SSNPP program also includes a number of socialization and networking events. Faculty members host events at their homes, which allow the scholars to interact with faculty and ABSN students in a social environment. The scholars attend sporting events and are introduced to local arts, theater performances, and museum visits. The importance of networking and social etiquette skill is taught by an etiquette consultant, and the scholars demonstrate learned skills during a formal dinner event sponsored by the DUSON Alumni Association. New cohorts of MADIN II scholars are socialized to the school of nursing environment by previous scholar cohorts, alumni of the school, and current ABSN students. The scholars are encouraged to attend Nursing Student Nurse Association events and are welcomed to attend ABSN program events such as a family day event and a summer barbecue, which gives them opportunities to begin building relationships with students outside of their MADIN II cohort. The scholars participate in at least one community volunteer experience such as building homes with Habitat for Humanity, participating in community assessments or community interventions with Partnership for a Healthy Durham (a coalition of local organizations focused on physical, mental, and social health/well-being of local residents), or feeding the homeless with the local rescue missions.
Continued Connectivity Program The CCP was created for scholars who have their senior year of study to complete at their current academic institution. The goal is for these students to maintain momentum, to complete their undergraduate studies, and to stay connected to DUSON and the MADIN II team and their mentors and advisors. Regularly scheduled contact with the MADIN II Academic Coordinator is maintained through e-mail, text, Skype, and telephone calls. Recruitment visits provide additional opportunities for face-to-face meetings of encouragement and support. Additional methods for maintaining connectivity include postcards, care packages, Facebook messaging, and conference calls with MADIN II scholars. After graduation from their undergraduate programs, these MADIN II scholars attend the first week of the SSNPP program with the current summer MADIN II cohort to begin the process of integration and team-building with the cohort with which they will matriculate into the ABSN program.
Succeed to Excellence Program The SEP is a program of academic and emotional support and financial assistance (through stipends or scholarships) that empowers learning among the MADIN II scholars after they enroll in the Duke University ABSN program. The components of this program include personal advising,
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mentoring, study groups, tutoring, academic advising, ongoing test-taking strategies, and the National Council Licensure Examination (NCLEX) review sessions throughout the scholar's four semesters in the ABSN program. Lunch and learn seminars focused on study skills, test-taking strategies, budgeting and professional communication have been developed to minimize time constraints in the scholars' already demanding schedules. Academic advising is an important component of the SEP program because scholars are required to maintain a minimum 3.2 grade point average (GPA). Scholars are encouraged to seek assistance with academics early in their matriculation. The scholars are required to attend quarterly individual meetings with the academic coordinator to review grades and discuss future career development. Should a scholar have academic performance problems, learning improvement plans are developed with the scholar that are used to help guide the student to resources designed to target specific areas of need. Peer and alumni tutors (PAT) are available for every course in the ABSN program and are used as needed by the scholars. Such programs have been successful in translating course concepts, teaching study skills, reinforcing the nursing process, and minimizing anxiety (Degazon & Mancha, 2012). The PAT program was initially developed specifically for MADIN II scholars and has since been adopted by the ABSN program for use by all students. Although the PAT program is designed to provide students an opportunity to have concepts reinforced, many tutors found that students also just needed study strategies or an understanding ear from a fellow student who has successfully completed the course. MADIN II scholars have successfully used the tutors, and some now serve as tutors themselves for the PAT program. As scholars enter their final semester, they attend NCLEX review sessions provided by the ABSN program, are provided a current edition of a NCLEX study guide, and have access to other NCLEX resources to support development of additional strategies for test preparation. Currently, all students have access to Assessment Technology Institute, LLC (ATI) Nursing Education resources for NCLEX preparation. The MADIN II scholars are provided individualized guided NCLEX study preparation through ATI, which begins in the middle of the last semester. SEP builds on the scholarship and leadership development that was initiated when students worked with faculty mentors on research projects in SSNPP. Scholars are encouraged to create abstracts for presentation at a local or national professional meeting, and opportunities are provided to attend a national nursing conference to gain professional knowledge, enhance social and networking skills, and learn how to interact with nursing colleagues and leaders. Mentoring, professional guidance, and emotional support of the scholars continue after matriculation as students begin their professional nursing careers and contemplate graduate school and other professional opportunities. In addition to their MADIN II faculty advisors, the scholars have ABSN advisors and a peer advisor for additional support and mentorship.
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Many scholars do not have family members within driving distance, and it is important to meet the needs usually provided to them from the family setting. We create that family atmosphere with “Sunday Dinners,” which are held monthly at various faculty members' homes. These dinners are used for a time of emotional support, encouragement, and appreciation to the scholars for hard work. Academic progress is not addressed during these dinners, which are a “work-free” zone. In an effort to nurture the whole person and create the most comprehensive development program possible, MADIN II created a system of social supports identified as “Mama/Papa Mentors.” This mentorship initiative began in 2011 and was established to provide scholars with a linkage to a mature individual with whom they can bond, seek wisdom, or reach out to for personal support. The goal of this initiative is to provide a supportive resource outside of the school of nursing for the scholars. There are no specific expectations on time or frequency of contact; it is left for the mentors and scholars to determine the best methods of maintaining contact, whether through telephone, e-mail, or face-to-face meetings. The Mama/Papa Mentors were found to be trusted confidants who were available and interested in their mentee's personal joys, goals, and challenges. They provided personal support of a nonacademic nature and fortified the scholars' sense of belonging. Community service remains a valued experience, and the SEP encourages scholars are to identify a group or individual volunteer experiences that fit within the larger context of their responsibilities as ABSN students.
Financial Assistance Financial barriers are a continual concern for MADIN II scholars, so these issues are addressed on an ongoing basis throughout the program. Scholars are contacted by a financial aid advisor immediately after ABSN and MADIN II admission decisions are released. During SSNPP, they are offered the opportunity to meet individually with school of nursing financial aid officers, and discussions of federally supported scholarship programs such as the US Public Health Service Commissioned Officers Student Training and Extern Program and the military, are presented. Throughout their 16-month course of study in the ABSN Program, scholars regularly receive information about scholarship and loan opportunities, and ongoing financial counseling is provided. Because of the academic rigor of the ABSN curriculum, all ABSN students are advised to not take on any external employment while enrolled in the program. To help scholars optimize their funds, we offered budget seminars as part of SSNPP and again during the ABSN program. MADIN II provides each scholar with uniforms (scrubs) needed for clinical experiences and books for each semester. In addition, most of the scholars receive approximately US$7,500 in scholarships, which is divided over four semesters. Many scholars have also qualified for Robert Wood Johnson New Careers in Nursing Scholarship awards for URM students, which vary in amount but are approximately US$10,000 divided
over four semesters. DUSON has addressed the significant need for scholarship support among ABSN students changing from a merit-based scholarship program to a need-based scholarship program, for which most of the MADIN II scholars qualified. One significant achievement was the creation of an early tuition reimbursement agreement made between an affiliating hospital and the MADIN II Program. This program allowed scholars to be eligible for employment after graduation at the hospital, thereby giving them the opportunity for a tuition reimbursement benefit provided by that hospital to all new graduate nurses. This program was provided to the 2011 and 2012 MADIN II cohorts but is no longer in existence. Expenses associated with other MADIN II initiatives such as seminars and outings designed to socialize scholars and increase their knowledge of networking and etiquette were initially funded by staff donations and were later covered by discretionary account funding and contributions from the DUSON Alumni Association.
Program Outcomes SSNPP Recruitment and Program Completion The MADIN II Program has admitted 24 scholars to date. In the first year (2011), six schools were visited, and information/recruitment sessions were held with 168 students, generally science majors and typically classified as juniors and seniors. The informational messages stressed (a) leadership careers in nursing, (b) pursuit of PhDs and DNPs in nursing, along with the routes and processes for achieving those ends, and (c) the mission, goals, expectations, and curriculum of the MADIN II Program. In addition to the pipeline schools, information on the MADIN II Program was disseminated through a brochure distributed during non‐MADIN II recruitment trips by members of the ABSN admissions staff as they visited other institutions around the country. The overall recruitment yield for MADIN II included students contacted through the general recruitment processes of the school of nursing. These recruitment efforts yielded 21 applicants to the SSNPP program, and 10 were admitted to create the first MADIN II cohort (2011). These results were consistent with the projected number of 20 applicants and 10 admissions. Of the 10 admissions, 60% were from pipeline schools, and 40% were from the general population of academic institutions. In 2012 (second year of the program), the MADIN II Program extended admission offers to 11 students from a pool of 42 applicants. Seven students accepted the offers. One student from the previous 2011 MADIN II cohort, who had not matriculated into the ABSN program in fall 2011, rejoined the program, attended a portion of the SSNPP for team-building activities, and matriculated with the MADIN II 2012 cohort in fall 2012. Of the seven students, four (57%)% were from pipeline schools or had heard of the MADIN II Program by word of mouth from previous scholars, and three (43%) were from the general
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population of academic institutions. In 2013 (third year of the program), 10 students were extended admission offers into the MADIN II Program from a pool of 42 applicants. Again, 7 of the 10 students accepted offers. All students who participated in MADIN II SSNPP successfully completed the program. Table 1 shows the outcomes of those who have successfully completed the preentry phase of the MADIN II Program (SSNPP). Relationships with the contacts at the targeted universities were critical to the success of recruitment visits and receipt of viable applications. Recruitment visits that included scheduled time with targeted students yielded much more interest and applications than booths.
ABSN Program Matriculation Cohort 2011. Of the 10 MADIN II scholars who completed the SSNPP program, five scholars matriculated into the ABSN program in August 2011. Four graduated on time in December 2012 and successfully passed the National Council Licensure Examination for Registered Nurses (Table 1). Of the five students who did not matriculate into the ABSN program with the 2011 MADIN II Cohort, two were admitted into other nursing programs, and one worked for a year and subsequently matriculated into the ABSN program the following year. The other two students elected careers outside of nursing, but are both enrolled in master's degree programs. Cohort 2012. In August 2012, seven MADIN II scholars matriculated into the ABSN program. All seven progressed into the last semester of the ABSN program, and it is anticipated that six will graduate on time in December 2013. One student decelerated because of illness but is scheduled to graduate in May 2014. Cohort 2013. In August of 2013, four of the seven MADIN II scholars who completed SSNPP matriculated into the ABSN program. The current MADIN II scholars are performing well academically as demonstrated by GPA ranging from 3.5 to 3.9 on a 4.0 scale. They continue to acclimate to Duke and have engaged in extracurricular activities including creating an affinity organization within the school for all underrepresented minorities, and one has been elected as their cohort's class representative.
Barriers and Challenges of MADIN II Scholars The barriers and challenges faced by MADIN II scholars are not unlike those of minority students in majority institutions. Minority students, including those in nursing (Loftin, Newman, Dumas, Gilden, & Bond, 2012), experience a variety of personal, environmental, and institutional barriers to transition into and success in the collegiate environment (Cason et al., 2008; Loftus & Duty, 2010; Opp, 2001; Thomas & Thurber, 1999). An integrative review of 17 studies of perceived barriers to minority nursing student success (Loftin et al., 2012) identified recurring themes including inadequate financial support, lack of emotional and moral support, a sense of
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isolation and loneliness, discrimination, need for advising and academic support, lack of minority faculty to serve as mentors and role models, little sense of professional socialization, limited computer access and technology competence, and deficiency of cultural competence among nonminority peers. Barriers reported by MADIN II scholars included insufficient financial support, a sense of isolation and loneliness, lack of minority faculty to serve as mentors and role models, and perceptions of underdeveloped crosscultural understanding and insensitivity toward minorities on the part of some nonminorities in the environment. Many of the MADIN II scholars expressed constant worry about the cost of tuition and living expenses, an issue frequently identified as a significant barrier to minority nursing student success (Loftus & Duty, 2010; Smith, Williams-Jones, Lewis-Trabeaux, & Mitchell, 2012) The scholars faced three financial impediments that impacted their access to a nursing education: (a) individual family income lower than the federal poverty level; (b) loan debt incurred to cover the cost of their first degree; and (c) the cost of attending an elite private university with high-priced tuition of over US$70,000 for the 16-month accelerated BSN program. Several scholars were at their maximum lifetime financial aid allowance or were unable to secure sufficient funds. Students from low socioeconomic backgrounds are frequently unable to secure qualified cosigners when loans are sought. Consequently, most attrition or failure to progress from the MADIN II summer preentry program to the accelerated BSN program has been because of the inability to afford the cost of the education. Other scholars, who were able to secure loans, find themselves at graduation with excessive debt incurred during the completion of their two or more collegiate degrees. In exit discussions held with the MADIN II scholars, they shared reflections about their experiences as minority students at a majority institution. Several scholars reported the misperception held by some students in their academic cohort that MADIN II scholars receive preferential treatment and access to resources and information that other students do not receive. Scholars also expressed perceptions of being treated differently from their nonminority peers and being held to different or higher expectations and reported experiencing insensitivity and lack of understanding in interactions with some faculty and peers. Denbo (1988, 1990) found that faculty expectations greatly affect student performance. When faculty has high expectations of students, they have high expectations of themselves (Lumsden, 1997). Another theme expressed by scholars was a sense of isolation and loneliness, despite being a member of a cohort of similarly situated MADIN II peers in which teamwork is stressed and social events are regularly scheduled. Although there is meaningful assimilation of scholars with the greater cohort of ABSN peers, it is primarily academic rather than social in nature. In these cases, dissonance is most frequently associated with differences in socioeconomic status and cultural incongruence. Because of the increasing ethnic/minority population within the school of nursing, a minority
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nursing affinity group specific to minority students was created by the students. Ethnicity/Racial affinity organizations can reduce feelings of social and cultural isolation and have a positive impact on students' persistence and success (Aspray & Bernat, 2000; Dumas-Hines, Cochran, & Williams, 2001; Smith et al., 2012). When scholars were asked to what extent they felt the curriculum adequately addressed concepts such as minority health issues, health disparities, factors that contribute to health and well-being among people of color, and cultural competence, all responded that there was insufficient attention to minority and other issues of diversity in the classroom—a matter of considerable concern to minority students whose career aspirations are often linked to addressing such issues with vulnerable populations. An inclusive classroom is one in which faculty acknowledge and respond to the diversity represented in the classroom and students work together to create and sustain an environment in which everyone feels safe, supported, and encouraging learning about each other and their patient populations (Billings & Kowalski, 2008). Over time, in the nursing school environment, there is growing evidence that perceptions of students by faculty have become more positive, more supportive, and active and committed participants in facilitating student success. Proactively, a growing number of faculty have identified a need to increase their sensitivity and effectiveness in teaching, advising, and counseling minority students. Some of MADIN II scholars faced additional challenges of a developmental nature. Although these challenges are not limited to MADIN II scholars, there are hindrances that could interfere with the scholars reaching their desired outcomes as nurse leaders. These include a need to develop and/or polish social, networking, and interpersonal skills. Interpersonal skills along with effective and sensitive written and oral communication promote an atmosphere of confidence and trust that grows valuable relationships and inspires a group or a team to accomplish the tasks of the organization (National Conservation Training Center, 2010). Efforts to build and enhance capacity in these areas are very much expectations developed through specific activities and interventions. A second challenge and finding was that academic excellence does not automatically equal good writing skills (Johnson, Symes, Bernard, Landson, & Carroll, 2007). Some MADIN II scholars, although academically strong, with GPAs higher than 3.2, needed writing instruction, tutorials, and editing assistance. Strong writing skills are fundamental to academic and professional success. It is important that any such writing impediments be overcome as scholars prepare for their success and their futures. Teaching and engaging in activities to increase organizational and time management skills are among the priority areas for socializing students toward success. Benefits of time management include reduction of stress and frustration, enhanced confidence, feeling a sense of empowerment from getting things done, feeling
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better, and having time to enjoy the simple pleasures of life (Dudovskiy, 2013).
Conclusions The MADIN II Program is committed to creating equity in the diversity of nurse leaders through an increase and enhancement in the quantity of nursing educational opportunities for underrepresented students. MADIN II scholars are an exquisite group of students prepared to be among the next generation of nurse leaders. The MADIN II Program incorporates substantial evidencebased workable strategies to ensure that MADIN II scholars excel, complete their undergraduate ABSN academic program, achieve licensure, and move directly into higher education within the nursing profession. To bring leadership to the reduction and/or elimination of health disparities locally and nationally, URM students must be actively recruited, developed, supported, and nurtured. It is essential to create an atmosphere that not only embraces diversity but also cultivates the development of a student body that will enable us to have a richer understanding of our world. URM students should be prepared to function in leadership roles in order to address the issues that affect the delivery of health care locally and abroad, and faculty should partner in these goals and provide tools and resources that are needed to facilitate excellence.
Acknowledgments We would like to extend our sincere thanks to the University of Maryland Baltimore County Meyerhoff Program, President Freeman Hrabowski, Mitsue Wiggs, and our beloved mentor, LaMont Toliver, who contributed their time and mentorship in the creation of the MADIN II Program and our visionaries Dean Catherine Gilliss and Dr. Dorothy Powell.
References American Association of Colleges of Nursing (2013). Fact sheet: Enhancing diversity in the nursing workforce. Retrieved from, http://www.aacn.nche.edu/media-relations/ diversityFS.pdf 2013. Aspray, W. & Bernat, A. (2000). Recruitment and retention of underrepresented minority graduate students in computer science. Report of a workshop, March 4-5, 2000. Washington, DC: Computing Research Association. (from, http://www.cra. org/). Billings, D. M. & Kowalski, K. (2008). Inclusive teaching. Journal of Continuing Education in Nursing, 39, 296–297. Cason, C. L., Bond, M. L., Gleason-Wynn, P., Coggin, C., Trevino, E. & Lopez, M. (2008). Perceived barriers and needed supports for today's Hispanic students in the health professions: Voices of seasoned Hispanic health care professionals. Hispanic Health Care International, 6, 41–50. Coffman, J. M., Rosenoff, E. & Grumbach, K. (2001). Racial/Ethnic disparities in nursing. Health Affairs, 20, 263–272. Cooper, L. A., Roter, D. L., Johnson, R. L., Ford, D. E., Steinwachs, D. M. & Powe, N. R. (2003). Patient-centered communication, ratings of care, and concordance of patient and physician race. Annals of Internal Medicine, 139, 907–915.
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Covey, Stephen R. (2004). The 7 habits of highly effective people: Powerful lessons in personal change. (Revised ed.). New York: Free Press. Degazon, C. E. & Mancha, C. (2012). Changing the face of nursing: Reducing ethnic and racial disparities in health. Family and Community Health, 35, 5–14. Denbo, Sheryl (1988). Improving minority student achievement: Focus on the classroom. Washington DC: American University Mid-Atlantic Equity Center. Denbo, Sheryl (1990). Effective schools for culturally diverse students: An annotated bibliography. Washington, DC: American University Mid-Atlantic Equity Center. Dudovskiy, J. (2013). The importance of time management. Retrieved from, http://research-methodology.net/the-importanceof-time-management/2013. Dumas-Hines, F. A., Cochran, L. L. & Williams, E. U. (2001). Promoting diversity: Recommendations for recruitment and retention of minorities in higher education. College Student Journal, 35, 190–196. Goeppinger, J., Miles, M. S., Weaver, W., Campbell, L. & Roland, E. J. (2009). Building nursing research to address health disparities: Engaging minority baccalaureate and master’s students. Nursing Outlook, 57, 158–165. Health Resources and Services Administration (2006). The rationale for diversity in the health professions: A review of the evidence. Retrieved from, http://bhpr.hrsa.gov/healthworkforce/ reports/diversityreviewevidence.pdf 2006. Health Resources and Services Administration (2010). The registered nurse population: Findings from the 2008 national sample survey of registered nurses. Retrieved from, http://bhpr. hrsa.gov/healthworkforce/rnsurveys/rnsurveyfinal.pdf 2010. Humes, K. R., Jones, N. A. & Ramirez, R. R. (2011). Overview of Race and Hispanic Origin: 2010. 2010 Census Briefs. Retrieved from, http://www.census.gov/prod/cen2010/briefs/c2010br-02.pdf 2011. Johnson, M. K., Symes, L., Bernard, L., Landson, M. J. & Carroll, T. L. (2007). Mentoring disadvantaged nursing students through technical writing workshops. Nurse Educator, 32, 168–172. Loftin, C., Newman, S. D., Dumas, B. P., Gilden, G. & Bond, M. L. (2012). Perceived barriers to success for minority nursing students: An integrative review. ISRN Nursing, 2012, 806543, http://dx.doi.org/ 10.5402/2012/806543. Loftus, J. & Duty, S. (2010). Educating ethnic minority students for the nursing workforce: Facilitators and barriers
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to success. Journal of National Black Nurses Association, 21, 7–16. Lumsden, Linda (1997). Expectations for students (ERIC Digest, Number 116). Eugene, OR: Eric Clearinghouse on Educational Management. Maton, K. I., Pollard, S. A., McDougall Weise, T. V. & Hrabowski, F. A. (2012). Meyerhoff Scholars Program: A strengths-based, institution-wide approach to increasing diversity in science, technology, engineering, and mathematics. Mount Sinai Journal of Medicine, 79, 610–623. Maton, K. I., Sto. Domingo, M. R., Stolle-McAllister, K. E., Zimmerman, J. L. & Hrabowski III, F. A. (2009). Enhancing the number of African Americans Who Pursue STEM PhDs: Meyerhoff Scholarship Program Outcomes, Processes, and Individual Predictors. Journal of Women and Minorities in Science and Engineering, 15, 15–37. National Conservation Training Center (2010). USFWS Leadership Competency Development Model. Shepherdstown, WV: National Conservation Training Center (Retrieved from, http://nctc.fws.gov/LED/CompetencyModel/Sidebar/documents/ USFWS_Leadership_Competency_Development_Model.pdf). Opp, R. D. (2001). Enhancing recruitment success for two-year college students of color. Community College Journal of Research and Practice, 25, 71–86. Smith, C. B., Williams-Jones, P., Lewis-Trabeaux, S. & Mitchell, D. (2012). Facilitators and barriers to success among ethnic minority students enrolled in a predominately white baccalaureate nursing program. Journal of National Black Nurses Association, 23, 41–51. Stolle-McAllister, K., Sto. Domingo,, M. R. & Carrillo, A. (2011). The Meyerhoff Way: How the Meyerhoff Scholarship Program helps Black students succeed in the sciences. Journal of Science Education and Technology, 20, 5–16. Sullivan Commission (2004). Missing persons: Minorities in the health professions. A report of the Sullivan Commission on Diversity in the Healthcare Workforce. Retrieved from, http:// www.aacn.nche.edu/media-relations/SullivanReport.pdf 2004. Thomas, T. C. & Thurber, H. J. (1999). Strategies for the recruitment and retention of Native American students: Executive summary. Educational Document Reproduction Service No: ED435514. University of Maryland, Baltimore County (2013). Meyerhoff Scholars Program. Retrieved November 4, 2013, from, http://meyerhoff.umbc.edu/ 2013.
A
MERICANS LIVE IN an increasingly diverse society. Individuals of minority race/ethnicity comprised 31% of the U.S. population in 2000 and 37% in 2012, and this percentage is projected to exceed 50% by 2043 (American Association of Colleges of Nursing, 2013; Humes, Jones, & Ramirez, 2011). However, the composition of the nation's health care workforce has not kept pace with these demographic changes (Health Resources and Services Administration, 2006; Sullivan Commission, 2004). For example, in 2008, members of racial/ethnic minorities comprised 34.4% of the U.S. population but only 16.8% of the
*Assistant Professor, Duke University School of Nursing. †Associate Dean for Global and Community Health Initiatives, Duke University School of Nursing. ‡Making a Difference in Nursing Program Coordinator, Duke University School of Nursing. Address correspondence to Dr. Carter: Assistant Professor, Duke University School of Nursing. E-mail: [email protected] (B.M. Carter), [email protected] (D.L. Powell), [email protected] (A.L. Derouin), [email protected] (J. Cusatis) 8755-7223
registered nurse workforce (Health Resources and Services Administration, 2010). Underrepresentation of racial and ethnic minorities in the health professions can significantly impact both access to care and the quality of care received. The Sullivan Commission reported that the lack of resemblance between the U.S. health care workforce and the diverse populations they serve is leaving “too many Americans feeling excluded by a system that seems distant and uncaring” (Sullivan Commission, 2004, p. 1). Health care providers who share a common background with the person(s) to whom they provide care may be more aware of and sensitive to their patients' beliefs, values, and cultures (Coffman, Rosenoff, & Grumbach, 2001). There is also evidence that individuals are more comfortable interacting with and are more likely to feel empowered by health professionals of the same racial or ethnic background (Health Resources and Services Administration, 2006). Other benefits of patient/provider concordance include longer health care visits, better interpersonal care, and higher levels of positive affect and satisfaction among patients (Cooper et al., 2003; Health Resources and Services Administration, 2006). In addition, minority health professionals are more likely
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to practice in medically underserved areas and provide health care to minority populations (Health Resources and Services Administration, 2006). In response to the need to increase racial and ethnic diversity in the nursing profession, the Duke University School of Nursing (DUSON) established the Making a Difference in Nursing (MADIN) Program. A proposal to the Duke Endowment campaigned for a program that would cultivate an enhanced interest in nursing careers and begin addressing underrepresentation of minorities in health care, most specifically nursing. This program would build an infrastructure to increase interest in nursing careers through a summer internship program for a competitively selected group of minority students who were recruited from historically Black colleges and universities (HBCUs). MADIN became a reality in the summer of 2009 with the a group of eight minority rising juniors and senior collegelevel (nonnursing disciplines) students who participated in a coordinated program of career exploration and forecasting, mentoring, role investigation, and scientific inquiry in nursing. Weekly seminars were conducted to expose the MADIN students to a wide variety of nursing careers followed by shadow experiences. Students were also able to participate in Graduate Record Examination (GRE) review courses, career development initiatives, and a scholarly research project. Out of the eight students who participated, one has completed an Master of Science in Nursing (MSN) program, three have completed a Bachelor of Science in Nursing (BSN) nursing program, and one has been accepted into an Accelerated Bachelors of Science in Nursing (ABSN) program. The MADIN program was continued in 2010 with a group of five minority students of which three of the students were accepted into a nursing program. Because of the success of the MADIN program, an The Health Resources and Services Administration (HRSA) grant was submitted for MADIN II that would address improving equitable health outcomes among diverse populations and those most at-risk for health disparities by cultivating nursing leaders from underrepresented minority (URM) groups with a passion to promote transformative and substance evidenced-based change. The aim of the MADIN II Program is to improve the diversity of the nursing workforce by expanding nursing education opportunities for economically disadvantaged URM students to prepare for, enroll in, and graduate from the school's ABSN program. The MADIN II Program, a federally funded Health Resources and Services Administration Workforce Diversity initiative, is committed to developing the next generation of minority nurse leaders by academically, experientially, and socially preparing scholars for the highest levels of nursing service, research, education, and practice. Rooted in the Stephen Covey mantra “Begin with the end in mind” (Covey, 2004), MADIN II is committed to providing not only support for completion of the ABSN program but also the guidance needed to encourage minority students to pursue doctoral study in nursing [Doctor of Philosophy (PhD) or Doctor of Nursing Practice (DNP)]. The ultimate goal of the program is to cultivate URM nursing graduates with advanced knowl-
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edge and leadership skills who can address health disparities and positively influence health care issues currently plaguing underrepresented populations.
The MADIN II Model The structure of the MADIN II model was adapted from the highly successful Meyerhoff Scholarship Program model at the University of Maryland, Baltimore County (UMBC). The Meyerhoff Program was established in 1988 to prepare African American male undergraduate students to become leading research scientists in math, science, and engineering at the PhD level (Maton, Sto. Domingo, Stolle-McAllister, Zimmerman, & Hrabowski, 2009). Over time, the program evolved to become more gender and racially inclusive and was “opened to people of all backgrounds committed to increasing the representation of minorities in science and engineering” (University of Maryland, 2013). Since its inception, the Meyerhoff Program has enrolled over 1200 scholars and graduated 800 alumni, with nearly 300 students currently enrolled in graduate and professional programs. Key principles of the Meyerhoff Scholars Program (Maton, Pollard, McDougall Weise, & Hrabowski, 2012; StolleMcAllister, Sto. Domingo, & Carrillo, 2011) were used to develop MADIN II Program strategies such as (a) targeted recruitment; (b) scholarships, stipends, and other financial assistance; (c) a 6-week summer bridge program, which includes a scholarly research project; (d) social and academic support including study groups and academic mentoring; (e) personal advisement, counseling, and tutoring; (f) administrative involvement and school of nursing community support; and (g) familylike atmosphere. The MADIN II framework consists of four unique components: recruitment, the Summer Socialization Nursing Preentry Program (SSNPP), the Continued Connectivity Program (CCP), and the Succeed to Excellence Program (SEP). Similar to the Meyerhoff Program model, this is a comprehensive program that provides URM students with social, financial, and academic support systems. Each of the four components has distinctive purpose and goals and is integral to the students' successful matriculation in and progression through the ABSN program. These four components have been vital to ensuring the successful achievement of the ultimate MADIN II goal: promoting the development of URM professional nurses who seek advanced education while aiming to improve health disparities.
Recruiting Targeted recruitment was essential to successful achievement of the program outcomes. MADIN II recruited highachieving/high-potential URM students with strong analytical and problem-solving skills who also met the standard admission requirements for the Duke ABSN program and had a desired trajectory to pursue advanced level education. Applicants also expressed an interest in providing health care to vulnerable groups following graduation. We primarily recruited students to the
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MADIN II Program by collaborating with faculty and counselors among the science departments at targeted minority-serving universities and/or majority universities known to have a critical mass of minority students in the sciences. Universities with nursing programs were not included among the pipeline recruitment sources to avoid competition with campus-based nursing programs. Seven minority serving institutions of higher education and institutions with a documented record of strong academic programs and enrolling a substantial population of URMs were cultivated as our “pipeline institutions” for recruitment and development of symbiotic relationships. Key persons within each institution's offices of student affairs or science departments were identified and provided information about MADIN II and the opportunities available in nursing. They in turn identified students within their academic programs who were interested in pursuing a career in nursing. The pipeline recruitment sources included HBCUs in the southern United States (Bennett College for Women in North Carolina, Jackson State University in Mississippi, Spelman College for Women in Georgia, and Xavier University of Louisiana) and other institutions that have diverse enrollment within the sciences such as UMBC Meyerhoff Scholars Program, Florida International University, and University of Texas at San Antonio. Institutions with large populations of Hispanic/Latino, Native Americans, and Asian Pacific Islanders were also approached. Table 1 reflects applicant pools yielded from recruitment visits. During the first year of recruitment, the ABSN program recruiter was able to incorporate information about MADIN II into ABSN program recruitment and make targeted visits on behalf of the program. The recruiter was well-versed in the components of MADIN II and attended team meetings regularly. During the second year, because of transitions in the school's office of admission and student services, targeted visits to the selected pipeline schools were made by the MADIN II Project Director and
Academic Coordinator instead of ABSN program recruiter. When available, first-year MADIN II scholars would participate in these events and speak with students about the program from their perspective. Additional approaches toward recruitment included PowerPoint presentations, table-top presentations, and one-on-one interaction with interested applicants. In addition to making personal visits, we also sent print materials to advisors and student recruitment events. The recruitment process also included Web site promotions and feature stories about MADIN II students in the Duke University Magazine and Duke School of Nursing Alumni publications. To increase the likelihood that successful graduates of the SSNPP (described in the next section) would elect to enter the Duke University ABSN program, we proposed early admission for students admitted to MADIN II. This proposal was supported by the ABSN Admissions Committee, and the admission status was clarified to include the following stipulations: satisfaction of all ABSN admission requirements and demonstrated outstanding performance during SSNPP, as evidenced by two letters of reference from SSNPP faculty. This collaboration between MADIN II and the ABSN Admissions Committee in 2011 moved us swiftly toward realization of a larger pool of URM applicants and MADIN II-qualified candidates. The collaborative approach remained in place for the subsequent recruitment cycles. Over time, the MADIN II recruitment process was integrated into the comprehensive recruitment strategies of the DUSON ABSN program. This broadened our recruitment pipeline and the richness of the recruitment pool by engaging URM student applicants to Duke who had not previously been aware of or considered the MADIN II Program as an option for their nursing education. During the recruitment phase, MADIN II applicants now experience two levels of record review (on-campus or Skype-facilitated faculty interviews): one by the ABSN Admissions Committee and one by the MADIN II Selection Committee. Students
Table 1. MADIN II Demographics Cohort 2011 Total applicant pool SSNPP Total number offered admission Total number entered program Characteristics of SSNPP participants Mean age (years) Race/Ethnicity Black Hispanic/White Hispanic/Black American Indian Male First generation college Resident of medically underserved community Total number completed SSNPP ABSN program Total number matriculated Total number graduated
Cohort 2012
Cohort 2013
21
42
42
10 10
11 7
10 7
24.3
22.6
25.6
8 2 0 0 2 7 6 10
4 1 1 1 1 4 4 7
5 1 1 0 0 5 Unknown 7
5 4
7 N/A
4 N/A
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are now simultaneously considered for the MADIN II Program and the ABSN program; however, acceptance/denial into one program does not affect the other.
Summer Socialization Nursing Preentry Program The SSNPP is a 6-week curriculum designed to cultivate an enhanced interest in professional nursing, leadership, and scholarship. The students live and study together in on-campus apartments while attending daily learning activities and social/team-building events and participating in community service. The objectives of SSNPP are to (a) develop a basic understanding of professional nursing practice; (b) identify, study, and present a nursing problem through literature review; (c) develop a personal career trajectory plan; and (d) cultivate leadership and team-building skills and an attitude for success. To continue into the next component of the program, MADIN II scholars must successfully complete and graduate from MADIN II SSNPP. The students have a rigorous weekly schedule (see Table 2 for sample week), which includes an introductory professional nursing course (an ABSN first-semester credit course); guided pathophysiology readings to enhance understanding of the ABSN first-semester pathophysiology course; seminars
on nursing science, nursing practice, and nursing leadership; precepted shadowing experiences in various nursing academic, research, and practice roles; simulated experiences in nursing practice and decision making in the Center for Nursing Discovery; and weekly team-building activities. In addition, under the guidance of a faculty mentor, each MADIN II scholar is introduced to various parts of the nursing research process and mentored in the development of a scholarly research project. Similar to the Research Enrichment and Apprenticeship Program (Goeppinger, Miles, Weaver, Campbell, & Roland, 2009), a model designed to facilitate minority research career development, the incorporation of guided faculty research projects is important to enhance the undergraduate students' interest in research while simultaneously providing them with future mentors and knowledge of the research process. Typical scholarly projects include (a) review of the research mentor's data to create a poster presentation, (b) literature review with summary of findings, and (c) participation in research activities (e.g., data collection, site visits, etc.). The scholarly project provides an avenue for mentorship of the MADIN II scholars by nursing faculty and strengthens the scholars' professional and scientific writing skills. These mentoring
Table 2. MADIN II Scholars 2013 SSNPP Weekly Agenda Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
June 23 Church (Optional) Call if you would like to attend
June 24 8:00 AM
June 25
June 26
June 27
June 28
June 29
Mentored Shadowing (Hospital)
9:00 AM
Class Introduction to Professional Nursing
Class Intro to Biological and Physical Manifestations of Disease
10:00 AM Nursing Resource Seminar Using your Resources
WRIGHTSVILLE BEACH DAY TRIP
Socialization to Nursing Chief Nursing and Patient Care Services Officer
11:00 AM
12:00 Noon LUNCH 1:00 PM Socialization to Nursing Office of Institutional Equity
2:00 PM Socialization to Nursing Director, Diversity, Equity & Inclusion Office of Institutional Equity
LUNCH
LUNCH Debrief of Shadow Experiences
LUNCH
Nursing Resource Seminar Professional Writing Skills
Nursing Resource Seminar Successful Budgeting During the ABSN Program
Center for Nursing Discovery Nursing Skills
LUNCH Nursing Resource Seminar Understanding and Managing Stress
3:00 PM Introduction to Professional Nursing Independent Study
Sunday Dinner 4-6pm
MORAL MONDAY (Voluntary participation only) 4:00 PM
Socialization to Nursing “Diversity in Nursing; How will you contribute”
Introduction to Professional Nursing Self-Study
5:00 PM Dinner
Pick up at TBD Dinner and American Dance Festival at DPAC Dinner at 6pm DPAC at 8pm
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relationships typically continue after the MADIN II scholar enters the ABSN program. Scholars attend a three-part seminar (2 hours per session) on professional writing skills and also have access to an editor for their final project papers. The SSNPP program also includes a number of socialization and networking events. Faculty members host events at their homes, which allow the scholars to interact with faculty and ABSN students in a social environment. The scholars attend sporting events and are introduced to local arts, theater performances, and museum visits. The importance of networking and social etiquette skill is taught by an etiquette consultant, and the scholars demonstrate learned skills during a formal dinner event sponsored by the DUSON Alumni Association. New cohorts of MADIN II scholars are socialized to the school of nursing environment by previous scholar cohorts, alumni of the school, and current ABSN students. The scholars are encouraged to attend Nursing Student Nurse Association events and are welcomed to attend ABSN program events such as a family day event and a summer barbecue, which gives them opportunities to begin building relationships with students outside of their MADIN II cohort. The scholars participate in at least one community volunteer experience such as building homes with Habitat for Humanity, participating in community assessments or community interventions with Partnership for a Healthy Durham (a coalition of local organizations focused on physical, mental, and social health/well-being of local residents), or feeding the homeless with the local rescue missions.
Continued Connectivity Program The CCP was created for scholars who have their senior year of study to complete at their current academic institution. The goal is for these students to maintain momentum, to complete their undergraduate studies, and to stay connected to DUSON and the MADIN II team and their mentors and advisors. Regularly scheduled contact with the MADIN II Academic Coordinator is maintained through e-mail, text, Skype, and telephone calls. Recruitment visits provide additional opportunities for face-to-face meetings of encouragement and support. Additional methods for maintaining connectivity include postcards, care packages, Facebook messaging, and conference calls with MADIN II scholars. After graduation from their undergraduate programs, these MADIN II scholars attend the first week of the SSNPP program with the current summer MADIN II cohort to begin the process of integration and team-building with the cohort with which they will matriculate into the ABSN program.
Succeed to Excellence Program The SEP is a program of academic and emotional support and financial assistance (through stipends or scholarships) that empowers learning among the MADIN II scholars after they enroll in the Duke University ABSN program. The components of this program include personal advising,
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mentoring, study groups, tutoring, academic advising, ongoing test-taking strategies, and the National Council Licensure Examination (NCLEX) review sessions throughout the scholar's four semesters in the ABSN program. Lunch and learn seminars focused on study skills, test-taking strategies, budgeting and professional communication have been developed to minimize time constraints in the scholars' already demanding schedules. Academic advising is an important component of the SEP program because scholars are required to maintain a minimum 3.2 grade point average (GPA). Scholars are encouraged to seek assistance with academics early in their matriculation. The scholars are required to attend quarterly individual meetings with the academic coordinator to review grades and discuss future career development. Should a scholar have academic performance problems, learning improvement plans are developed with the scholar that are used to help guide the student to resources designed to target specific areas of need. Peer and alumni tutors (PAT) are available for every course in the ABSN program and are used as needed by the scholars. Such programs have been successful in translating course concepts, teaching study skills, reinforcing the nursing process, and minimizing anxiety (Degazon & Mancha, 2012). The PAT program was initially developed specifically for MADIN II scholars and has since been adopted by the ABSN program for use by all students. Although the PAT program is designed to provide students an opportunity to have concepts reinforced, many tutors found that students also just needed study strategies or an understanding ear from a fellow student who has successfully completed the course. MADIN II scholars have successfully used the tutors, and some now serve as tutors themselves for the PAT program. As scholars enter their final semester, they attend NCLEX review sessions provided by the ABSN program, are provided a current edition of a NCLEX study guide, and have access to other NCLEX resources to support development of additional strategies for test preparation. Currently, all students have access to Assessment Technology Institute, LLC (ATI) Nursing Education resources for NCLEX preparation. The MADIN II scholars are provided individualized guided NCLEX study preparation through ATI, which begins in the middle of the last semester. SEP builds on the scholarship and leadership development that was initiated when students worked with faculty mentors on research projects in SSNPP. Scholars are encouraged to create abstracts for presentation at a local or national professional meeting, and opportunities are provided to attend a national nursing conference to gain professional knowledge, enhance social and networking skills, and learn how to interact with nursing colleagues and leaders. Mentoring, professional guidance, and emotional support of the scholars continue after matriculation as students begin their professional nursing careers and contemplate graduate school and other professional opportunities. In addition to their MADIN II faculty advisors, the scholars have ABSN advisors and a peer advisor for additional support and mentorship.
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Many scholars do not have family members within driving distance, and it is important to meet the needs usually provided to them from the family setting. We create that family atmosphere with “Sunday Dinners,” which are held monthly at various faculty members' homes. These dinners are used for a time of emotional support, encouragement, and appreciation to the scholars for hard work. Academic progress is not addressed during these dinners, which are a “work-free” zone. In an effort to nurture the whole person and create the most comprehensive development program possible, MADIN II created a system of social supports identified as “Mama/Papa Mentors.” This mentorship initiative began in 2011 and was established to provide scholars with a linkage to a mature individual with whom they can bond, seek wisdom, or reach out to for personal support. The goal of this initiative is to provide a supportive resource outside of the school of nursing for the scholars. There are no specific expectations on time or frequency of contact; it is left for the mentors and scholars to determine the best methods of maintaining contact, whether through telephone, e-mail, or face-to-face meetings. The Mama/Papa Mentors were found to be trusted confidants who were available and interested in their mentee's personal joys, goals, and challenges. They provided personal support of a nonacademic nature and fortified the scholars' sense of belonging. Community service remains a valued experience, and the SEP encourages scholars are to identify a group or individual volunteer experiences that fit within the larger context of their responsibilities as ABSN students.
Financial Assistance Financial barriers are a continual concern for MADIN II scholars, so these issues are addressed on an ongoing basis throughout the program. Scholars are contacted by a financial aid advisor immediately after ABSN and MADIN II admission decisions are released. During SSNPP, they are offered the opportunity to meet individually with school of nursing financial aid officers, and discussions of federally supported scholarship programs such as the US Public Health Service Commissioned Officers Student Training and Extern Program and the military, are presented. Throughout their 16-month course of study in the ABSN Program, scholars regularly receive information about scholarship and loan opportunities, and ongoing financial counseling is provided. Because of the academic rigor of the ABSN curriculum, all ABSN students are advised to not take on any external employment while enrolled in the program. To help scholars optimize their funds, we offered budget seminars as part of SSNPP and again during the ABSN program. MADIN II provides each scholar with uniforms (scrubs) needed for clinical experiences and books for each semester. In addition, most of the scholars receive approximately US$7,500 in scholarships, which is divided over four semesters. Many scholars have also qualified for Robert Wood Johnson New Careers in Nursing Scholarship awards for URM students, which vary in amount but are approximately US$10,000 divided
over four semesters. DUSON has addressed the significant need for scholarship support among ABSN students changing from a merit-based scholarship program to a need-based scholarship program, for which most of the MADIN II scholars qualified. One significant achievement was the creation of an early tuition reimbursement agreement made between an affiliating hospital and the MADIN II Program. This program allowed scholars to be eligible for employment after graduation at the hospital, thereby giving them the opportunity for a tuition reimbursement benefit provided by that hospital to all new graduate nurses. This program was provided to the 2011 and 2012 MADIN II cohorts but is no longer in existence. Expenses associated with other MADIN II initiatives such as seminars and outings designed to socialize scholars and increase their knowledge of networking and etiquette were initially funded by staff donations and were later covered by discretionary account funding and contributions from the DUSON Alumni Association.
Program Outcomes SSNPP Recruitment and Program Completion The MADIN II Program has admitted 24 scholars to date. In the first year (2011), six schools were visited, and information/recruitment sessions were held with 168 students, generally science majors and typically classified as juniors and seniors. The informational messages stressed (a) leadership careers in nursing, (b) pursuit of PhDs and DNPs in nursing, along with the routes and processes for achieving those ends, and (c) the mission, goals, expectations, and curriculum of the MADIN II Program. In addition to the pipeline schools, information on the MADIN II Program was disseminated through a brochure distributed during non‐MADIN II recruitment trips by members of the ABSN admissions staff as they visited other institutions around the country. The overall recruitment yield for MADIN II included students contacted through the general recruitment processes of the school of nursing. These recruitment efforts yielded 21 applicants to the SSNPP program, and 10 were admitted to create the first MADIN II cohort (2011). These results were consistent with the projected number of 20 applicants and 10 admissions. Of the 10 admissions, 60% were from pipeline schools, and 40% were from the general population of academic institutions. In 2012 (second year of the program), the MADIN II Program extended admission offers to 11 students from a pool of 42 applicants. Seven students accepted the offers. One student from the previous 2011 MADIN II cohort, who had not matriculated into the ABSN program in fall 2011, rejoined the program, attended a portion of the SSNPP for team-building activities, and matriculated with the MADIN II 2012 cohort in fall 2012. Of the seven students, four (57%)% were from pipeline schools or had heard of the MADIN II Program by word of mouth from previous scholars, and three (43%) were from the general
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population of academic institutions. In 2013 (third year of the program), 10 students were extended admission offers into the MADIN II Program from a pool of 42 applicants. Again, 7 of the 10 students accepted offers. All students who participated in MADIN II SSNPP successfully completed the program. Table 1 shows the outcomes of those who have successfully completed the preentry phase of the MADIN II Program (SSNPP). Relationships with the contacts at the targeted universities were critical to the success of recruitment visits and receipt of viable applications. Recruitment visits that included scheduled time with targeted students yielded much more interest and applications than booths.
ABSN Program Matriculation Cohort 2011. Of the 10 MADIN II scholars who completed the SSNPP program, five scholars matriculated into the ABSN program in August 2011. Four graduated on time in December 2012 and successfully passed the National Council Licensure Examination for Registered Nurses (Table 1). Of the five students who did not matriculate into the ABSN program with the 2011 MADIN II Cohort, two were admitted into other nursing programs, and one worked for a year and subsequently matriculated into the ABSN program the following year. The other two students elected careers outside of nursing, but are both enrolled in master's degree programs. Cohort 2012. In August 2012, seven MADIN II scholars matriculated into the ABSN program. All seven progressed into the last semester of the ABSN program, and it is anticipated that six will graduate on time in December 2013. One student decelerated because of illness but is scheduled to graduate in May 2014. Cohort 2013. In August of 2013, four of the seven MADIN II scholars who completed SSNPP matriculated into the ABSN program. The current MADIN II scholars are performing well academically as demonstrated by GPA ranging from 3.5 to 3.9 on a 4.0 scale. They continue to acclimate to Duke and have engaged in extracurricular activities including creating an affinity organization within the school for all underrepresented minorities, and one has been elected as their cohort's class representative.
Barriers and Challenges of MADIN II Scholars The barriers and challenges faced by MADIN II scholars are not unlike those of minority students in majority institutions. Minority students, including those in nursing (Loftin, Newman, Dumas, Gilden, & Bond, 2012), experience a variety of personal, environmental, and institutional barriers to transition into and success in the collegiate environment (Cason et al., 2008; Loftus & Duty, 2010; Opp, 2001; Thomas & Thurber, 1999). An integrative review of 17 studies of perceived barriers to minority nursing student success (Loftin et al., 2012) identified recurring themes including inadequate financial support, lack of emotional and moral support, a sense of
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isolation and loneliness, discrimination, need for advising and academic support, lack of minority faculty to serve as mentors and role models, little sense of professional socialization, limited computer access and technology competence, and deficiency of cultural competence among nonminority peers. Barriers reported by MADIN II scholars included insufficient financial support, a sense of isolation and loneliness, lack of minority faculty to serve as mentors and role models, and perceptions of underdeveloped crosscultural understanding and insensitivity toward minorities on the part of some nonminorities in the environment. Many of the MADIN II scholars expressed constant worry about the cost of tuition and living expenses, an issue frequently identified as a significant barrier to minority nursing student success (Loftus & Duty, 2010; Smith, Williams-Jones, Lewis-Trabeaux, & Mitchell, 2012) The scholars faced three financial impediments that impacted their access to a nursing education: (a) individual family income lower than the federal poverty level; (b) loan debt incurred to cover the cost of their first degree; and (c) the cost of attending an elite private university with high-priced tuition of over US$70,000 for the 16-month accelerated BSN program. Several scholars were at their maximum lifetime financial aid allowance or were unable to secure sufficient funds. Students from low socioeconomic backgrounds are frequently unable to secure qualified cosigners when loans are sought. Consequently, most attrition or failure to progress from the MADIN II summer preentry program to the accelerated BSN program has been because of the inability to afford the cost of the education. Other scholars, who were able to secure loans, find themselves at graduation with excessive debt incurred during the completion of their two or more collegiate degrees. In exit discussions held with the MADIN II scholars, they shared reflections about their experiences as minority students at a majority institution. Several scholars reported the misperception held by some students in their academic cohort that MADIN II scholars receive preferential treatment and access to resources and information that other students do not receive. Scholars also expressed perceptions of being treated differently from their nonminority peers and being held to different or higher expectations and reported experiencing insensitivity and lack of understanding in interactions with some faculty and peers. Denbo (1988, 1990) found that faculty expectations greatly affect student performance. When faculty has high expectations of students, they have high expectations of themselves (Lumsden, 1997). Another theme expressed by scholars was a sense of isolation and loneliness, despite being a member of a cohort of similarly situated MADIN II peers in which teamwork is stressed and social events are regularly scheduled. Although there is meaningful assimilation of scholars with the greater cohort of ABSN peers, it is primarily academic rather than social in nature. In these cases, dissonance is most frequently associated with differences in socioeconomic status and cultural incongruence. Because of the increasing ethnic/minority population within the school of nursing, a minority
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nursing affinity group specific to minority students was created by the students. Ethnicity/Racial affinity organizations can reduce feelings of social and cultural isolation and have a positive impact on students' persistence and success (Aspray & Bernat, 2000; Dumas-Hines, Cochran, & Williams, 2001; Smith et al., 2012). When scholars were asked to what extent they felt the curriculum adequately addressed concepts such as minority health issues, health disparities, factors that contribute to health and well-being among people of color, and cultural competence, all responded that there was insufficient attention to minority and other issues of diversity in the classroom—a matter of considerable concern to minority students whose career aspirations are often linked to addressing such issues with vulnerable populations. An inclusive classroom is one in which faculty acknowledge and respond to the diversity represented in the classroom and students work together to create and sustain an environment in which everyone feels safe, supported, and encouraging learning about each other and their patient populations (Billings & Kowalski, 2008). Over time, in the nursing school environment, there is growing evidence that perceptions of students by faculty have become more positive, more supportive, and active and committed participants in facilitating student success. Proactively, a growing number of faculty have identified a need to increase their sensitivity and effectiveness in teaching, advising, and counseling minority students. Some of MADIN II scholars faced additional challenges of a developmental nature. Although these challenges are not limited to MADIN II scholars, there are hindrances that could interfere with the scholars reaching their desired outcomes as nurse leaders. These include a need to develop and/or polish social, networking, and interpersonal skills. Interpersonal skills along with effective and sensitive written and oral communication promote an atmosphere of confidence and trust that grows valuable relationships and inspires a group or a team to accomplish the tasks of the organization (National Conservation Training Center, 2010). Efforts to build and enhance capacity in these areas are very much expectations developed through specific activities and interventions. A second challenge and finding was that academic excellence does not automatically equal good writing skills (Johnson, Symes, Bernard, Landson, & Carroll, 2007). Some MADIN II scholars, although academically strong, with GPAs higher than 3.2, needed writing instruction, tutorials, and editing assistance. Strong writing skills are fundamental to academic and professional success. It is important that any such writing impediments be overcome as scholars prepare for their success and their futures. Teaching and engaging in activities to increase organizational and time management skills are among the priority areas for socializing students toward success. Benefits of time management include reduction of stress and frustration, enhanced confidence, feeling a sense of empowerment from getting things done, feeling
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better, and having time to enjoy the simple pleasures of life (Dudovskiy, 2013).
Conclusions The MADIN II Program is committed to creating equity in the diversity of nurse leaders through an increase and enhancement in the quantity of nursing educational opportunities for underrepresented students. MADIN II scholars are an exquisite group of students prepared to be among the next generation of nurse leaders. The MADIN II Program incorporates substantial evidencebased workable strategies to ensure that MADIN II scholars excel, complete their undergraduate ABSN academic program, achieve licensure, and move directly into higher education within the nursing profession. To bring leadership to the reduction and/or elimination of health disparities locally and nationally, URM students must be actively recruited, developed, supported, and nurtured. It is essential to create an atmosphere that not only embraces diversity but also cultivates the development of a student body that will enable us to have a richer understanding of our world. URM students should be prepared to function in leadership roles in order to address the issues that affect the delivery of health care locally and abroad, and faculty should partner in these goals and provide tools and resources that are needed to facilitate excellence.
Acknowledgments We would like to extend our sincere thanks to the University of Maryland Baltimore County Meyerhoff Program, President Freeman Hrabowski, Mitsue Wiggs, and our beloved mentor, LaMont Toliver, who contributed their time and mentorship in the creation of the MADIN II Program and our visionaries Dean Catherine Gilliss and Dr. Dorothy Powell.
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