The New Face of Nursing

By Chris Williams

She sits alone in her hospital bed, thoughts racing through her mind. The staff is doing the best they can despite their inability to speak her language. She's unsure how to bring up her questions and communicate her fears. Surrounded by unfamiliar faces, she wonders who will take care of her children while she's in the hospital. How long will she be away from her job? What if the hospital food doesn't match her religion's diet? Can she trust these caregivers when they don't understand her story?

photo of a patient in hospital bed with back towards camera

A workforce that is as diverse as the population it serves is essential to providing high-quality nursing care. Wayne State University's College of Nursing has long recognized the need to create a workforce that reflects the diversity of Detroit and the surrounding community. Along with its community health partners, the college is leading the way through innovative urban health education, training and community partnerships.

Barriers to effective health care can include overt discrimination, but often include other factors such as language/communication barriers, lack of transportation, lack of insurance, cultural and religious differences, biases toward sexual orientation, and differences in socioeconomic status. These barriers inhibit effective communication and prevent the development of trust and understanding between the patient and health care provider, which is crucial to successful health outcomes and patient satisfaction. A practitioner who understands a person's unique life situation, traditions and beliefs can best offer solutions that promote healthy living and encourage adherence to prescriptions, medical tests and follow-up appointments. In addition, studies have shown that patients often communicate more openly with health care providers who are of a similar racial or ethnic background. Researchers familiar with the nuances and traditions of a specific culture may have greater insights or a curiosity into the development of effective strategies that can positively impact the health care of a diverse patient population.

Unfortunately, the "face" of the health care professional often does not reflect the diversity of the communities that they serve. According to the National Center for Health Workforce Analysis, only 9 percent of all nurses are men and 75 percent of all nurses are white. This lack of diversity is concerning, especially when the Centers for Disease Control and Prevention and the U.S. Department of Health and Human Services state that minorities are more at risk for stroke, asthma, diabetes and HIV. To offer effective care, the nursing workforce must reflect the diversity in the populations it serves. Change in the workforce begins in education - and not only in the classroom. To recruit and educate future clinicians, educators and researchers from diverse backgrounds, colleges of nursing must reassess everything from internal processes and student recruitment to opportunities available for clinical training and mentorship.

Located in one of the nation's most diverse cities, Wayne State is home to faculty and students from nearly every country, race and socioeconomic class. Several renowned hospitals, health care centers and clinics are at the university's doorstep, providing countless opportunities for experiential learning in the care of a multicultural population. The College of Nursing is uniquely positioned to educate its students from diverse cultures and backgrounds and integrate them into the workforce.

The Wayne State University College of Nursing has been the recipient of numerous grants from the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services, each designed to address the issue of diversity in the nursing workforce. Its most recent HRSA grant - a prestigious four-year, $1.8 million Nursing Workforce Diversity grant - is tackling that issue at the ground level by supporting incoming freshmen from diverse and disadvantaged backgrounds. Expanding access to a nursing career to those from underrepresented groups who have been admitted through participation in this grant is one way the college aims to improve patient health and treatment outcomes. With support from the grant, the college is creating a sustainable model for student success as well as working to improve the health of the culturally diverse populations of Southeast Michigan and beyond.

The college recently completed the first year of this grant and has planned improvements in how students are recruited, educated and supported in an academically challenging program. The lessons learned through this grant may ultimately be disseminated to other nursing programs in Michigan and throughout the country.

Fostering a culture of diversity

He sits at the table, head in his hands. His son is sick and his wife is at work. Help can't arrive until 9 a.m. and his clinical rotation starts at 7 a.m. He's only four credits from a degree, but this hands-on experience is essential to graduating. But between sick kids, a full-time job and his wife's career, it's nearly impossible to make it to his clinical site on time. If only there was more flexibility; he could easily make it to afternoon or evening shifts. The way the schedule is now, though, he's afraid dropping out might be the only way to keep it together.

The student experience has changed in the last few decades, with students of various ages and cultures - many of whom are first-generation students - coming to campus. They're often single parents who are working full time, entering an atmosphere that may not have taken their background into consideration. If colleges are unable to foster environments that value diversity and acknowledge these diverse student situations, students cannot succeed, and the workforce will suffer. Even when schools successfully recruit students from a variety of backgrounds, they must examine their processes to identify structural and procedural obstacles that may inhibit student success.

To that end, the grant has incorporated opportunities to enhance ongoing workforce diversity discussions. In year one of the grant, the Wayne State College of Nursing enlisted its community partner, the Henry Ford Health System, to present a series of cultural competency and humility workshops, which were facilitated by Dr. Denise White-Perkins, director of the Institute on Multicultural Health. During these workshops, College of Nursing faculty and staff engaged in meaningful discussions and worked to identify unconscious biases that might make them less aware of student needs.

Sometimes, we only see things through the lens of our experiences and fail to look at the story of the student, team member or patient we're working with. If we understood their perspective, we'd have a better idea of how to work with them.
-Denise White-Perkins, Henry Ford Health System

"If you look at the faculty in many schools of nursing, we tend to be older, predominantly white and female. Certainly my experience as an undergraduate student is much different from students' experiences today. I wasn't working full time, I wasn't married, I didn't have children. It was very different," said Dr. Katherine Zimnicki, the grant's principal investigator. "There's often an assumption that 'I'm not biased,' yet there is a whole element of microbias, where you don't even realize that the decisions you make are a reflection of your assumptions. It is true in our interactions with our patients, and it is true in our interactions with our students as well."

During the workshops, facilitators asked faculty and staff to consider their own possible biases and privileges through a series of interactive activities. The discussion then grew broader, examining potential biases that might be embedded in the structure of the college; how they might affect recruitment, admission, retention and graduation; and what could be done to overcome them. This required participants to consider processes from a different perspective and look beyond their own situations.

"Sometimes, we only see things through the lens of our experiences and fail to look at the story of the student, team member or patient we're working with," said White-Perkins. "If we understood their perspective, we'd have a better idea of how to work with them."

The hope is that these discussions will identify issues that can be addressed in order to alleviate stressors and barriers. One area in which these discussions are beginning to bear fruit is scheduling. For example, historically, the college's clinical groups start early in the morning, which often poses a challenge for students who might have transportation limitations, children, full-time jobs or other obligations. The college is now exploring the possibility of expanding or staggering clinical times, which could be more supportive of the needs of a diverse population.

The grant also allowed for the creation of an advisory board with representatives from the college and its professional and clinical partners to address these and other issues and ultimately foster a more inclusive college community that will continually reassess its policies and make adjustments to alleviate obstacles for underrepresented students. This institutional change is crucial, and something that could be applied to universities nationwide, allowing them to not only recruit a diverse student body but also facilitate an environment that positions them to thrive.

Encouraging student success

They sit in the classroom on the first day, looking at the strangers around them. They've worked hard to get here - many are the first in their families to attend university. But will it be worth it? After the stress of mastering test scores and applying to college, will they be able to handle the homework load and ultimately make their way into nursing school? Are their fellow students friends or competitors? As the first in their families to attend college, how can they best navigate university life? And the bigger question: How will they pay for it all?

Diversity in nursing depends on colleges recruiting and graduating a student body that represents the community. To do that, schools must foster an atmosphere that minimizes obstacles and supports student success and ensures that students from a variety of cultures have the tools to succeed. That begins with recruitment.

Traditionally, college admission has been heavily weighted on GPA and test scores, despite studies showing that students who might not score the highest on these examinations still have the ability to succeed. Additionally, at Wayne State, students must complete two applications to become a B.S.N. student: One for entry to the university and, following completion of prerequisites, one for admission to the College of Nursing. This two-step process puts added stress and pressure on students who have already worked hard to gain admission to university - many of whom are first-generation students without parents who can share lessons learned through their own college experiences.

Being successful at university is about more than academics. It's about those relationships that you form with your classmates and faculty as well as the commitment to your program and university.
-Dr. Katherine Zimnicki, Wayne State University College of Nursing

In 2016, the College of Nursing began using a holistic admission process to directly admit freshmen. The college uses the existing holistic admission process to identify students who meet the criteria to be admitted to the B.S.N. Direct Admit for Freshmen pathway as well as receive workforce diversity grant support. This process uses not only metrics such as test scores, but attributes and experiences that have been identified by the College of Nursing as important to the role of the professional nurse. Specifically, the admission process looks beyond GPA - although it is still a factor - and considers community service, essays, references and other criteria. This gives students who might not traditionally test well but show potential and drive the opportunity to gain a quality nursing education at Wayne State University. The grant supports 16 freshmen students admitted in each of the four years of the grant. "This approach to admission removes the stressors associated with applying separately to the College of Nursing and thereby allows them to be more involved in the university and participate in activities and experiences that will be beneficial both as a student and as a nurse," said Zimnicki. "So far, our freshman students have progressed just fine. Admitting them as freshmen does not seem to affect their ability to progress in the program.

"This provides a more even playing field. There is a lot out there that says test scores are not necessarily the best indicator of a student's ability to succeed at the university or college level. Many colleges and universities throughout the country are looking at a holistic admission process as a way to achieve a much more diverse student body."

In addition to tuition assistance, students enrolled through the grant program receive a monthly stipend to help with day-to-day expenses intended to reduce the number of hours worked outside of school while taking classes. Students are also required to attend weekly study groups, have access to tutoring and meet regularly with a dedicated Academic Services Officer.

"We try to make the study groups diverse, not just the people who are from their own ethnic or social background," said Zimnicki. "They have to study together for four hours a week. We also provide tutoring, and they have a dedicated academic advisor in the college who they're required to meet with at least once a month."

Promoting academic success on campus, however, is just one area in which colleges need to support students. They must also leverage partnerships with local hospitals, clinics and nonprofit organizations and implement unique solutions to ensure these students have social groups and professional mentors who help them thrive.

The activities of the grant include social or nursing-related functions, such as a trip to the Detroit Institute of Arts and the Charles H. Wright Historical Museum, a demonstration in nursing's Simulation Lab, bowling, and a picnic on Belle Isle. These activities give students a chance to build friendships and form bonds that will hopefully last beyond graduation. Creating these networks can also support academic success.

"Being successful at university is about more than academics. It's about those relationships that you form with your classmates and faculty as well as the commitment to your program and to the university," said Zimnicki.

The grant also provides students with a dedicated academic advisor who students must meet with throughout the year to help keep them on track. The grant also pairs students with professional nurses who serve as mentors, providing students advice, encouragement and networking opportunities as they navigate from college to the real world.

The grant relies on partnerships with professional organizations, such as the Detroit Black Nurses Association, American Arab Nurses Association and others for student networking. Grant representatives meet quarterly with leaders in these organizations to improve communication and plan student opportunities to attend professional meetings, meet mentors and take part in other social functions that promote diversity in the profession of nursing.

"We had a student who said, 'I never saw anybody who looked like me.' She felt very isolated, even in this urban setting," said Zimnicki. "By linking her with mentors from professional organizations and faculty, we helped her feel part of a group. We helped her to see she can succeed, and she is now a graduate of the College of Nursing serving
the metropolitan Detroit area, which is what this grant is
all about!"

Firsthand nursing experience

Even before classes begin, students are often anxiously looking toward life beyond graduation. What will it take to put classroom lessons into practice? Where will they work? What opportunities are available outside of the hospital setting? As students prepare to leave college and enter the workforce, how will they keep their passion alive and serve the communities they love? Is there anything that can be done to immerse them into the nursing world even as they begin to acclimate to college life?

Crucial to the College of Nursing's work in understanding how to improve workforce diversity is providing a bridge between academic success and real-world experience. This happens before students enrolled through the grant take their first nursing classes. To allow opportunities for firsthand experience and practical knowledge, the grant provides students the opportunity to participate in a program through which they can become a Certified Nursing Assistant (CNA). This training, which occurs following their first year of undergraduate studies, provides students with not only a financial boost, but also offers early exposure to the health care field and an early window to working professional nurses.

"Financially, you can make more money as a part-time CNA than at many minimum wage jobs," said Zimnicki. "It also gets their leg in the door of a health care system, so that in addition to an avenue for employment, the student is exposed to nursing role models. They get experience with some basic entry-level patient care skills like learning how to take blood pressure and ambulate patients, and this increases their confidence in their ability to be successful in the nursing program."

Firsthand immersion into the world of nursing begins before students' first day of classes. Through the grant, the college also partners with the southeast chapter of the Michigan Area Health Education Center (AHEC) for a weeklong event featuring a variety of activities on campus and throughout the city. While there are study skills and mentoring sessions, there are also trips to the Detroit Historical Museum, a trip on the QLine, and a walkthrough of a community clinic and community garden. The goal of this week is to expose students to the city of Detroit as well as the resources available through Wayne State and the College of Nursing. This exposure not only prepares them for nursing careers, but it could also plant the seeds that help them diversify the workforce in their own community following graduation.

"If we are stimulating and encouraging local students to get these degrees and licenses and get into these careers, then we're going to develop a workforce that wants to stick around and serve the people and place they grew up around," said AHEC's Sam Young.

Part of the immersion week also includes a visit to the AHEC-run Covenant Community Care clinic, where students meet with practitioners and receive an up-close look at what a community health center does, and view the unique needs facing Detroit residents and the opportunities to serve beyond traditional hospital settings.

"The role of the nurse is becoming more critical to community health centers," said Young. "We need their expertise and their ability to educate patients. Nurses have a specialized set of skills that allow them to perform critical care functions, but also take a step back and observe specialized things with patients."

Moving toward success

She's back in the hospital, but she's not scared. She's been treated well and has a plan for healthy living when she leaves that accommodates both her busy schedule and her religious commitments. It was easier this time. Her nurse spoke her language and was familiar with her background; in fact, he grew up right down the road from her. From the moment she first talked to him, the nurse put her at ease. He knew her story; he was easy to trust.

The Workforce Diversity program grant welcomed its second cohort in fall 2018. Long term, Zimnicki said she hopes the program results not only in individual student success but also in institutional changes throughout the college - and beyond.

"Success will be measured as each cohort progresses through the College of Nursing, through cultural surveys that show we have made improvements in the cultural climate of the college, or perhaps in changes to the nursing curriculum, the physical building, or the structure of the program itself. For example, maybe we create a reflection room for students who want to pray or meditate during the day, a quiet place that is open to all. Perhaps we can make scheduling of classes more flexible or identify those key strategies that will improve the success of all students within the college. The possibilities are tremendous!"

Already, the college has made strides to take advantage of its metropolitan location and make more students throughout the Detroit area aware of the opportunities available to them at the College of Nursing. "We're doing purposeful outreach and recruitment of students from schools within Detroit, as well as those outside of the city, instead of waiting for people to come to us," said Zimnicki. "We have a great reputation nationally and in Michigan, so showcasing that with potential students is important."

Lessons learned through this program could also reverberate outside of Detroit. Zimnicki said that other universities could put many of the same programs into practice, and that eventually programs should be able to accommodate diversity and provide underrepresented students with similar opportunities using existing resources throughout their institutions. Throughout the planning and initial implementation of the program, Zimnicki said, College of Nursing faculty and staff identified programs at Wayne State and with its partners that could keep this work going after the grant period ends.

"The question always becomes sustainability. You have to do something after those four years are up. For all of our students, it is important to have strategies that support them throughout the entire program," said Zimnicki. "We cannot be dependent on grants because every time there's a budget hearing in Washington, you never know when they're going to cut this kind of funding to support diversity in the workforce."

Anticipating this, sustainability was built into the program. The college leverages academic tutoring and support programs from throughout the university and works closely with student groups to provide social support. Whenever possible, resources from throughout Wayne State are put to use to help students, ensuring that the tools to success will remain when the grant period ends.

But beyond that, success will be seen years down the road, when the nursing workforce is a reflection of the diverse community it serves.

Learn more how the diversity grant Empowers Student Success.

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