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1 THE NURSING PROFESSI ON DIVERSITY CHALLENGE: INDIVIDUAL AND INSTITUTIONAL FACTOR S THAT INFLUENCE THE ACADEMIC AND NCLEXRN SUCCESS OF RACIAL/ET HNIC MINORITY STUDENTS IN AN ASSOCIATE DEGREE PROGRAM By LOUISE AURELIEN A DISSER TATION PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF EDUCATION UNIVERSITY OF FLORIDA 2011
2 2011 Louise Aur lien
3 To m om dad & JJJ
4 ACKNOWLEDGMENTS I than k God for having blessed me with so much! Yes Lord (Dad), t ime and time again you said: My grace is sufficient for you, for my power is made perfect in weaknesses Therefore, I will boast all the more gladly about my weaknesses, so that Christs power may rest on me For when I am weak, then I am strong (2 Corinthians 12: 910). I thank my parents for sending me to the United States in order to pursue higher and better education. Your vision, loyalty, love and prayers have carried me through all t hese yea rs. MERCI BEAUCOUP!!! I thank my children JJ and Polemsky for their patience with me. JJ mom loves you from the depths of her soul. I also thank my siblings Gabrielle, Yola, Rousseau and Dominique for always believing in me. My sincere and deepest grati tude goes to my doctoral chair, Dr. Luis Ponjuan, for his continued guidance, teaching, patience and support to produce excellent work. I thank my other committee members, Dr. Campbell, Dr. Garvan, and Dr. Stacciarini. Each one of you has prompted me to vi ew things in different ways and bring it all together. I could not have ask ed for a better and more supportive team! I thank the LEAD cohort, especially Becky S. Ten e cia, Jillian, Donna Rosa Amy, Lisa, and Toni I am inspired by all of you. You are an amazing brilliant bunch! I am so proud to have met all of you and experience d this journey with you. I thank my colleagues at P BSC especially Kellie, Rhonda, Buddy and Wendell for their assistance during the data collection period. Special thanks to Barba ra Pryzby and Cindy Goegelman for their continued support. Charlene, I dont have the words to thank you for your editing skills and your generosity. Lastly, m y heartfelt thanks to all my girlfriends, especially Immacula, Karen, Myrlande J. Aliette, and Myrna for being my prayer partners over the years. I also want to thank Nadia Cecelia C. Lois, Susan, Claire, Kenny and so many others who have supported along the way
5 TABLE OF CONTENTS ACKNOWLEDGMENTS ...............................................................................................................4 page LIST OF TABLES ...........................................................................................................................7 LIST OF FIGURES .........................................................................................................................9 LIST OF DEFINITIONS ...............................................................................................................10 ABSTRACT ...................................................................................................................................11 CHAPTER 1 INTRODUCTION ..................................................................................................................13 Background .............................................................................................................................18 Racial/Ethnic Minorities in Nursing during the PostCivil War Era ...............................19 Racial/Ethnic Minorities in Nursing during the World War II Era .................................20 Racial/Ethnic Minorities in Nursing during Civil Rights Movement Era .......................21 Racial/Ethnic Minorities in Nursing during the 1970s through 2000s ............................22 Current Enrollment Rates of Racial/Ethnic Minority Nursing Students .........................23 Current Retention Rates of Racial/ethnic Minority Nursing Students ............................23 Current Graduation Rates of Racial/ethnic Minority Nursing Students ..........................24 Statement of the Problem ........................................................................................................25 Purpos e of the Study ...............................................................................................................25 Significance of Study ..............................................................................................................26 Summary .................................................................................................................................27 2 REVIEW OF THE LIT ERATURE ........................................................................................29 Literature Related to Racial/Ethnic Minority Nursing Students .............................................30 Individual and Institutional Factors that Influence the Ac ademic and NCLEX RN Success of Racial/Ethnic Minority Nursing Students .........................................................30 Race/Ethnicity .................................................................................................................30 Nursing Course Grades (NCG)/Nursing Grade Point Averages (NGPA) .......................36 The HESI Exit Exam (E2) Scores ...................................................................................42 Financial Aid ...................................................................................................................46 Theoretical Framework ...........................................................................................................51 Jeffreys Nursing Undergraduate Retention and Success (NURS) Model .............................51 Conceptual Model ...................................................................................................................54 Summary .................................................................................................................................54 3 METHODOLOGY .................................................................................................................60
6 Research Method and Design .................................................................................................60 Research Questions and Hypotheses ......................................................................................61 Setting .....................................................................................................................................62 Identification of Population Sample .......................................................................................63 Data Collection Method ..........................................................................................................64 Ethical Considerations ............................................................................................................65 Study Variables Measured Variables ...................................................................................66 Dependent Variables .......................................................................................................66 Independent Variables .....................................................................................................67 Reliability & Validity of HESI E2 ..........................................................................................69 Reliability of the HESI E2 ...............................................................................................69 Content Validity of the HESI E2 .....................................................................................69 Construct Validity of the E2 ............................................................................................70 Criterion Validity of the E2 .............................................................................................70 Data Analysis ..........................................................................................................................71 Study Limitations ....................................................................................................................71 Summary .................................................................................................................................72 4 RESULTS ...............................................................................................................................76 Descriptive S tatistics of Dependent Variables .......................................................................76 Research Questions and Hypotheses ......................................................................................77 Summary .................................................................................................................................84 5 DISCUSSION .........................................................................................................................96 Relationship between Race/Ethnicity and Academic and NCLEX RN Success .................97 Relationship between NCG/NGPA and Academic Success .................................................101 Relationship between NGPA and NCLEX RN Success ....................................................102 Relationship between HESI E2 Exam Scores and Academic and NC LEX RN Success ...103 Relationship between Financial Support/Aid and Academic and NCLEX RN Success ...105 Summary ...............................................................................................................................106 6 IMPLICATIONS ..................................................................................................................108 Policy Recommendations .....................................................................................................108 Future Directions for New Studies .......................................................................................117 REFERENCES ............................................................................................................................120 BIOGRAPHICAL SKETCH .......................................................................................................131
7 LIST OF TABLES Table page 31 Description of the sample by cohort admission date .........................................................73 32 Description of the sample by gender .................................................................................73 33 Nu rsing students by race/ethnicity and gender ..................................................................73 34 Nursing students by race/ethnicity and admission date .....................................................74 35 Nursing program gradin g scale, letter grade and grade points ..........................................74 36 Summary of dependent and independent variables ...........................................................75 41 Nursing course grade (NUR 1023) by race ........................................................................86 42 Nursing course grade (NUR 1213) by race ........................................................................86 43 Descriptives for NUR 1023 and NUR 1213 NGPAs by race/ethnicity .............................87 44 Oneway ANOVA for NUR 1023 and NUR 1213 NGPAs by race/ethnicity ...................87 45 Post Hoc tests NGPAs by race/ethnicity ............................................................................88 46 Group Statistics: Means NGPA for NCLEX RN ............................................................88 47 Independent Samples Test (NGPA) for NUR 1023 and NUR 1213 .................................89 48 Descriptives: HESI E2 examination scores by race/ethnicity ............................................89 49 Oneway ANOVA for HESI E2 scores by race/ethnicity ..................................................89 410 Post Hoc tests HESI E2 scores by race/ethnicity ...............................................................90 411 Group Statistics: HESI E2 examination mean scores by NCLEX RN status ..................90 412 Independent Samples Test HESI E2 by NCLEX RN status ............................................90 413 Financial support (aid) by race/ethnicity ...........................................................................90 415 Group Stati stics: Financial aid by HESI E2 scores NUR 1023NUR 1213 ......................91 416 Independent Samples Test Financial aid by HESI E2 scores NUR 1023NUR 1213 .......92 417 Academic success by race/ethnicity ...................................................................................92 418 Comparison of enrollment attrition graduation rates by race/ethnicity .............................93
8 419 NCLEX RN Pass rates by race/ethnicity ........................................................................93
9 LIST OF FIGURES Figure page 21 Model of Nursing Undergraduate Student Retention (NURS) ..........................................58 22 Conceptual Model: Predictors of academic and NCLEX RN success of racial/ethnic nursing minority students ...................................................................................................59 41 Grade distribution for NU 1023 by race/ethnicity .............................................................94 42 Grade distribution for NUR 1213 (12131) by race/ethnicity .............................................95
10 LIST OF DEFINITIONS ADN Associate Degree Nursing : Refers to the registered n urse who completes an established two year nursing program and earned an Associate of Science Degree in Nursing. Attrition Refers to students dropping out of the nursing program. Voluntary attrition is when a student drops out due to personal (nonacad emic) reasons compared to involuntary attrition because of academic reasons (failure or dismissal). BSN Baccalaureate Degree Program : Sometimes denot ed as BSN ( Bachelors of Science Degree in Nursing) refers to the four year nursing program in higher educat ion. Graduation rate The number of students who complete the ADN program in 150% of the stated program length [National League for Nursing Accrediting Commission (NLNAC), 2008]. This means the number of students who complete the ADN program in 6 semesters. HESI ( E2 ) Health Educ ation Systems Inc. HESI Exit Exam IRE Institutional Research Effectiveness. NCLEX RN National Council Licensure Examination for Registered Nurses : Refers to the nationally approved licensing exam for registered nurses enacted in 1982. NCG Nursing Course Grade NGPA Nursing Grade Point Average. Race/Ethnicity Refers to a students self reported race or ethnic origin Racial and Ethnic Minoritie s r efers to students who self identify as Black/African American or Hispanic Stopout Refer s to a break in continuous enrollment for one or more semesters (excluding summer sessions and intercessions). Withdrawal When a student officially withdraws from a college course or courses due to personal and/or academic reasons. W/F Withdrawal/Failing ( W/F) : w hen a student has a failure status in a nursing course or courses and decides to officially withdraw due to personal and/or academic reasons.
11 Abstract of Dissertation Presented to the Graduate School of the University of Florida in Pa rtial Fulfillment of the Requirements for the Degree of Doctor of Education THE NURSING PROFESSI ON DIVERSITY CHALLENGE: INDIVIDUAL AND INSTITUTIONAL FACTOR S THAT INFLUENCE THE ACADEMIC AND NCLEXRN SUCCESS OF RACIAL/ET HNIC MINORITY STUDENTS IN AN ASSOCIA TE DEGREE PROGRAM By Louise Aur lien December 2011 Chair: Luis Ponjuan Major: Higher Education Administration The purpose of this quantitative study was to examine the relationship between individual and institutional factors that influence the academi c and NCLEX RN success of racial/ethnic minority nursing students in an Associate Degree Nursing program. The independent variables were race/ethnicity, nursing course grades (NCG) nursing grade point average (NGPA), HESI E2 exam scores, and financial su pport/ aid (yes/no); and the dependent variables were academic success and NCLEX RN success. The study used Marianne Jeffreys Nursing Undergraduate Retention and Success (NURS) model as the theoretical framework. Data was collected from an existing studen t database on eight cohorts of (White, Black/African American, & Hispanic) nursing students (N=617) who have or should have already graduated and taken the NCLEX RN. Results from statistical analyses revealed significant relationship between race/ethnici ty and academic success, but no significant relationship between race/ethnicity and NCLEX RN success. Hispanic nursing students had the lowest enrollment rate. Black/African American nursing students had higher attrition rates than the other two racial/e thnic groups Additional results indicated significant relationship between NCG, NGPA, and HESI E2 mean scores and
12 academic and NCLEX RN success Policy recommendations to facilitate the academic success of all (primarily Hispanic & Black/African American ) nursing students are provided.
13 CHAPTER 1 INTRODUCTION The nursing profession is currently experiencing a national shortage of qualified registered nurses (RNs). Even more critical is the underrepresentation of RNs from racial/ethnic minority groups. Concurrently, the United States racial and ethnic diversity is exponentially growing. The most recent data from the U.S. Census Bureau identify the Hispanic population growth between 2000 and 2010 to be 43%, representing now 16% of the total population and the largest minority group in the United States. During the same period, the Black/African American population increased by 12.3% accounting for 12.6% of the nations total population (March, 2011). While these racial/ethnic minority groups are steadily expa nding within the general population, their persistent underrepresentation in the nursing profession is persisting and alarming. This disproportion of racial/ethnic minority presence in the nursing workforce is of critical significance. Results from the 20 08 National Sample Survey of Registered Nurses (NSSRN) indicate that only 16.8% of RNs are from ethnic/racial minority groups. Of these, Blacks/African Americans (non Hispanic) and Hispanics/Latinos of any race respectively comprise 5.4% and 3.6 % of RNs (H RSA, September 22, 2010). Although, these percentages show improvement from the 2004 NSSRN data, which revealed 4.2% of Blacks/African Americans (non Hispanic) and 1.7% of Hispanics/Latinos RNs they remain insignificant when compared to the racial/ethnic diversity shift occurring in the United States general population. Other racial/ethnic minority groups, such as American Indians/Alaskan Natives and Hawaiian Natives/Pacific Islanders, are also underrepresented in the registered nursing workforce, but the y will not be included in this study.
14 In 2004, the diversity challenge in the health professions caught the attention of the Kellogg Foundation that commissioned two landmark initiatives to address the issue: an Institute of Medicine (IOM) panel and the Sullivan Commission. The IOM report: In the Nations Compelling Interest: Ensuring Diversity in the Health Care Workforce draws attention to the substantial differences in the racial/ethnic composition of the healthcare workforce compared to the U.S. popul ation The report argues that an increase in the diversity of the healthcare workforce is critical to minimize health disparities (2004). The Sullivan Commission report: Missing Persons: Minorities in the Health Professions concludes that racial and ethnic diversity in the health care workforce has extensive consequences for the U.S. health care system. The report further maintains that increasing diversity in the health care professions (including nursing) will not only improve health care access, satisfac tion and quality for racial/ethnic minority patients, but also assure a sound health care system for all of our nations citizens (2004). More recently, in 2008, the Robert Wood Johnson Foundation partnered with IOM on a two year initiative to assess and t ransform the nursing profession. On October 5, 2010, the IOM published a report titled: The Future of Nursing: Leading Change, Advancing Health, which also calls for a greater emphasis on increasing racial/ethnic diversity within the profession. These in itiatives recognize the crisis and recommend an increase in racial/ethnic diversity within the nursing profession as a solution to reducing health disparities between minority and majority populations. The National Institute of Health ( NIH, 20062007.) d efines health disparities as differences in the incidence, prevalence, mortality, and burden of diseases and other adverse health conditions that exist among specific population groups in the United States. Lack of health insurance, geographical locati on, low socioeconomic status, language and literacy
15 barriers, and patients perception of provider patient relationship/interaction are among the contributing factors to healthcare access and disparities According to the 2004 IOM report, racial /ethnic minority patients are more likely to seek care from healthcare professionals from their own race, not only because of geographic accessibility but also for personal preference and language. These patients are also more satisfied with the care they receive fr om them. Recent research by Tucker et al., (2010) reports that the higher the percentage of racially and ethnically diverse staff members employed at a health care facility, the more satisfaction patients report about their care The 2004 IOM report furt her cites that racial and ethnic minority providers are more likely than their non minority colleagues to serve in minority and medically underserved communities Based on these facts, i mprovement in health care access and quality for racial /ethnic minor ity patients can be partly achieved with the academic and NCLEX RN success of racial/ethnic minority nursing students, and Associate Degree Nursing (ADN) programs play a crucial role in the promotion and realization of such outcomes The longstanding rac ial/ethnic minority discrepancy in the nursing workforce is a serious concern and challenge facing ADN programs as they are being urged to graduate more racial/ethnic minority students. All the aforementioned reports agree that health professions institut ions and programs (including nursing) play a vital role in shaping the progress of their recommendations. This call to improve educational outcomes of racial/ethnic minority nursing students coincides with President Obamas higher education reform, which plans to invest in community colleges with the purpose to equip a greater share of young people and adults with high demand skills and education for emerging industries ( I nvestments in Community Colleges http://www.whitehouse.gov/issues/ higher education 2009). The Presidents proposal is aiming at restoring Americas educational leadership status of having the highest proportion of
16 college graduates in the world by 2020 (President Obama, Feb. 24, 2009). On March 30, 2010, President Obama signed into law the Health Care and Education Reconcili ation Act of 2010 (Pub.L. 111152, 124 Stat. 1029), which contains the Student Aid and Fiscal Responsibility Act of 2009 ( SAFRA ) (H.R. 3221). The latter expands federal Pell Grant a nd changes federally subsidized private loans to direct loans. Such federal support is welcomed both by i nstitutions of higher education that are currently facing declining resources and Blacks/African Americans and Hispanics/Latinos nursing students. Furt hermore, the nursing literature cites financial needs as one of the factors influencing the success of these students in nursing education (Amaro et al., 2006), and consequently contributing to their underrepresenta tion in the nursing workforce. Thus makin g any form of financial assistance an appreciated proposition. Both the National League for Nursing (NLN) and the American Association of Colleges of Nursing (AACN) support the call from the Sullivan Commission and the IOM to increase racial/ethnic minorit y students in nursing programs and the profession. These two national organizations represent nursing education at the Associate and Baccalaureate degree levels and have respectively published position statements on the issue (NLN, 1979, 2009; AACN, 1997, 1999, 2010). Although recruitment and enrollment efforts have produced positive gains for nursing schools the past few years, retention of racial/ethnic minority nursing students remains a significant issue as reflected in the imbalanced profile of the nur sing workforce. The literature is replete with research that discloses the complexities surrounding the retention issue that nursing programs (ADN and BSN) face with their enrolled students, particularly those of racial/ethnic minority backgrounds (Evans, 2003; Fletcher, Williams, Beacham, Elliott, Northington, Calvin, Haynes, Winters, & Davis, 2003; Gardner, 2005a; Stewart, 2005; Valencia Go, 2005; Wilson, Andrews, & Leners, 2006). The high attrition rates
17 of racial/ethnic minority nursing students furthe r intensify the national nursing shortage of nurses, and jeopardize the prospect of supplying racial/ethnic minority nurses. Many researchers have studied and reported on the factors that influence retention, and have proposed strategies to increase [enrol lment] and retention rates of racial/ethnic minorities in nursing programs (Amaro, Abriam Yago, & Yoder, 2006; Evans, 2004; Fletcher, et al., 2003; Gardner, 2005a; Gilchrist & Rector, 2007; Guhde, 2003; Mills Wisneski, 2005; Shelton, 2003; Stewart, 2005; V alenciaGo, 2005; Wilson, Andrews, & Leners, 2006; Yoder, 1997; Yoder, 2001). However, all these efforts have yet to produce the desired outcome of equal racial/ethnic minority representation in the nursing workforce to the U.S. population. Challenged by r esearch findings, many retention projects have been initiated and efforts to identify and address the special needs of racial/ethnic minority nursing students, as well as their perceived experiences and barriers to success have been undertaken (Amaro, Abri am Yago, & Yoder, 2006; Davis, 1999; Evans, 2004; France, Fields, & Garth, 2004; Gardner, 2005b; Gooden, 2001; Yoder, 1996; Yoder, 1997; Yoder, 2001). It is very important to note that academic success refers to students who graduate on time from the ADN program within 4 semesters Additionally, the National Council Licensure Examination for Registered Nurses (NCLEX RN) success refers to a graduate registered nursing student who passes the NCLEX RN on the first trial. Passing the NCLEX RN is the ultimate professional goal of all nursing students post graduation. It is a requirement for licensure, which will allow graduates to enter the nursing workforce as RNs. First time pass rates statistics are a concern for nursing programs as they are a point of ref erence for state boards of nursing, accrediting bodies, and public opinion of educational quality. The National Council of State Boards of Nursing (NCSBN) monitors this examination and publishes quarterly first time pass rates for each institution. This re gulatory agency ensures provision of safe and competent
18 care by licensed nurses. NCSBN publication of NCLEX RN statistics does not contain a breakdown of specific data regarding racial/ethnic minority registered nursing graduates on their performance on t he NCLEX RN. However, institutional reports are available and contain this data. Smith (2009) maintains that by now we (nurse educators) should be experts in minority recruit ment, retention and graduation, since for decades, nursing programs in the U .S. have developed and tested initiatives, which unfortunately have yet to produce long term structural changes within nursing education (p. xxii). This lack of positive outcomes further warrants the need to scrutinize the topics of retention of racial/ethnic minority stu dents in nursing education. T he following segment of the paper will provide additional background information on the integration of racial/ethnic minority students within nursing education. It is important to note that the background inform ation primarily addresses Blacks (African Americans), as they were the first group in the United States to pave the way and advocate for the inclusion of racial/ethnic minorities in the nursing profession, and more literature is available. In contrast, the paucity of historical data on Hispanic/Latino inclusion/presence within the nursing literature makes it difficult to provide a comprehensive overview of their journey through the nursing profession in the U.S However, the small amount retrieved is incorporated in the background. Background In order to set the context for this study, this section will provide a historical overview of racial/ethnic minorities access and inclusion to nursing education, along with the influence of affirmative action. The se historical trends have contributed to the underrepresentation of racial/ethnic minorities within the nursing workforce. From the post Civil War era to the World War II Era, the preclusion of equal educational opportunities certainly did not help the sit uation.
19 Additionally, current enrollment, retention, and graduation rates of racial/ethnic minority students will also be discussed in this section. Racial/Ethnic Minorities in Nursing during the Post Civil War Era Racial/ethnic minorities have struggled for access to nursing education from the initial establishment of nursing schools that primarily catered to White, middle class females at a time when blatant racism was rampant (Hine, 1989). In 1873, following the Civil War era when nursing care was carried out by volunteer nurses and former slaves, three nursing schools were founded and opened their doors to only White female candidates. They were located at Bellevue Hospital in New York City, Massachusetts General Hospital in Boston, and New Haven Hos pital in Connecticut. By the end of the 1800s the number of nursing schools in the U.S. grew to more than 400. However, African Americans [Blacks] were denied access to all these schools, with the exception of the New England Hospital for Women and Childr en in Boston, which admitted one Negro and one Jewish student each year. In 1897, Mary Eliza Mahoney graduated as the first Black professional nurse (Carnegie, 1995; Hine, 1989; Journal of Blacks in Higher Education [JBHE], Winter 2001/2002). The practi ce of racial discrimination, segregation, quota system and exclusion of African Americans and other people of color served as barriers to access nursing programs and the nursing profession (Hine, 1989). Since White professionals were reluctant to provide c are for Blacks, Black physicians founded their own hospital facilities and nursing schools (Hine, 1989; JBHE, Winter 2001/2002). In 1891, the surgeon Daniel Hale Williams established the first hospital school of nursing for Black women at Provident Hospita l in Chicago. By 1920, thirty six nursing schools for Blacks were operating (Carnegie, 1995). Other nursing schools for B lacks were also initiated within independent institutions. These private institutions (colleges and universities) referred to as Histor ically Black Colleges and Universities (HBCUs) were set up
20 and supported by religious missionary societies and private donors. Such was the case of the Atlanta Baptist Seminary established in 1886, which was later renamed Spelman College in honor of Laura Spelman, John D. Rockefellers wife (JBHE, Winter 2001/2002). The exclusion from membership in the National League for Nursing Education (NLNE) and the American Nurses Association (ANA) accentuated the marginalization of Black nurses. However, in1908, a group of 52 black nurses gathered at St. Marks Episcopal Church in New York City and founded the National Association of Colored Graduate Nurses (NACGN), and elected Martha Minerva Franklin as president (Hine, 1989). Racial/Ethnic Minorities in Nursing during the World War II Era Prior to World War II, the NACGN was the only organization to undertake recruitment effor ts to promote participation of Black students in the nursing profession (Hine, 1989, p. 145). However, this approach changed during World W ar II (WWII) as W hite nurses went back to being homemakers leading to the shortage of professional nurses. This high demand for nurses led to the Federal governments passing of the Bolton Bill of 1943, which contained an anti discrimination amendment. Th is new bill established the United States Cadet Nurse Corps and provided financing for basic education that benefited over 3,000 Black nurses (Carnegie, 1995). The overwhelming need for nurses obliged the bending of the racial barriers of the profession. The integration of racial/ethnic minorities within the nursing corps in the military preceded that of the nations armed forces by many years (JBHE, Winter 2001/2002). During the same period (WWII), in 1944, the U .S Army welcomed large numbers of Puerto Rican troops to serve in the Caribbean and South Atlantic Theater of Operations. This decision caused the Army Antilles Department to repeal its previous policy regarding the exclusion of Puerto Rican nurses in the Army or Navy Corps. The nurses bilingual abilities were recognized as an invaluable asset to both patients and Continental providers in the delivery of
21 care in the hospitals. The Surgeon General's Office, the Governor of Puerto Rico, the Commissioner of Health of Puerto Rico and a group of reput able physicians collaborated to determine criteria that would be used to grant Puerto Rican nurses entrance into the Army Nurse Corps. Thirteen Puerto Rican Nurses were commissioned to work at the Post of San Juan and Camp Tortuguero, both posts in Puerto Rico (P.R.) (Army Nurse Corps Archives, July 7, 2009). In 1951, the NACGN merged with the American Nurses Association (ANA), and dissolved presuming that the objectives for Black nurses would be embraced and carried out by the ANA. Additionally, on May 17, 1954 in the Brown v. Board of Education of Topeka decision, the United States Supreme Court ruled that racial segregation in Americas schools was unconstitutional. These steps toward inclusion seemed very promising in providing equal educational opportunities for Blacks who aspired to become nurses. Subsequently, in the 1950s, leaders of predominantly White nursing programs agreed to enroll more Blacks. Unfortunately, their effort yielded a steep decline in the number of Black students (Carnegie, 1964 as cited in Barbee, 1993; Hine, 1989). This decline led Carnegie (1964) to suggest that there was still a need for Black schools of nursing (as cited in Barbee, 1993). Racial/Ethnic Minorities in Nursing during Civil Rights Movement Era The Ci vil Rights mo vement of the 1960s confronted and protested against all forms of racial subordination and discrimination against racial/ethnic groups present within American higher education and nursing schools. As the movement expanded, racial/ethnic minorities demanded social justice, which prompted legislative changes and court rulings, such as the Civil Rights Act of 1964 and the Nurse Training Act of 1964, banning segregation, providing funding and forcing nursing schools to open their doors to racial/ethnic minority nursing students (Hine, 1989). The Higher Education Act of 1965 provided funds not only to help low income students but also for the admission and support of ethnic minority students. In 1965, the National Student
22 Nurses Association (NSNA) established th e Breakthrough to Nursing project with the goal of increasing the number of minority healthcare providers (NSNA, 2004). Racial/Ethnic Minorities in Nursing during the 1970s through 2000s In the 1970s and 1980s, federal funds made possible the formation of several minority recruitment programs, w hich accounted for the increase in racial/ethnic minority enrollments (Barbee & Gibson, 2001). Unfortunately, in the 1990s, the extinction of these provisional funds affected the s ustainability of these programs and c ontributed to the persistent underrepresentation of racial/ethnic minorities in the nursing workforce (Barbee & Gibson, 2001). In December 1971, under the leadership on Lauranne Sams, the National Black Nurses Association (NBNA) was formed. This move re sulted from growing concerns regarding the inequities in health care for African Americans and the lack of increase of Black RNs to speak up on such issues. Additionally, the ANA neglected to invite Black nurses to serve in key leadership roles within the organization and to recognize their significant contribution to the nursing profession (Hine, 1989). G reat concern ha d also surfaced as the justification for Title VI (Affirmative Action) of the Civil Rights Act of 1964 has been challenged in the courts on constitutional grounds with such cases as: Regents of University of California v. Bakke (), Hopwood v. Texas (), Grutter v. Bollinger (03), and Gratz v. Bollinger (). These cases demonstrated that the struggle for racial/ethnic minority integration in education persist ed and exist ed in nursing education as well. Still in the early twenty first century, as mentioned in the Sullivan Commission 2004 report, even with a 44% increase in racial/ethnic minority enrollment made between 1991 and 2003 in BSN programs, the shortages of underrepresented minority nursing students clearly remain (p.56). The voice of Hispanic nurses during this period emerged In 1971, Ildaura MurilloRohde, the first Hispanic nurse to earn a PhD, founded the National Association of Hispanic
23 Nurses (NAHNTM), designed and committed to improving the quality of health and nursing care of Hispanic consumers and toward providing equal access to educational, professional, and economic opportunities for Hispanic nurses (NAH NTM, 2011). Current Enrollment Rates of Racial /Ethnic Minority Nursing Students The data published by the NLN shows evidence of improvement in racial/ethnic minority e nrollments in nursing programs. According to the 20092010 National League for Nursing NLN Data ReviewTM, racial/ethnic minority nursing students represented 26% of all enrollments in ADN programs with 11.9% African Americans, 7.9% Hispanics/Latinos, 5.0% Asians, and 1.2% American Indians (NLN 2011). These numbers indicate a 2.2% decline fro m the previous year (20082009) with the following breakdown: 13.9% African Americans, 7.6% Hispanics/Latinos, 5.7% Asians, and 1.0% American Indians (NLN, 2009). This drop is worrisome as it reflects the lack of consistency in tackling the persistent issu e of underrepresentation of racial/ethnic minorities in the nursing workforce to care for the rapidly growing racial/ethnic population in the United States. Current Retention Rates of Racial/ethnic Minority Nursing Students The NLN reports that as of 2004, ADN programs had a first year retention rate of 83% (NLN, 2008). However, it is important to note that not only does this data lack to furnish a breakdown by racial/ethnic groups, it is not indicative of program completion, and consequently requiring further exploration. The persistent underrepresentation of racial/ethnic minorities in nursing remains problematic. Based on the 2008 NSSRN findings (HRSA, 2010), it is obvious that nursing programs still struggle with retention of this group to generate f avorable outcomes of a representative nursing workforce. Recruitment and enrollment of racial/ethnic minority students are ineffective and unproductive, when the students are not retained and do not achieve
24 their goal of becoming RNs. Therefore, it is esse ntial that ADN programs establish suitable environments that promote the retention of these students. Current Graduation Rates of Racial/ ethnic Minority Nursing Students In spite the high attrition and low retention rates, nursing programs across the U .S. have reported an increased in graduation rates of racial/ethnic minority students. According to the National League for Nursing NLN Data ReviewTM for year 20082009, the graduation rate for racial/ethnic minority students from pre licensure registered n ursing programs (both ADN & BSN programs) was 24.5 % in 2006. This represented a 4.5% increase from the previous three years and was an even 1.0% distribution across all racial/ethnic categories (Asians, African Americans, and Hispanics), with the exception of American Indians who only gained 0.3 % In 2007, the graduation rate slightly dropped to 23.6% (NLN, 2009). While these percentages indicate an upward trend, they still lag behind the muchdesired racial/ethnic minority representation in the nursing wor kforce. This background has shed some light on the historical trend of marginalization of racial/ethnic minorities in nursing education, leading to their underrepresentation in the nursing workforce. The effects of the segregation movement have spawned into a full blown public health issue, as supported by the existing health disparities among racial/ethnic minorities. In 2008, roughly 60% of all nursing students graduated from ADN programs (NLN, 2008). Despite evidence of such contribution to the nursing workforce, there remains an alarming lack of supply of racial/ethnic minority RNs, which the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) refers to as a prescription for danger, negatively affecting patients outcomes (JCAHO, 2002). The 2008 National Sample Survey of Registered Nurses (NSSRNs) report shows the total RN population to be made of only 15.1% of racial/ethnic minorities (HRSA, September 2010). This upward trend is welcomed, but not enough to mirror the current
25 33% eth nic/racial minority population of the United States, nor does it address todays healthcare disparities respective to this group. Statement of the Problem The U.S. Census Bureau latest report substantiates forecasts of a rapidly growing racial/ethnic minor ity population, while the 2008 NSSRN reveals a homogeneous nursing workforce, unreflective of the United States population. The Sullivan Commission, the IOM and two of the major nursing educational organizations (NLN and AACN), along with other health care organizations have been once again alerted on the issue. In order to tackle this major challenge, ADN programs across the nation are being urged to graduate more racial/ethnic minority students. Unfortunately, most of these programs still struggle with re tention of this student population. Because of the nationwide nursing shortage, it is critical to focus on the retention of racial/ethnic minority nursing students in ADN programs. Knowing which individual and institutional factors that may assist or hinde r these students from persisting to graduation is necessary to achieve a diverse nursing workforce. Individual factors are classified into race/ethnicity, nursing course grades, and HESI exit (E2) examination scores. Th e selected institutional factor is fi nancial support. Purpose of the Study The purpose of this quantitative study is to examine the relationship between the selected individual and institutional factors that influence the academic and NCLEX RN success of racial/ethnic minority nursing studen ts enrolled in an ADN program. Students retention through the nursing program will be examined using Jeffreys Nursing Undergraduate Retention and Success (NURS). The need to explore this complex nursing education phenomenon of racial/ethnic minority nurs ing students retention leads to the following research question: What
26 is the relationship between selected individual and institutional factors and the academic and NCLEX RN success of racial/ethnic minority nursing students in an ADN program? Signific ance of S tudy The steady increase of the racial/ethnic minority segment of the United States population necessitates a similar trend in the racial/ethnic composition of the nursing workforce, to improve the health outcomes of this group. Between 1977 and 1997, racial/ethnic minority in the nursing workforce grew from 6.3% to 9.7% (Buerhaus & Auerbach, 1999). As note d earlier, report from the 2008 NSSRN shows the total RN population to be made of 15.1% of racial/ethnic minorities (HRSA, September 22, 2010). Due to the underrepresentation of racial/ethnic minorities in the nursing workforce in spite of current progress in enrollment and graduation rates, it is imperative for educational leaders to determine the reasons for the early departure of this group of students, so as to implement strategies that promote racial/ethnic minority students successful completion of an ADN program. Many quantitative and qualitative research studies exploring the plight of racial/ethnic minority nursing students have been undertaken, primarily at the baccalaureate level. However, the results have been inconsistent and vary from one nursing program to another. Glossup (2001) remarked that there are fewer studies aiming at describing variables that may predict completion of a n ursing program than those conducted to predict NCLEX RN success; thus the need to investigate these outcomes. A quantitative study on selected individual and institutional factors influencing the retention and NCLEX RN success of these students in an ADN program is warranted. It is important for several reasons. First, valuable data analysis will reveal some of the underlying reasons such as demographic, cognitive, and financial factors that may be related to the lack of success of this group of students, and may assist faculty in the examination and
27 revision of curriculum, and instructional approaches in order to meet the learning needs of these students. The study results will offer faculty information that will facilitate early recognition of at risk st udents. This early identification will allow facultys provision of the necessary counseling and support to promote academic success and the probability of ontime graduation. Second, the data will provide nursing program administrators with greater unde rstanding of variables associated with academic and NCLEX RN success of racial/ethnic minority students in an ADN program. The study results will prompt administrators to design and implement new strategies to break down barriers and promote higher retent ion and NCLEX RN pass rates of this population. Third, the findings will serve as supporting evidence for institutional administrators of the need to establish new policies and strategies such as tutoring, support groups, and financial support. Summary Ma ny initiatives and organizations have recently drawn attention to the persistent underrepresentation of racial/ethnic minority in the nursing workforce and the imperative need to change it. In the academic year 2005 2006, roughly 24% of all nursing students who graduated from an ADN program were racial/ethnic minorities (NLN, 2008). Evidence of such contribution to the nursing workforce is barely noticeable in the nursing workforce and not supplying enough racial/ethnic minority registered nurses. Also, t here remains a disparity between the United Sates racial/ethnic population and the nursing workforce composition. The National Advisory Council on Nurse E ducation and Practice (NACNEP, 2008) urges nurse educators to resolve the situation by improving the r etention and graduation rates of this group of students Also compelled by President Obamas higher education reform, ADN programs need to not only recruit, but also retain individuals that represent the United States population. A
28 quantitative study to fu rther explore selected individual and institutional factors influencing the academic and NCLEX RN success of racial/ethnic minority nursing students is obligatory.
29 CHAPTER 2 REVIEW OF THE LITERATURE Colleges and departments of nursing are faced with the ambitious aim of assuring the academic and NCLEX success of racial/ethnic minority students, so as to counter their underrepresentation in the nursing workforce. Based on some of the most recent graduation rates from nursing programs, the interventions re lated to key benchmarks have yet to appropriately address the issue of racial/ethnic diversity of the nursing workforce to better reflect the nations changing demographic profile. Researchers have attributed these low levels of representation of this group of students to their low retention rates As Jeffreys (2004) puts it: the most persistent trend in student persistence research is that student attrition persists (p. 4). Therefore, understanding which individual and institutional factors that influenc e the academic and NCLEX RN success of racial/ethnic minority nursing students is invaluable to all stakeholders. The purpose of this study is to examine the relationship between the selected individual and institutional factors that influence the academic and NCLEX RN success of racial/ethnic minority nursing students enrolled in an ADN program. The individual factors explored in this study are race/ethnicity, nursing course grades (NCG), nursing grade point average (NGPA) ( for the first two didactic cou rses), and HESI exit (E2) examination scores. The selected institutional factor is financial support. For more than six decades, the nursing literature has consistently explored the student nurse within nursing education. In general, predictive studies have been undertaken to examine the relationship between individual and institutional variables and academic and NCLEX RN success. However, there is a paucity of studies in the nursing literature that closely examine racial/ethnic minority students in ADN pr ograms. This chapter will present a review of pertinent scholarly research that identify the individual and institutional factors that influence the retention
30 and NCLEX RN pass rates for nursing students in general, from either the baccalaureate or associ ate degree level. Furthermore, an overview of Jeffreys Nursing Undergraduate Retention and Success (NURS) Model will be presented. Jeffreys NURS Model is the selected theoretical framework that will guide this investigation Literature Related to Raci al /Ethnic Minority Nursing Students Numerous research studies and doctoral dissertations have investigated variables that predict first time NCLEX RN pass rate and academic success as a form of retention. However, the results are inconsistent and vary fr om one nursing program to another. The majority of the studies only cover some aspects of student retention in nursing programs, and most samples are from BSN programs, while the greater number of graduates who sit for the NCLEX RN examination are from AD N programs (NLN, 2009; Yin & Burger, 2003). Additionally, there is a paucity of both quantitative and qualitative evidence concerning NCLEX RN pass rates associated with racial/ethnic minority students. In order to identify early predictors of academic an d NCLEX RN success, more research focused on racial/ethnic minority students in associate degree nursing (ADN) programs need to be undertaken. As mentioned earlier, since only a few of the studies were conducted with samples from ADN programs this review of the literature will report findings from the general nursing student population without regard to degree level (BSN and ADN). Hence, this literature review reports on the research examining the correlation between selected individual and institutional factors and academic and NCLEX RN success. Individual and Institutional Factors that Influence the Academic and NCLEX RN Success of Racial/Ethnic Minority Nursing Students Race/Ethnicity Many researchers in nursing have identified race/ethnicity as a r isk factor that significantly affects the retention of college students. An earlier study by Oliver (1985) reported
31 great disparity in an ADN program completion between Black and Caucasian students. Similarly, Yocom and Scherubel (1985) found that minoriti es at a baccalaureate nursing program were less likely to complete or pass the NCLEX RN. Gardner (2005) report ed that the high attrition rate of ethnic/racial minority nursing students is a contributing factor to the underrepresentation of these individua ls in the nursing profession. An analysis of racial/ethnic minority students records admitted to a Minority Retention Project at California State University showed the attrition rate to be 80% and primarily due to academic reasons (Gardner, 2005a ). Camp bell and Dickson (1996) conducted an integrative review and meta analysis of 47 nursing studies that were published in the United States between 1981 and 1990. The studies investigated predictors of retention, graduation and NCLEX RN pass rates of baccalaureate nursing students. Only five of the studies they reviewed included race/ethnicity as a demographic variable. Of these studies, only two yielded significant results, rendering it difficult to identify any consistent trends, patterns, or gaps. Other nursing researchers have found that racial/ethnic minority students to be most at risk for stopouts or dropouts, take longer to complete their education, and have lower first time pass rates in the NCLEX RN (Bessent, 1997; Byrd, Garza, & Niewiadomy, 1999; C row, Handley, Morrison & Shelton, 2004; Endres, 1997; Haas, Nugent, & Rule, 2004; Harris, 2006; Jeffreys, 2007; Seago & Spetz, 2005; Sayles, Sheldon & Powell, 2003). Haas, Nugent and Rule (2004) sought to determine if first time success on the NCLEX RN e xamination could be accurately predicted of 351 students who graduated between 1991 and 2001. The authors used a discriminant analysis with a stepwise procedure to predict student success on the NCLEX RN. The overall NCLEX RN first time pass rate for the group was 90.3% Results obtained through chi square analysis indicated that the failure rate of African
32 American students (18.8% or n = 6) was significantly higher than that of Caucasian students (8.1% or n = 25). Asian students also demonstrated a signi ficantly higher failure rate (37.5 % ) than Caucasian students, though the sample size was small (n = 8). On the other hand, the only two Hispanic students in the study passed the NCLEX RN on the first trial (Haas et al., 2004). It is important to mention t hat the small number of Hisp anic and Asian students in their study limits its generalizability A study by Seago and Spetz (2005) of California Community C ollege nursing (ADN) programs sought to determine whether ethnic minority groups have different succ ess rates. The authors examined factors related to on time completion rates, attrition rates, and NCLEX RN first time pass rates of racial/ethnic diverse students from California Community C ollege nursing (ADN) programs. The study findings indicate that A sian nonFilipino and African American students had lower ontime completion r ates than the statewide average and the lowest rate of success with only approximately 50% graduating by 2002. Also, the nursing programs with higher percentages of Asian and Afr ican American students had higher attrition rates in spite of support services. Additionally, these programs had lower NCLEX RN first time pass rates, even when controlling for other program characteristics. It is interesting to note that the authors did not accentuate on the findings for Hispanics/Latinos in this study, given their high proportion in California's population. The researchers are aware of the limitations of their findings related to geography, and omission of variables (predictors) for both individual and institution ( Seago & Spetz, 2005). Another study of national scale by Crow, Handley, Morrison, and Shelton (2004) aimed to identify current interventions used by BSN programs to promote academic success and predict NCLEX RN success. Parti cipants were voluntary recruits from the 513 generic BSN programs
33 listed in Official Guide to Undergraduate and Graduate Nursing Schools (NLN, 2000 as cited in Crow et. al., 2004). The researchers found that programs with higher percentages of White stude nts were more likely to have higher passing rates than programs with smaller percentages; additionally, programs with higher percentages of Hispanic students reported lower pass rates (p. 184). They recommend further studies to investigate the relationshi p between ethnicity and NCLEX RN success (Crow et al., 2004). Similarly, research by Sayles, Sheldon and Powell (2003) exploring predictors of success in nursing education involving a sample of 78 nursing graduates from an ADN program; found that African American students were less likely to be successful in the NCLEX RN than their White counterparts. The findings from these previous studies are consistent with a study by Byrd, Garza, and Niewiadomy (1999), which concluded that the demographic variables such as race/ethnicity along with admission and progression criteria were predictive of students' completion of a BSN program. Results implied a correlation between race/ethnicity and graduation from a nursing program and NCLEX RN first time pass rate. Th e researchers found that White students were more likely to graduate than racial/ethnic minorities (Byrd et al., 1999). However, the researchers caution interpretation of the data due to the uneven racial/ethnic representation in the sample. Additionally, a more recent study by Harris (2006), examining the records of 167 nursing students who graduated from a BSN program in the Southeastern United States between May, 1999 and December, 2003, yielded comparable findings. The investigator found that White nurs ing students were 0.48 times more likely to pass NCLEX RN the first time than racial/ethnic minority students. Conversely, other researchers found no correlation between race/ethnicity and first time pass rate in the NCLEX RN (Briscoe & Anema, 1999; Endr es, 1997; Hardin, 2005; Higgins,
34 2005; Jeffreys, 2007; Washington & Perkel, 2001; Yin & Burger, 2003). For instance, Endres (1997) conducted a retrospective study to look at the strongest predictors of NCLEX RN success. The random sample included of 50 Af rican American, 50 Foreignborn, and 50 Caucasian, who were selected from 1,2 05 nursing graduates from four BSN programs in Texas. The author concluded that there were no significant differences between the passing and failing rates among the three ethnic groups, therefore rejecting race/ethnicity as a predictor to NCLEX RN success (Endres, 1997). Similarly, Jeffreys (2007) did not find race/ethnicity to be a significant predictor of first time NCLEX RN pass rate; neither did Higginss (2005) study of 213 ADN students yield any statistical significance between race and nursing program completion and NCLEX RN success. However, when Endres (1997) further analyzed the data, she found an interesting relationship between student progression and NCLEX RN suc cess/failure. African American graduates who passed the NCLEX RN were more likely to require significantly more semesters to complete the nursing curriculum than passing foreign born and White graduates. Failing African American graduates also needed mor e semesters to complete the nursing curriculum than failing White graduates Also, foreignborn graduates who failed the NCLEX RN required more semesters to complete the nursing curriculum than passing foreign born graduates They also needed more semesters to complete the nursing curriculum than failing African American and W hite graduates (Endres, p. 369, 1997). Jeffreys (2007) conducted a retrospective evaluation study assessing the entry, progression, graduation and licensure characteristics of cul turally diverse ADN students. The sample consisted of 112 students who entered their first clinical nursing course during fall or spring semester of the 1997 1998 academic year. The author tracked students progress via
35 three different retention pathways (ideal, continuous, and interim/stopout), and three attrition pathways (first semester failure, voluntary and involuntary). Jeffreys (2007) noted that Hispanic students had the highest percentage of stopouts and the highest first semester failure. Further more, Black students had the highest percentage of voluntary attrition and the highest percentage of non graduates (ibid). This finding is reflective of the Black students attrition rate in higher education, especially those attending predominantly W hite institutions (Bessent, 1997; Gardner, 2005; Oseguera, 2005; Taxis, 2002; & Stewart, 2005 as cited in Jeffreys, 2007). As was the case in Endres (1997) study, Jeffreys (2007) further analyzed the data and found White students to have the highest percentag e of graduates, and Blacks to have taken longer to complete the nursing program than Asians and Whites. Evidently, further comparison of the ethnic groups yielded important information that demonstrated differences in retention rate among the distinctive r acial/ethnic minority groups that are supported by other researchers (i.e. Seago & Spetz 2005) cited earlier in this paper In light of the changing racial/ethnic demographic in the United States, further exploration of the role of the race/ethnicity vari able in predicting academic and NCLEX RN success in nursing programs is warranted. Briscoe and Anema (1999) conducted a study in which one of the six hypotheses was to examine the relationship between race and the ability to pass the NCLEX RN. The conv enience sample included 19 W hite/nonHispanics, 13 Blacks/nonHispanics, 5 students of African descent, and 1 Hispanic from an ADN program The researchers found statistical significant relationship between students of African descent and poor first time N CLEX RN pass rate; but found no significant correlation between the other racial/ethnic groups and NCLEX RN success; yielding mixed results related to race/ethnicity. The small sample size and the inconsistencies of these results limit the generalizability of this study.
36 The findings from these studies represent the evidence that racial/ethnic minority nursing student s may be at greater risk of academic difficulty and attrition. Most of the results suggests that Whites were more likely to graduate on time from nursing programs and succeed in the NCLEX RN (Campbell & Dickson, 1996; Byrd et al., 1999; Sayles et al., 2003; Seago & Spetz, 2005), while others proposed that Blacks, Asian and Hispanic students needed longer period of time toward program completion, and Black and Hispanic students were more likely to drop out from a nursing program (Endres, 1997; Jeffreys, 2007). At the same time, others (Briscoe & Anema, 1999; Endres, 1997; Hardin, 2005; Higgins, 2005; Jeffreys, 2007; Washington & Perkel, 2001; Yin & Burger, 2003) found some or no significant correlation between race/ethnicity and first time NCLEX RN pass rate. Because of the conflicting findings, the variable of race/ethnicity alone cannot be considered the most significant predictor of retenti on and NCLEX RN success of minority students. Nursing Course Grades (NCG)/ Nursing Grade Point Averages (NGPA) Although nursing course grades have been shown to have some predictive value for academic and NCLEX RN success, limited studies demonstrating a relationship between the two variables have been published in the nursing literature (Byrd et al., 1999; Gallag her, Bomba, & Crane, 2001; Jeffreys, 2007). The majority of studies focused on the predictive value of nursing course grades to NCLEX RN success which will be presented later in this section. Although licensure is the optimal goal for students, additional studies examining the correlation between nursing course grades and academic success may assist nurse educators in early identification of atr isk students and the implementation of early interventions promoting retention and eventually NCLEX RN success. Byrd et al., (1999) found grades in nursing courses to be predictive of graduation from a BSN program. Gallagher et al., (2001) examined the f inal academic grades for the first nursing
37 course (NUR 101), in order to determine their ability to predict successful nursing program completion. This course introduces students to fundamental nursing concepts and care of patients. The investigators conc luded that the NUR 101 course average is predictive of successful completion of the nursing program. They further stated NUR 101 grade has the potential to identify students who may be at risk for failure in our program or on NCLEX RN (p.134). Consequently, the faculty increased the course grade average from 74% to 76% (C grade) as the lowest grade necessary for successful completion of all nursing courses ( Gallagher et al., 2001). Similarly, findings from a more recent study by Jeffreys (2007) suppor t these previous conclusions regarding nursing course grades. The independent variable MS1 was the introductory nursing course and included contents from fundamentals and medical surgical nursing. The author reported grades in MS1 to have significantly inf luenced the type of retention, progression, graduation, and licensure. Additionally, Jeffreys evaluated the course grade distribution for each retention and attrition category. Eighty three percent of students in the ideal retention group had earned grades of B or greater in MS1. These students consistently demonstrated higher mean grades in each nursing course, as opposed to those who voluntarily dropped out. Furthermore, a C+ grade in MS1 was the most predominant grade among students who voluntar il y dropp ed out (40%), and those enrolled continuously but took longer than 4 semesters to complete the program (56%), as well as those who stopped out (32%). Thus, the study concluded that nursing course grades were predictive of academic success (Jeffreys, 2007) Nursing research has consistently demonstrated a strong correlation between nursing course grades and NCLEX RN success or failure. In a national survey of 160 BSN programs, 36.3% of the programs reported using specific course grades as a predictor of NC LEX RN
38 success (Crow et al., 2004). Some researchers maintain that failure in even one nursing course is associated with NCLEX RN failure (Alexander & Brophy, 1997; Endres, 1997). For example, Endres (1997) found the risk for failure in the NCLEX RN to increase with the number of C grades or lower in nursing theory courses. The author further reported a significant relationship between a students grades in certain nursing courses (psychiatric mental health nursing, maternity nursing, pediatric nursing, adult health nursing I and II, and nursing care of the critically ill) and success on the NCLEX RN (ibid, 1997). Likewise, Nnedus (2000) ex post facto study of graduates from three BSN programs in Southeastern U.S. identified grades in a selected nursing course of psychiatry as the best predictor of NCLEX RN success, while grades in pediatric nursing offered the least predictability. Alexander and Brophy (1997) conducted a retrospective study that covered a five year period (July 1988 February 1994). The researchers sought to determine the relationship between admission, progression, and exit variables with NCLEX RN performance and the identification of students at risk. They used a quota sampling technique of 188 graduates, which included all (n = 94 ) first time NCLEX RN failures from July 1988 through Fe bruary 1994, and an additional n = 94 randomly selected graduates who had passed the NCLEX RN on their first trial during the same period. The authors noted statistically significant differences in nursing course grades between graduates who passed and those who failed the NCLEX RN. The most significant difference between the two groups occurred in the theory nursing courses (e.g. childbearing, nursing adult I and II, child/family); and g rades in f ive of the six clinical nursing courses (all but mental health nursing) provided the greatest differentiation between the groups (Alexander & Brophy, 1997).
39 Congruously to Alexander and Brophys (1997) findings are Barkley, Rhodes, and Dufours (1998) f indings from their investigation on the relationship between grades in six nursing courses (psychiatric/mental health, adult health I and II, pediatric, obstetric, and critical care nursing) and performance on the NCLEX RN. The researchers found strong co rrelations between grades in the pediatric and psychiatric mental health nursing courses with performance on the NCLEX RN, and moderate correlations between grades in the remaining courses and performance on the NCLEX RN. The higher the number of Cs obtained by a student in clinical or theory nursing courses, the higher the probability of failure in the NCLEX RN (Barkley et al., 1998). Likewise, Uyehara, Magnussen, Itano, and Zhang (2007) found significant correlations between NCLEX RN success and nur sing GPA, and course grades in Fundamental nursing course. Consistent with previous research, a comparison study by Roncoli, Lisanti, and Falcone (2000) of a random sample of 19 BSN nursing students from four graduating classes who passed the NCLEX RN wi th 19 students who did not pass, also reported similar results. They found that nursing students, with A and B grades in nursing courses, were significantly more likely to pass the NCLEX RN than those who obtained Cs in nursing courses or repeated nursing courses. A recent study by Bentley (2008) found the number of Cs in clinical nursing courses to be significantly correlated with negative NCLEX RN results. Similar findings were reported by another study by Beeman and Waterhouse (2001), who examined the records of 289 nursing graduates. The sample included students from the traditional and accelerated BSN programs at the University of Delaware between 1995 and 1998. The researchers found a significant correlation between the number of Cs that a student e arned in nursing courses and negative performance on the NCLEX RN. The number of C+ grades or
40 lower in nursing theory courses had the highest negative correlation with NCLEX RN success, followed by grades in specific nursing courses. Graduates who passe d the NCLEX RN had significantly higher grades in all didactic nursing courses. The researchers used a discriminant analysis function, which correctly classified more than 94% of the students who passed and more than 92% of the students who failed. Approx imately 31% of the variance in passing and failing was accounted for by the discriminant analysis ( Beeman & Waterhouse, 2001). Seldomridge and DiBartolo (2004) also conducted a retrospective descriptive study, and sought to identify the best models for pr edicting NCLEX RN success and failure at three points in the nursing curriculum: pre admission, after the completion of 1 year of nursing courses, and immediately prior to graduation. The sample consisted of 186 graduates of a traditional BSN program, at a rural, mid Atlantic public institution from 1998 through 2002. Using logistic regression, four models were developed that included predictors of medical surgical course test averages, the number of Cs in nursing courses, and overall grade point average a t the end of junior year and senior year nursing courses. Findings indicated students who passed the NCLEX RN had higher mean test averages in both adult health I & II nursing courses compared to those who failed. Students with no grades of C or below in junior year courses had a 100% chance of success on the NCLEX RN, while those with 5 or more Cs, only had a 50% chance of being successful. The second logistic model accurately predicted 98.7% of the students who passed, but only 5.6% of the students who failed. At the end of senior year nursing courses, the third logistic model accurately predicted 94% of NCLEX RN passes and 33.3% of failures (Seldomridge & DiBartolo, 2004). The authors argue that the pass/fail nature of the NCLEX RN limits the use of more sophisticated statistical procedures, which is further compounded by the low failure rate in comparison to the high pass
41 rate, rendering it difficult to predict failure as accurately as success. These findings are consi stent with those noted by Bee son and Kissling (2001) who investigated a sample of 505 generic, transfer, and seconddegree graduates of a baccalaureate nursing program. They found that students who passed the NCLEX RN earned fewer grades of C or below in nursing courses. Conversely, those who had an increasing number of Cs in nursing courses had a higher probability of NCLEX RN failure. The researchers developed a logistic regression model with a simple formula to predict NCLEX RN performance based on the number of Cs or lower grade s in nursing courses through the junior year and the Mosby Assessment Test scores from the end of the first semester in the senior year. In the validation sample, the model accurately predicted 85.7% of the students who passed and 66.7% of those who failed The logistic model for the entire sample w as significant in predicting 76% of the students who failed in the NCLEX RN (Beeson & Kissling, 2001). Stuenkel (2006) conducted a systematic review of a BSN program in California and explored the predictive v alue of nursing course theory grades in order to facilitate the identification of atrisk students. Data was collected from 312 students records from six graduating classes who took the NCLEX RN for the first time between December 1997 and March 2001. T he researcher performed discriminant analysis of the predictor set of variables which included pharmacology, pathophysiology, medical surgical, maternal child, mental health, community, and leadership course grades, and concluded that those who passed NCLE X RN held higher mean scores for nursing theory grades. On the other hand, refuting most of the findings reported so far, Horton (2006) investigated the predictors of graduation and NCLEX RN success of 351 students who attended a small Midwestern BSN program from 1994 2005. Independent variables included pre nursing
42 science course grades, grades in junior and senior nursing courses, and grade point averages at various points in the nursing program. Neither demographic variables, nor pre nursing science course grades, nor the number of C grades earned in nursing courses were identified as predictors of graduation or NCLEX RN success (Horton, 2006). The HESI Exit Exam (E2) Scores Most nursing programs use some type of standardized testing at different phases of their curriculum (pre admission, at the end of every semester, mid curriculum, and/or before graduation). Most relevant to this study is the computerized Health Education Systems Inc. (HESI) HESI Exit Exam (also referred to as the E2) that is use d in the last semester of the ADN program before graduation. The E2 is a 150item comprehensive exam that is based on NCLEX RN test blueprint and usually administered to students near the completion of the nursing curriculum. Its purpose is to measure the ir preparedness for the NCLEX RN. The HESI E2 further identifies students strengths and weaknesses and the possible need for remediation prior to taking the official licensure exam ( NCLEX RN) HESI has four versions of the E2 available for RN students. In order to evaluate the effectiveness of remediation, students are retested with a different version of the E2 (Morrison, Adamson, Nibert, & Hsia, 2004). RN students serve as the norming group for the test items that are included on the RN version of the E2 (Morrison et al., p. 41S, 2004). Many researchers found that end of program exit exams were strong predictors of NCLEX RN outcomes. In four annual validity studies of the E2, the researchers studied large national samples of nursing students from di ploma, associate, and baccalaureate degree programs as well as practical nursing students. Aggregate data was collected from 19,554 subjects over four consecutive years. The standardized comprehensive examination was found to be highly accurate, between 9 6.42% and 98.46%, in predicting NCLEX RN success for all types of
43 nursing students (Lauchner, Newman & Britt, 1999; Newman, Britt & Lauchner, 2000; Nibe rt & Young, 2001; Nibert, Young & Adamson, 2002). Although the predictive value of the E2 of NCLEX RN failure has been questioned by Spurlock and Hanks (2004), some researchers ( Hanks & Lauchner 1999; Daley, Kirkpatrick, Frazier, Chung & M oser, 2003) respectively found the E2 to be 96.425% and 100% accurate in predicting NCLEX RN failures. In order to provide data about middle scoring students, the E2 study in year 4 included scoring categories ranging from A to H, with A being the highest scoring and H being the lowest category. The five scoring intervals were as follows: A/B (90.00 99.99), C (85.0089.99), D (80.0084.99), E/F (70.0079.99), and G/H 69.99. The previous E2 studies revealed significant differences in NCLEX RN failure rate between low scoring and highscoring students ( x = 571.401, P = .001). In year 4, chi square analysis of the students scores for each of the five scoring intervals showed significant differences ( X = 618.816, P = .001) among scoring intervals of RN students. As the scoring interval decreased, the NCLEX RN failures increased. No significant difference was found in the predictive accuracy of the E2 regardless of the type of programs (ADN, BSN, or diploma) (Lauchner, et al., 1999; Newman et al., 2000; Nibert & Young, 2001; Nibert et al., 2002), nor students levels at each of the five scoring intervals (Nibert et al., 2002). Yoho, Young, Adamson, and Britt (2007) conducted a descriptive, longitudinal, correlation case study to determine the accuracy of the HESI nursing standardized examinations in predicting ADN student success in a southwest Texas school. The sample consisted of a cohort of 139 students enrolled betw een August 2002 and October 2004. The HESI exams were administered at different point s in the program: admissions assessment (A2), mid curricular point (MC), and exit (E2). The researchers wanted to identify students who were academically
44 prepared and able to succeed in the program, those at risk for failure once enrolled, and those likely to benefit from remediation in order to be successful on the NCLEX RN. The study assessed the strength of the math and reading comprehension A2 scores in predicting the ADN student populations MC scores, the accuracy of the MC scores in predicting E2 scores, and the accuracy of E2 scores in predicting NCLEX RN success. The researchers established a score of 850 as the minimally acceptable HESI score for both the MC and the E2. Of the original 139 students, 38 withdrew in the first year, and 24 withdrew in the second year, contributing to 62 students who did not complete the program in 2 years. Additional results for the remaining 77 students indicated that the MC score s were positively correlated with E2 scores ( r = .617; p = .01), and the first version of the E2 was 94.83% accurate in predicting NCLEX RN success. The MC was highly predictive of E2 scores, and the E2 was highly predictive of NCLEX RN success (Yoho et al., 2007). Similarly, Lewis (2005) study of 182 nursing programs totaling 19,695 students in enrollment concluded that the E2 accurately predicted NCLEX RN success at a rate of 97.8%. The author also found better student performance on the E2 ( p< .0005) in schools where consequences (progression, remediation, etc) were attached to E2 performance. Additional support is offered by Higgins (2005) study of ADN students that showed statistically significant relationship between the E2 and passing the NCLEX RN ( r = 0.518). Also, a multidimensional study by Hardin (2005) suggested ADN graduates with higher passing scores on HESI midcurricular examination and the E2 had a higher NCLEX RN success rate. Some nursing programs have established program progress ion policies based on students scores in assessment exams. Students are often allowed to retake the E2 multiple times until achievement of the minimum score set by the program. Nibert, Young and Britt (2003) reviewed
45 45 programs with progression policies and identified students who did not meet minimal HESI E2 scores either failed a key course, were denied eligibility for graduation, or approval to take NCLEX RN. Likewise, Lewis(2005) retrospective research identified significant difference between HESI E2 scores of students in nursing programs with benchmark policies than those in programs without progression policies. Conversely, Spurlock and Hanks (2004) questioned the ability of the HESI E2 to predict NCLEX RN failures, therefore, recommending nursi ng programs to consider multiple aspects for progression beyond the HESI E2, and nurse educators to be concerned with the sensitivity and positive predictive value (PPV) as the most important characteristics of scores (p.165). Spurlock and Hanks (2008) f urther cautioned against the practice of multiple retakes of the E2, as they have found that only students first scores on the E2 is significantly related to NCLEX RN outcomes (p.165). The additional scores decrease the strength of the relationship bet ween the two variables. Also, this practice may give schools a false sense of security, because the initial scores on the E2 are the most reliable in predicting NCLEX RN success. This section covered published literature about HESI exams and their predic tive value of NCLEX RN success. HESI has been very proactive in conducting research establishing the reliability and the validity of its products (A2, MC, specialty, and E2). The available publications, using large samples, may be one of the reas ons for i ts national popularity. Nevertheless Spurlock and Hanks (2004, 2008) raised questions about the ability of a single variable to accurately predict NCLEX RN failure, especially for educators who are considering adopting progression policies based on E2 sc ores. In the same way, Spector and Alexander (2006) indicated that progression or exit exams are valuable tools in predicting NCLEX RN success. Nonetheless, the researchers recognized and encouraged a comprehensive assessment
46 program throughout the curric ulum with sufficient remediation, vital in promoting students readiness for NCLEX RN. Therefore, more studies looking at HESI exams predictive value of NCLEX RN failure are needed in the general student population as well as among racial/ethnic minorities, confirming the significance of this study. Institutional Factors Since nursing programs are now enrolling higher rates of racial/ethnic minority students, additional issues of retention and NCLEX RN success have emerged. Although the graduation rate for racial/ethnic minority students has improved, it has not produced the significant, desired change in the proportion of ethnic/racial minority nurses. Once minority students are accepted into nursing programs, retention efforts must be undertaken to pr omote successful outcomes. The American Association of Colleges of Nursing (AACN) issued a statement on Diversity and Equality of Opportunity stressing that nursing programs must provide a supportive learning environment and curriculum in which students, staff and faculty from all walks of life and from the entire spectrum of society are full participants in the educational process (AACN, 1997, p.3). Many institutional factors, such as faculty mentoring/support, professional/social i ntegration, and financ ial aid that influence academic and NCLEX RN success, have been identified in the nursing literature. This portion of the literature review will primarily focus on financial aid since it is beyond the scope of this study to explore the other institution al factors. Financial Aid Many racial/ethnic minority nursing students experience financial struggles. In order to finance their college education, most of them have to work, thus making financial concerns a significant source of stress and competitor of time commitment for study. Gardner (2005a) maintains racial/ethnic minority students can greatly benefit from financial counseling and assistance. Many nurse researchers have examined the educational experiences of racial/ethnic
47 minority nursing students Lack of finances (Amaro et al., 2006), and or the need for financial assistance (Taxis, 2006) are some of the recurring themes (institutional factors) that have emerged in the literature to explain the low retention rate of this group of students. Taxis (2006) conducted an investigation of the experiences of nine Latina/Hispanic senior students and graduates from a BSN program with regard to institutional factors that influenced their retention and graduation. From the data analysis of individual intervie ws, focus groups and questionnaire responses, financial support was among the key factors in the academic success of racial/ethnic minority students. Nurse Educators from a BSN program in Texas undertook a project aiming at assisting disadvantaged students (including ethnic/racial minorities). They adapted strategies suggested by Pallack, Gary, and Perdue (1997, as cited in Stewart, 2005). Prior to the project implementation, the nur sing program had less than a 70% NCLEX RN first time pass rate, and had received a warning from the State Board of Nurse Examiners (Stewart, 2005). The faculty, with the support of central administration, took a proactive approach to reduce attrition and increase NCLEX RN first time pass rate. The benefits of the program inc luded a monthly stipend. Financial support along with alterations done to the curriculum were very successful, proven by the 90% graduation and NCLEX RN first time pass rates over the course of two years (Stewart, 2005). Evans (2007) report ed the percept ions of nursing students who participated in a Nursing Workforce Diversity Grant (ALCANCE) in southcentral Washington State. The targeted populations were Hispanic/Latinos and American Indians. Among the services provided were stipends of $1,500 dollars per semester for nursing students. Grant personnel sought evidence of the effectiveness of the provided services. Fifteen entering students completed the questionnaire,
48 which added up to 37 completed questionnaires in the course of 3 years. Most students (26 out of 49 responses) expressed high satisfaction with the financial services provided by the grant, primarily because it allowed them more time with their family and to study (Evans, 2007). The financial assistance was critical in the retention efforts o f this program. Nugent, Childs, Jones, and Cook (2004) describe the development of a Mentorship Model for the Retention of Minority Students (MMRMS). One of the four concepts incorporated in the model was financial support. The program offered a monthly s tipend that was allotted to qualified program participants. This was made possible through funding from the Nursing Workforce Diversity Grant through the U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA), Bur eau of Health Professions, Division of Nursing. The program reported an increase in minority enrollment of 18% in summer 2001. The first graduating class in 2003 saw a 100% retention rate and an 81.3% graduation rate. The enrollment rate for summer 2002 wa s 10% with 100% retention. Nugent et al., (2004) assert ed without faculty and institutional awareness and support, the implementation of the strategies identified in the retention model would be isolated and the outcomes would be limited (p.93). Taking a different approach, the Coppin State University Helene Fuld School of Nursing (HFSON) in Baltimore Maryland developed and implemented a program to address the recruitment and retention of underserved minority nursing students (Gordon & Copes, 2010). The Coppin Academy for Pre Nursing Success (CAPS) was funded through a Nursing Workforce Diversity Grant awarded by the Department of Health and Human Services, Health Resources and Services Administration (HRSA) (Gordon & Copes, 2010). It constitutes a unique partnership between a historically black university (HBCU) and the Baltimore City Public Schools System. From grade 8 through completion of the BSN program, CAPS
49 participants receive support in the form of mentoring, tutoring, stipend to 12th grad ers, academic, career, and financial aid counseling Among the major components included in the year round comprehensive program was the provision of monthly stipends and financial aid counseling. The CAPS program reported a retention rate above the unive rsitys average rate. The first cohort group to graduate from HFSON in 2008 ha d all been successful in the NCLEX RN on their first trial (Gordon & Copes, 2010). Another successful program that was the recipient of the Nursing Workforce Diversity Grant th rough the U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA), Bureau of Health Professions, Division of Nursing, was featured in the fifth National Advisory Council on Nursing Education and Practice (NACNEP) r eport (NACNEP, December 2007). The project was entitled Preparing the Next Generation of Nurses (NGN) from Clayton College and State University (CCSU). The goal was to increase the number of minority and disadvantaged students able to enroll in and compl ete a BSN program, which in turn would increase nursing workforce diversity. The project had a three fold approach: 1) pre entry preparation for high school juniors and seniors and college freshmen and sophomores; 2) focused retention efforts for enrolled junior and senior nursing students; and 3) monthly student stipends ($250 dollars) to support financially disadvantaged students. In December 2004, all but one student passed both the exit exam and the NCLEX RN on the first attempt (Wilson, 2007 as cited in the Fifth NACNEP Report, 2007). A different recruitment and retention project was developed by the University of Texas at El Paso, School of Nursing (UTEP SON) for economically disadvantaged Hispanic nursing students (Anders, McInnis Edmonds, Monrea l, & Galvan, 2007). Two of the major objectives of the project consisted of: 1) increasing the number of Hispanic enrollee by 25% over the year -
50 three baseline, and 2) graduate an additional 10 BSN prepared Hispanic nurse s in year four and five. As of 2007, all 43 students enrolled in the project either received a stipend or a scholarship; and had access to academic coaches. In addition, each student had to meet weekly with the educational outreach manager to discuss academic progress as well as any social and financial issues. The researchers reported that less than 12% (n =5) of the students have had to repeat a course and were subsequently successful. Only one student dropped out of nursing, but enrolled in another health science major. The eight students who completed the program in 2007 were all successful in NCLEX RN on their first trial (Anders, et al., 2007). The majority of the findings reported in this previous section were from interventions studies. The results showed that strategies that incorpor ate financial aid along with the other types of support (i.e., faculty mentoring, academic support, etc .) improved the academic and NCLEX RN success of at risk nursing students, primarily racial/ethnic minorities Promoting the academic success of racial/ ethnic minority nursing students will translate in increased representation of these subgroups in the nursing profession. As emphasized in the Sullivan Report (2004), this improvement will eventually generate greater access to healthcare and a reduction in health disparities for racial/ethnic minority patients in the United States. The research addressing the selected individual and institutional factors influencing the academic and NCLEX RN success of [racial/ethnic minority] nursing students has shed som e light on the factors related to the current problem of racial/ethnic underrepresentation within the RN workforce. This racial/ethnic diversity in the n ursing workforce is a necessity and nursing education has the big burden of being the gateway. Respondi ng to the call from national initiatives to have a workforce that reflects the racial/ethnic diversity of the general U .S population is only the first step in address ing the health care needs and disparities of patients
51 belonging to racial/ethnic minority groups. ADN programs have the challenging opportunity to partake in the execution of such endeavor s by ensuring the academic and NCLEX RN success of racial/ethnic minority students; hence the importance of this study. Theoretical Framework Discussions o n student retention and academic and NCLEX RN success have been extensively covered in the nursing education literature. For decades, many t heoretical models have attempted to explain the longitudinal process of retention. The proposed models include Durk heims Suicide Theory in 1951, Heiders Balance Theory in 1958, Spadys theoretically based m odel of the Undergraduate Dropout Process in 1971, Tinto s in 1975 when he introduced Tintos Student Integration Model, Bean and Metzers in 1985 with his Student Attrition Model, and Swails Geometric Model of Student Persistence and Achievement in 2003. An earlier longitudinal research by Astin in the 1970s on the student drop out problem helped uncover the category of student called stop out He operationall y defined the term stop out as students who interrupt their undergraduate education for a relatively brief period and return to complete their degree. Some researchers have employed alternative theoretical framework s to understand retention in nursing pr ograms. In this study, the researcher subscribed to Marianne Jeffreys Nursing Undergraduate Retention and Success (NURS) model (2004), as a theoretical framework that contains variables reflective of the educational progression in a n ADN program. The NURS model assist ed in the investigation of the relationship between the selected individual and institutional factors and the academic and NCLEX RN success of racial/ethnic minority nursing students. Jeffreys Nursing Undergraduate Retention and Success (NUR S) Model Jeffreys earlier NURS (Nontraditional Undergraduate Retention and Success ) model primarily focused on the retention and success of nontraditional nursing students. The original
52 NURS model was based on the work of Bean and Me tzers model of Nontra ditional U ndergraduate Student Attrition (1985) and Tintos Student Integration Model (1975). The NURS model resulted from findings obtained through Jeffreys research testing Bean and Metzers model and realized the limitations of all the models to be app lied to nursing students in general. Jeffreys then proposed a revised NURS model that encompasses components suitable for both the traditional (18 to 24 year s old) and nontraditional (over 25 years old) undergraduate nursing student. Its purpose is to investigate the multidimensional factors that influence undergraduate nursing student retention and success The new NURS model is geared toward the undergraduate nursing student (traditional or nontraditional, ADN, BSN, or Diploma programs, commuter or campus resident, ESOL or English speakers, young or mature, different racial/ethnic backgrounds, High school graduate or GED certificate holder, international student or U.S. resident) in general and is therefore applicable to this study sample. In developing the model, Jeffreys (2004) considered global and national immigration trends, traditional and nontraditional students, issues of attrition, the complex process of nursing student retention and interaction of influencing variables, and the lack of diversity in the nursing workforce. Jeffreys (2004, p. 277) maintains the NURS model is flexible enough to be used to guide assessment at the individual, subgroup, course, program, in stitution, or multisite level. The author also recognizes that the NURS model is tentative and would need revision as new empirical data become available (ibid). The NURS model proposes that retention decisions will be based on the interaction of student profile characteristics, student affective factors, academic factors, environ mental factors, and professional integration factors resulting in academic outcomes (course grades, cumulative GPA, and overall GPA) and psychological outcomes (satisfaction and stress) (Jeffreys, 2004).
53 The longitudinal and interactional focus of the NUR S model is very similar to both Tintos (1975) and Bean and Metzers (1985) models in that it investigates factors affecting students attrition/retention from program/college entry through completion Jeffreys (2004) asserts that the voluntary and/or i nvoluntary decision to remain in a course, persist in the nursing program, graduate, take the RN licensing exam, and enter the nursing workforce and/or begin a more advanced nursing program occurs during and at the conclusion of each nursing course (ibid. p.10). ). According to the NURS model, student profiles characteristics have a direct influence on academic factors, and each characteristic can impact retention directly and/or indirectly (p.30). Previous conceptual models like Tintos (1975) and Be an and Metzers (1985) have highlighted social integration as an essential, central element to undergraduate student retention and success. Now, Jeffreys NURS model contextualizes the issue and offers a new perspective designated as professional integrati on factors. These factors add to the students interaction with the social system of the college environment and are at the center of the model because they are at the crossroads of the decision to persi st, drop out, or stopout ( p.10). Furthermore, the NURS model proposes that persistence decisions are affected by interactions of profile characteristics, student affective factors, academic factors, environmental factors, professional integration factors, academic outcomes, psychological outcomes, and outside surrounding factors (Jeffreys, 2004). It is important to note that this study will n ot test the entire NURS model. T he model served as a guide to identify key variables related to nursing students retention and success to be incorporated in this stu dy. The conceptual model for this study (Figure 2 2 ) includes selected
54 variables from the NURS model that have been tested and concluded to have predictive values on academic and NCLEX RN success. Conceptual Model The conceptua l model of this study is b ased on Jeffreys' NURS (Nursing Undergraduate Retention and Success) model (2004) as a framework to illustrate the relationship between selected individual and institutional factors that have been shown to influence academic and NCLEX RN success of racial /ethnic minority nursing students Jeffreys' NURS Model is very comprehensive and exceeds the scope of this study. For this reason, the researcher selected variables from the original NURS model that fit under individual and institutional factors that will be investigated in this study in relation to academic and NCLEX RN success of racial/ethnic minority nursing students. This study is unique in that it primarily focuses on a specific group of nursing students (the racial/ethnic minority group). The indep endent variables include individual factors such as demographic vari ables: race/ethnicity and academic variables ( nursing course grades (NCG), nursing grade point average (NGPA), and HESI exit exam (E2) scores ) Race/ethnicity and gender are consistent wit h Jeffreys category of student profile characteristics at the beginning of the NURS model. Nursing course grades and HESI exit exam (E2) scores are classified under academic outcomes in the NURS model. The institutional factors consist of financial su pport, which is a subset of environmental factors in the NURS model. Finally, the model depicts the two dependent variables: academic success and NCLEX RN success, which are grouped under retention in Jeffreys model (2004). Summary This extensive literature review yielded limited empirical data that focused on the individual and institutional factors that influence the academic and NCLEX RN success of racial/ethnic minority nursing students at community/state colleges. Campbell and Dickson
55 (1996) noted that only five of the studies they reviewed included race/ethnicity as a demographic variable. Only two of these studies yielded significant results, rendering it difficult to identify any consistent trends, patterns, and gaps. Discussions or studie s examining these variables relating to the Hispanic/Latino population are almost nonexistent. This current search returned few studies (Bessent, 1997; Byrd, et al., 1999; Crow, et al., 2004; Endres, 1997; Gardner, 2005; Haas, et al., 2004; Harris, 2006; J effreys, 2007; Oliver, 1985; Seago & Spetz, 2005; Sayles, et al., 2003, Yocom & Scherubel, 1985) that examined the relationship between race/ethnicity and academic and NCLEX RN success. These investigators found that racial/ethnic minority nursing student s were more at risk for stopouts or dropouts, took longer to complete their program and had lower first time NCLEX RN pass rates. On the other hand, other researchers (Endres, 1997; Hardin, 2005; Higgins, 2005; Jeffreys, 2007; Washington & Perkel, 2001; Y in & Burger, 2003) found no correlation between race/ethnicity and first time pass rate in the NCLEX RN or nursing program completion (Higgins, 2005). Nursing course grades (NCG)/nursing grade point average (NGPA) was found to be predictive of successfu l completion of the nursing program (Byrd et al., 1999; Gallagher, Bomba, and Crane, 2001; and Jeffreys, 2007) and NCLEX RN success (Alexander & Brophy, 1997; Barkley et al., 1998; B eeman & Waterhouse, 2001; Beeson & Kissling, 2001; Bentley, 2006; Crow e t al., 2004; Endres, 1997; Nnedus, 2000; Roncoli et al., 2000; Seldomridge and DiBartolo, 2004; Stuenkel, 2006; Uyehara, et al., 2007). Students with As and Bs were more likely to successfully complete their nursing programs and pass the NCLEX RN. Conve rsely, one study by Horton (2006) found no correlation between nursing course grades and graduation or NCLEX RN success. Scores on standardized exam, such as the HESI E2, administered before graduation from
56 nursing programs have been a positive predictor of academic and NCLEX RN success (Campbell & Dickson, 1996; Hardin, 2005; Higgins, 2005; Lauchner, et al., 1999; Lewis, 2005; Morrison et al., 2008; Murray & Nibert, 2003; Newman et al., 2000; Nibert & Young, 2001; Nibert et al., 2002; Nibert et al., 2003; Yoho et al., 2007). Some researchers (Hanks, et al, 1999; Daley, et al., 2003) respectively found the E2 to be 96.425% and 100% accurate in predicting NCLEX RN failures. Conversely, Spurlock and Hanks (2004) questioned the ability of HESI E2 to predict NCLEX RN failures. The difficulty to accurately predict NCLEX RN failures has been encountered and brought up by other researchers using other variables. They argue that the pass/fail nature of the NCLEX RN is most likely the factor contributing to this dilemma. Institutional factors such as financial aid has been found to predict academic and NCLEX RN success (Amaro et al., 2006; Anders, et al., 2007; Evans, 2007; Gordon & Copes, 2010; Nugent et al., 2004; Stewart, 2005; Taxis, 2006; Wilson, 2007). Interventions from different nursing programs that targeted these variables in relation to academic and NCLEX RN success generated positive outcomes. Students who received so me type of financial support from the institution experienced improved academic out comes. In addition to identifying race/ethnicity as a current gap in the nursing literature, the majority of the research retrieved used samples from BSN programs, while approximately two third of all nursing students graduate from ADN programs. Consequently, findings from studies using data from the general nursing student population that investigated these variables (race/ethnicity and gender, NCG, NGPA, HESI exit exam (E2) scores, financial aid) were included in this review of the literature. The findings have not all been consistent due to the lack of replication of previous studies, along with variations in samplings, settings, study designs, instrumentations, and theoretical models. Therefore, selecting a sample from an ADN program
57 and including the v ariable of race/ethnicity is of great significance. This research will offer critical information to nurse educators in their effort to improve instruction, success and eventually comparable representation of these racial/ethnic minority groups within the registered nursing workforce.
58 Figure 2 1. Model of Nursing Undergraduate Student Retention (NURS) ________________________________________________________________________ From Nursing Student Retention: Understanding the Process and Making a Difference M.R. Jeffreys, 2004, p.6. Copyright 2004 by Springer Publishing, LLC, New York, New York 10036. Used with permission of publisher.
59 Figure 2 2. Conceptual Model: Predictors of a cademic and NCLE X RN s uccess of racial/ethnic nursing minority s tudents
60 CHAPTER 3 METHODOLOGY This retrospective quantitative study sought to examine the relationship between the selected individual and institutional factors that influence the academic and NCLEX RN success of racial/ethnic minority nursing students enr olled in an ADN program. For the purpose of this study, racial/ethnic minority was defined as Black / African American and Hispanic. The research design, a quantitative methodology using students records, is described along with rationale for this design. T he research question s and hypotheses, identification of population sample, ethical considerations, measures, data coll ection method and analysi s are discussed. This chapter ends with an explanation of the limitations of the methodology. The study use d demo graphic and academic data to compare and contrast racial/ethnic minority nursing students versus White students The study compare d these groups in performance areas such as graduation (academic success) and NCLEX RN pass rates. Research Method and Desig n According to Creswell (2008), quantitative research seeks to clarify phenomena by gathering numerical data that are analyzed using mathematical methods (in particular statistics). Leedy and Omrod (2001) offer the following explanation: Quantitative rese archers seek explanations and predictions the intent are to establish, confirm or validate relationships and to develop generalization that contribute to theory (p. 102). This study used a retrospective design, ex post facto (after the fact), which mean s that the possibility of manipulating the data no longer exist s as changes in the independent variables have already occurred in the natural course of events (Polit & Hungler, 1995); in other words, there was no manipulation of the variables. Historical and primary data was collected from the institutions archival and primary data sources.
61 Research Questions and Hypotheses The need to explore the multidimensional phenomenon of racial/ethnic minority nursing students academic and NCLEX RN success le d to the following research question: What is the relationship between selected individual and institutional factors and the academic and NCLEX RN success of racial/ethnic minority nursing students in an ADN program? Additionally this study will attempt to an swer the following specific questions: These hypotheses were first answered by descriptive analysis followed by Chi square, T test and ANOVA statistical analyses. Each hypothesis was tested independently and collectively. 1. Is there a significant relations hip between the nursing course grades (NCG) and the mean nursing grade point average ( NGPA) and the academic and NCLEX RN success of racial/ethnic minority nursing students? Hypothesis 1.a: There is no significant difference in nursing course grades and in the mean nursing grade point average between racial/ethnic minority and White nursing students. Hypothesis 1.b: There is no significant relationship between mean nursing grade point average (NUR 1023 and NUR 1213) and NCLEX RN Success. 2. Is there a sig nificant relationship between the HESI exit exam (E2) scores and the academic and NCLEX RN success of racial/ethnic minority nursing students? Hypothesis 2.a: There is no significant difference in HESI E2 scores between racial/ethnic minority and White n ursing students. Hypothesis 2.b: There is no significant difference in HESI E2 scores between nursing students who passed and those who fail the NCLEX RN. 3. Is there a significant relationship between financial support (financial aid) and the academic an d NCLEX RN success of racial/ethnic minority nursing students? Hypothesis 3.a : There is no significant difference in financial support (financial aid) between racial/ethnic minority and White nursing students. Hypothesis 3.b: There is no significant dif ference in academic success between nursing students who were financial aid recipients and nonfinancial aid recipients.
62 Hypothesis 3.c : There is no significant difference in HESI E2 mean scores, NGPAs for NUR 1023 and NUR 1213 between nursing students who are financial aid recipients and those who were nonfinancial aid recipients. 4. Is there a significant relationship between race/ethnicity and the academic and NCLEX RN success of racial/ethnic minority nursing students? Hypothesis 4.a : There is no sign ificant difference in academic success between racial/ethnic minority and White nursing students. Hypothesis 4.b: There is no significant difference in the NCLEX RN success between racial/ethnic minority and White nursing students. Setting The setting fo r this research study is a National League for Nursing Accrediting Commission (NLNAC) accredited ADN program located at a state college in the Southeastern region of the U.S. This ADN program is also approved by its State Board of Nursing, and is responsible for graduating the highest number of RNs in its local county. In the year 2010, the NCLEX RN pass rate for ADN programs in that region of the U.S. ranged from 58.97% to 98.78%. The NCLEX RN pass rate, for that same year, for ADN programs located in su rrounding counties ranged from 85.59% to 94.70%. The state college is a public two year institution that primarily offers associate degrees In fall 2009, a bout half of its student population belong ed to racial/ethnic minority groups, with 23.9% Black, 20.0% Hispanic, 3.8% Asian, 0.4% Native American, and 3.3% not reported. The remaining 48.6% self identif ied as White. The majority (86.6%) of the students who attend the college reside within the county, and 0.6% are from out of state. The remaining 12.8% ar e from surrounding counties. The state college offers many services for its student s. Some of these services consist of academic and financial aid advising, counseling, career, and testing centers, disability support, outreach recruitment and internationa l student services As of fall 2011, new students must attend both an online and oncampus orientation. This is all part of the new FirstYear
63 E xperience program to improve student retention. In the ADN program, t he academic suppo rt (mentoring, tutoring and remediation ) is provided by adjunct and full time faculty. Currently, no structured remediation program is available for the nursing students. In terms of outreach programs, s ome nursing faculty get involved by giv ing presentations at K 12 institution s during their career week. During the 200910 academic year, the state college served about 40,000 students enrolled in credit courses and nearly 12,500 students in noncredit courses. The credit course grade distribution for the 200910 academic year revealed an 18.8% attrition rate. The 11 year (200001 to 201011) program completion report showed that the institution granted a total of 21,700 Associate degrees in Arts (AA), 3,372 Associate degree of Sciences (AS), and 1,723 Associate of Applied Science degrees (AAS), with 1,754 of these degrees awarded to registered nursing students. The county where the college is located has 925 healthcare facilities, which include 17 hospitals, 56 nursing homes and 131 assisted living facilities. Most of the nursing graduates remain in the county to practice after graduation and success in the NCLEX RN. Identification of Population Sample Sample. The convenience sample for this study included eight nursing student cohorts representing White, Black/African American, and Hispanic students (N=617) that that were admitted to the nursing fundamentals course (NUR 1023) between s pring 2005 and f all 2008 to the pre licensure ADN program at the state college Of the 617 students, 60 (9.5%) were admitted in spring 2005; 68 (11.0% ) in fall 2005; 81 (13.1%) in spring 2006; 70 (11.3% ) in fall 2006; 81 (13.1%) in spring 2007; 90 (14.6% ) in fall 2007; 79 (12.8%) in spring 2008, and 88 (14.3%) in fall 2008. Students from other racial/ethnic minority groups and those with missing data were deleted from the sample. Table 3 1 provides a description of the sample per cohort admission date.
64 Gender. The sample comprised 90 (14.6%) males and 527 (85.4%) females (Table 3 2) According to the 20082009 National League for Nursing NLN Data Rev iewTM, males accounted for 15% of pre licensure ADN students enrolled in the United States in the years 20082009. Thus, the number of males in this sample is slightly lower than the national average. Gender and r ace. The nursing profession is historicall y known for being predominantly female and White. In this study, the sample consisted of 340 (64.5%) White female nursing students. The remaining female proportion per r ace/ethnicity included 114 (21.6%) Black/African/American and 73 (13.9%) Hispanic nurs ing students As reported earlier, male nursing students made up 14.6% of the sample for this study (n= 90). Of these, the racial/ethnic breakdown was as follows: 54 (60.0%) White, followed by 23 (25.6%) Black/African/American, and 13 (14.4%) Hispanic nurs ing students. Table 33 provides a description of the samples gender distribution according to race/ethnicity. Race and admission date. A cross tabulation provided the racial/ethnic representation of the sample Details on racial/ethnicity composition fo r each admitte d cohort are highlighted in Table 3 4. The current sample was predominantly White (n=394, 63.9%). The largest minority group w as Black/African American (n=137, 22.2 %), followed by Hispanic (n=86, 13.9%) According to NLN (2009), minority students accounted for 28.2% of nursing students enrolled in ADN programs, with 13.9% African Americans, 7.6% Hispanics/Latinos, 5.7% Asians, and 1.0% Americ an Indians (NLN, 2009). In this sample, the total percent age (36.1%) of racial/ethnic minority student s ( African Americans and Hispanics/Latinos ), enrolled at the state c ollege ADN program between spring 2005 and fall 2008, excee ds the national average Data Collection Method The data set for this study was obtained from the nursing student database mai ntained at the nursing department, and financial aid information was obtained from student database
65 maintained by the Institutional Research Effectiveness (IRE) at the state college Approval to conduct the study was granted by the Institutional Review Boa rd at both the University of Florida and IRE at the state college. A data collection excel file with students identification number was developed and submitted to the institutional effectiveness staff and they provided information on students financial a id status. Data collection on each student about s tudents profile characteristics, admission /enrollment in the ADN program until graduation or withdrawal from ADN program and academic outcomes was extracted from records kept in the nursing department. St udents HESI E2 exams scores were retrieved from students records stored in HESI database. Tracking of NCLEX RN success for the students who graduated was done by reviewing the nursing state board generated reports of students who voluntarily agreed to notify the ADN program. These reports were obtained from the ADN program director. In ord er to further verify licensure, the publicly accessible Florida.gov website where all licensed registered nurses are listed was searched Ethical Considerations Inst itutional Review Board (IRB) approval from the University of Florida and the state c ollege was obtained. Additionally, the researcher has been employed as a professor at the ADN program since spring 2004 having taught NUR 1023 and NUR 1213 ( fundamental & m edical/surgical nursing courses ) during the time period of the cohorts and may have had a role in the academic evaluation of some of the participants. However, since the faculty team teach es the nursing courses, the academic evaluations of the theory porti on of the course are always a team decision. Since the study participants ha d already graduated and/or had voluntar il y or involuntar il y withdrawn from the nursing program, there were no human interactions. A Student Data Collection sheet was developed feat uring the independent and dependent variables along with the demographic characteristics. In order to ensure confidentiality, a random numerical code
66 was assigned to each student to replace names social security number s and/or student identification numb er s This process of de identifying the data was deemed necessary by the researcher and host institution to comply with FERPA regulations. Study Variables Measured Variables Dependent Variables Academic s uccess: The first dependent variable in this study was academic success, supported by students performance in selected nursing courses (didactic) and HESI exit exam (E2), and progression through the program required curriculum in a sequential order without interruption or exit, within the specified time period of 4 semesters of full time enrollment. Academic success was operational ly defined as a variable with students being categorized as 0 = not graduated 1 = delayed graduation, and 2 = graduated ontime Students were categorized as graduated when the y complete the entire ADN curriculum requirements from the beginning to the end of the program. This means that they ha d earned a grade of C or higher in all their nursing courses (didactic) and a Satisfactory = S grade in the clinical component of every nursing course for the corresponding semester in the program, in all 4 semesters. This study examined grades for two didactic nursing courses Additionally, these students also needed to have achieved a passing score (score = 700 or above, as set by the ADN program) on their HESI exit exam (E2). Students designated as delayed graduation took longer than 4 semesters to complete the ADN program, due to personal or academic reasons. Students grouped in the category of not graduated were those who had to re peat one nursing course due to an F in the didactic component or an Unsatisfactory = U grade in the clinical component, or earned two Fs and/or two W/Fs (withdr e w while failing the course) in any didactic or clinical nursing course and had to involuntar il y withdraw. These students w e re denied graduation; either because they had to voluntar il y or involuntar il y withdraw for personal or academic reasons or decided to stop
67 out for one or more semes ters for personal reasons. The ADN program policy states: a st udent will not remain in the nursing program if any of the following occur: If the student receives: two (2) Fs in any combination of nursing courses with clinical components; or two (2) WFs in any combination of nursing courses with clinical compone nts; or one (1) F and one (1) WF in any combination of nursing courses with clinical components NCL EX RN Success: In 1994, the National Council of State Boards of Nursing (NCSBN) established the Computerized Adaptive Testing (CAT) and changed the sc oring to pass/fail. The actual test scores are reported neither to individual students nor to nursing programs. This pass/fail scoring is based on passing standards that are measured in logits; the lower the logit the higher the standard. The passing standards are reviewed every three years, based on empirical data obtained from the Post entry Competence study that explores the educational elements and new nurse preparation for practice and difficulty with client assignments (Li, 2006). The standards for 2006, 2007 and 2008 were established at 0.2800, 0.2100, and 0.2100 logits respectively on the NCLEX RN logistic scale ( www.ncsbn.org December, 2003 & 2006 News Releases). The passing standards have continued to increas e with every review. NCLEX RN success is defined as receiving a passing score on the exam on the first attempt. The NCLEX RN is a dichotomous variable and was coded as follows: 1 = pass on first attempt and 0 = fail on first attempt. Independent Variabl es The independent variables included in this study were: 1) individual factors in the form of race/ethnicity, nursing course grades (NCG/ NGPA), and st andardized examinations scores (HESI exit exam [ E2 ]) ; and 2) financial support (aid) as the institutiona l factor. Race/ethnicity: The concept of race and ethnicity are often used interchangeably and will be used as an independent variable in this study. It is a descriptive, demographic, categorical
68 variable providing background characteristics. Students self report their racial/ethnicity affiliation on admission records. For the purpose of this study, race/ethnicity was coded a s follows: 1 = White, 2 = Black/African American and 3 = Hispanic. It is important to n ote that the demographic variable gender was i ncluded in the description of the sample but not as a predictor of academic and NCLEX RN success. Gender was coded: 1= male and 2 = female. Nursing Course Grades (NCG)/Nursing Grade Point Averages (NGPA) : From the literature review, nursing course grades w ere found to be predictive of academic and NCLEX RN success. The nursing program uses a grading range that is different from most courses or other programs at the college. Students must obtain a grade of 75 = C or better to pass a didactic course. It i s important to note that students who withdr e w failing (W/F) were considered having obtained an F in the course even if the grade (F) is not reflected on their transcripts. However, students who withdrew for nonacademic reasons obtain a W. This action doe s not affect their overall grade point average (GPA) or status in the nursing program. The NCG was coded as W/F and F = 0, W = 1, C = 2, B = 3, and A = 4. The NGPA was coded as a continuous variable from 0 to 4. The nursing department grade scoring ranges are shown in Table 3 5. The HESI Exit Exam (E2): The E2 is a 150item comprehensive exam that is based on NCLEX RN test blueprint and usually administered to students near the completion of the nursing curriculum. Its purpose is to measure their prepare dness for the NCLEX RN. The E2 further identifies students strengths and weaknesses and the possible need for remediation prior to taking the licensure exam. HESI has four versions of the E2 available for RN students. In order to evaluate the success remediation, students are retested with a different version of the E2 (Morrison et al., 2003). RN students serve as the norming group for the test items that are
69 included on the RN version of the E2 (Morrison et al., p. 41S, 2003). For the purpose of this st udy, individual students scores were analyzed as a continuous variable. Financial status/support: Financial status/support was defined as money received from an y funding source such as: Pell G rant, subsidized and unsubsidized loans, grants, stipend, and s cholarships to pay for tuition, fees, and other school expenses. The coding was : financial recipient = 1, non financial recipient =0. Students were considered recipients if they received one or more type of financial contribution toward their education. St udents were considered nonfinancial recipients if they received nothing from the institution. One limitation regarding this variable is the fact that the researcher did not have information on students who may have received tuition reimburse ment from their employer. T able 3 6 provides definitions, level, and coding for study variables Reliability & Validity of HESI E2 Reliability of the HESI E2 In order to determine the reliability of the HESI exams, HESI performs an item analysis on each exam that is administered and returned to the company for a composite report of the aggregate data. Calculation of a point biserial correlation coefficient assists in the process of obtaining discrimination data for each test item. A Kuder Richardson Formula 20 (KR 20 Reliability Coefficient) is calculated for every exam administered to establish a measure of the tests overall reliability. The estimated reliability coefficients for these HESI exams ranged from 0.940 to 0.960, and the number of times the items were used on these exams ranged from 256 to 47,320 (Morrison et al., 2003). Content Validity of the HESI E2 Morrison et al., (2004) describe the content validity as: the effectiveness of the test items in measuring the basic nursing knowledge and skills of student s Before a test item is
70 incorporated into the HESI item bank, its content validity is established by nurse educators and clinicians. This ongoing process of establishing a test item relevance to entry level nursing practice is guided by the NCLEX RN tes t blueprints and syllabi from nursing programs. The HESI reviewers work really hard to assure that the E2 reflects the NCSBNs blueprints in test items distribution (Morrison et al., 2004). Construct Validity of the E2 Construct validity refers to whethe r a test measures specified traits or attributes at an abstract level adequately. In the case of the HESI exit exam (E2), the constructs reflect those found in the NCLEX RN test blueprints, and are identified by nursing faculties as well as by the NCSBNs practice analyses of recently graduated nurses. The E2 measures the constructs that are essential to entry level nursing practice. After taking the E2, HESI generates an individual report that provides individual and aggregate data on the student s perfor mance in the subject area tested (Morrison et al., 2003). In recent years, the use of the E2 has grown exponentially, from 7,192 to 25,241 E2 exams administered Morrison et al. (2003) further suggest that the increase of the E2 by nursing programs may be an indication that nursing faculty trust the data reported by the exam, and such confidence provides an additional indication of construct validity (p. 43S) Criterion Validity of the E2 In four annual validity studies of the E2, the researchers studied large national samples of nursing students from diploma, associate, and baccalaureate degree programs as well as practical nursing students. Aggregate data was collected from 19,554 subjects over four consecutive years. The standardized comprehensive exa mination was found to be highly accurate, between 96.42% and 98.46%, in predicting NCLEX RN success for all type s of nursing students (Lauchner et al., 1999; Newman et al., 2000; Nibert & Young, 2001; Nibert, Young, Adamson, 2002). Many
71 researchers conten d that the validity of a test, in this case the E 2 can be established by the consequence or meaning attached to it. For example, many schools use the HESI exams as benchmark for progression and remediation (Nibert et al ., 2003). Data Analysis The descript ive and inferential statistics data were analyzed with the Statistical Product and Service Solutions (SPSS) (version 19.0) program The descriptive statistics include d means, standard deviation and frequency distributions. Pearson Chi square was used to t est association between categorical variables and to measure the strength of the relationships among these variables. For the continuous data (i.e., HESI E2 scores and NGPA), t test was used to compare two means for significance difference. The ANOVA was also conducted to compare means between groups. Study Limitations This study has many limitations. This is a retrospective study, which uses a convenience sample of students records. The sample includes students from W hite, Black/African American, Hispan ic racial/ethnic backgrounds. Other demographic and student profile characteristics variables (i.e., age, marital status, family responsibilities, primary language, prior educational experience, learning styles, etc) may have influenced the dependent vari ables of academic and NCLEX RN success, but were not examined in this study. Next, this study is unable to account for all other institutional characteristics that may influence academic outcomes such as grades, graduation rates etc.. For example, thi s study exclusively focused on a public twoyear ADN program. Therefore, this study is unable to compare students from programs at other types of institution s (e.g. private ADN, public or private BSN, & diploma programs). However, the enrollment rates for racial/ethnic students at these types of institutions raise additional questions about the value of these alternative pathways
72 into the nursing profession. The data collection was from one ADN program in Southeastern United States Therefore, these result s are not representative of other ADN programs in community or state colleges in that region of the U.S. or nationally. Also, t he ADN program does not suggest that it represents other types of nursing programs at four year institutions. Besides the advent of four year nursing degree programs at historically two year institutions raises new questions about the educational experiences of these nursing students. Therefore, this study is unable to explain students educational experiences in these new nursing programs. Nonetheless this study provide s valuable data about the educational outcomes of racial/ethnic students in a public two year ADN program. Additionally, this study offers new data about the relationship between race/ethnicity and HESI E2 exam m ean scores. Given the population increases in underresepresented racial/ethnic groups, this study provides valuable information to nursing faculty and administrators Despite these limitations, this study hopes to advance the research literature on the is sues of academic ( retention ) and NCLEX RN success of racial/ethnic minority nursing students Summary This chapter described the methodology and design that were used in this study. It also provided a description of the sample, data collection, the variables, the validity and the reliability of the standardized exams. The selected design was especially appropriate because the study involve d examination of specific relationships using quantitative methodology. The study entail ed collecting data using a systematic retrospective review of students records and Board of nursing reports to obtain information about variables. Discussion of the data results will assist in answering the research questions. C hapter 4 present ed a description of the findings and a visual representation of all data analysis conclusions.
73 Table 3 1. Description of the s ample by c ohort a dmission date Admission Dates Frequency Percent Spring 2005 60 9.5 Fall 2005 68 11.0 Spring 2006 81 13.1 Fall 2006 70 11.3 Spring 2007 81 13. 1 Fall 2007 90 14.6 Spring 2008 79 12.8 Fall 2008 88 14.3 Total N=617 100.0 Table 3 2. Description of the sample by gender Demographics Frequency Percent Gender Male 90 14.6 Female 527 85.4 Total (N=617) 100 Table 3 3. Nursing students by ra ce/ethnicity and g ender Race Gender White Blacks/African American Hispanic Total N Percent N Percent N Percent N Percent Male 54 23 13 90 60.0% 25.6% 14.4% 14.6% Female 340 114 73 527 64.5% 21.6% 13.9% 85.4% Total 394 63.9% 137 22.2% 86 13.9% 617 100%
74 T able 3 4. Nursing students by r a ce/ethnicity and admission date Race Admission Date White Black/African American Hispanic Total Frequency Percentage N % N % N % N % Spring 2005 39 17 4 63 65% 28.3% 6.7% 100% Fall 2005 49 9 10 76 72.1% 13.2% 14.7% 100% Spring 2006 51 21 9 86 63.0% 25.9% 11.1% 100.0% Fall 2006 47 15 8 74 67.1% 21.4% 11.4% 100.0% Spring 2007 48 15 18 84 59.3% 18.5% 22.2% 100.0% Fall 2007 57 15 18 92 63.3% 16.7 % 20.0% 100.0% Spring 2008 44 22 13 85 55.7% 27.8 % 16.5% 100.0% Fall 2008 59 23 6 89 67.0% 26.1% 6.8% 100.0% Total 394 63.9 % 137 22.2 % 86 13.9 % 617 100% Table 3 5. Nursing program grading scale, letter g rade and grade p oints Letter Grades A B C F Score ranges 90 100 83 89 75 82 0 74 Grade points 4.00 3.00 2.00 0.00
75 Table 3 6. Summary of d ep endent and independent variables Independent Variables Measure Type Coding Individual Factors Level Race/ethnicity African American, Black, Hispanic, White categorical 1=White, 2=African Americans, 3=Hispanics Nursing course grades / Grades obtained on nursing courses categorical W/F and F = 0, W=1, C = 2, B = 3, and A = 4 Nursing grade point average Grade point average in nursing courses Continuous 0 to 4 HESI E2 Minimum passing score requir ed by ADN program Continuous 0 to 1500 Institutional Factors Financial support /aid Money received from any funding source such as: Pell grant, loans, grants, stipend, and scholarships to pay for tuition, fees, and other school expenses dichotomous fi nancial aid recipient = 1, nonfinancial aid recipient =0 Dependent Variables Measure Level Coding NCLEX RN Success Passing the NCLEX RN for licensure on first attempt dichotomous 0= Fail, 1= Pass Academic Success Progression through the program required curriculum categorical 2= grad at 4 semesters, 1=grad > 4 semesters, 0= not graduated
76 CHAPTER 4 RESULTS The purpose of this study was to examine the relationship between the selected individual and institutional factors that influence the academic and NCLEX RN success of racial/ethnic minority nursing students enrolled in an ADN program. The individual factors explored in this study are race/ethnicity, nursing course grades (NCG)/nursing grade point average (NGPA) for selected didactic courses and HESI exit (E2) examination scores. The selected institutional factor is financial support. This chapter presents the results of descriptive statistics and inferential analyses of study data accomplished using SPSS 19.0 for W indows (2010) statistical pack age The results are reported by question. First descriptive statistics are provided, which include frequency distributions, means and standard deviations of key variables followed by the results of the T test and ANOVA statistical analyses are presented. The data was analyzed to address the following research question: What is the relationship between selected individual and institutional factors and the academic and NCLEX RN success of racial/ethnic minority nursing students in an ADN program? Descript ive Statistics of Dependent Variables Academic s uccess. The dependent variable of academic success reflected students performance in selected nursing courses (didactic) and the HESI exit exam (E2), progressing through the program required curriculum in a sequential order without interruption or exit, within the specified time period of 4 semesters of full time enrollment. A cross tabulation of the dependent variable academic success, revealed that of the students (N=617) admitted between spring 2005 and f all 2008 to the ADN program 66.8% (n=412) met the ADN programs curriculum requirements and completed within 4 semesters, between fall 2006 and spring 2010.
77 Of the remaining students, 33.2% (n = 205), 12.6 % (n = 78) had delayed graduation, which means th at they completed the ADN program in five semesters or more. The other 20.6% (n = 127) never completed the ADN program for academic or personal reasons; i n other words, they voluntary or involuntary withdrew from the ADN program. NCLEXRN s uccess The 490 students who completed the ADN program either ontime or late (between fall 2006 and fall 2010) were eligible to take the NCLEX RN after graduation. The overall first time pass rate for the group was 86.3% (n=423). Although this is a cumulative pass rat e for 4 years, it is very close to the national figures (84.0% to 88.0%) published by NCSBN on a quarterly and yearly basis for that time period. Since the main focus of this study was to examine firsttime pass rates, the progress of the other 72 students who failed the NCLEX RN on their first trial was not tracked. Research Questions and Hypotheses The first research question asks : Is there a significant relationship between the nursing course grades and the mean nursing grade point average (NCG NGPA ) and the academic and NCLEX RN success of racial/ethnic minority nursing students? H ypothesis 1.a states: T here is no significant difference in nursing course grade s and in the mean nursing grade point average between racial/ethnic minority and White nurs ing students. Figures 41 and 42 and Tables 4 1 and 42 show the result of this analysis. The results for the nursing fundamental course (NUR1023), using a cross tabulation analysis, showed that Black/African American nursing students were more likely (20.4%, n=28) than the other two racial/ethnic groups to earn a failing grade (F) in the nursing fundamental course, followed by Hispanics (17.4%, n=15), compared with only 9.1% (n=36) of White students. On the other hand, White nursing students were more likely to earn an A (3.8% n=15), and a higher percentage (40.1%, n=158) of them earne d a B; in other words, about 78% of the As
78 and 75% of the Bs were earned by White nursing students (Figure 4 1). The most common grade earned by Black/African American and Hi spanic students for this course was a C, with 56.9%, n=78 and 47.7%, n=41 respectively The Chi square test showed significant difference between race/ethnicity and NCG (1023), X2 ( 6, N = 609) = 29.986, p< .000 ( Table 4 1). In the same way, the results for the medi cal/surgical course (NUR 1213) also revealed Black/African American nursing students to be more likely (14.9%, n=17) than any other raci al group to earn a failing grade (F), followed by Hispanic s (10.0%, n=8). Similar to the NUR 1023 nursing cour se, more White nursing students (9.4%, n=34) had earned an A in this course The Chi square test showed significant difference between race/ethnicity and NCG (NUR 1213), X2 ( 6, N = 549) = 14.989, p < .020 ( Table 4 2 & Figure 4 1) Additionally, mean nursi ng grade point averages (NGPA) for NUR 1023 and NUR 1213 were calculated for each racial group. The results for each nursing course respectively (NUR 1023 & NUR 1213) indicated that White nursing students had means 2.28 and 2.36, followed by Hispanic with =2.00 and 2.21, and Black/African American with =1.79 and 2.04. The one way ANOVA was computed to compare the three racial groups on their average performance in both courses. The results indicated that there were significant differences in the mean NGPA for NUR 1023 between racial groups, F(2, 614) = 14.364, p< .000 (Table 4 4) Scheffe multiple comparisons found that for both nursing courses Black/African American nursing students had statistically s ignificant lower nursing grade point averages than the other two groups (White and Hispanic) ( p MD ) and p values for NUR 1023 were as follows: White Black/African American ( MD =.496, p=.000), White Hispanic ( MD =.284, p =.048), and Black/African AmericanHispanic ( MD = .212, p=.282) (Table 4.5 ). Therefore, in light of thes e findings, the null hypothesis was rejected
79 Likewise, significant differences were found in the mean NGPA for NUR 1213 between racial groups, F(2, 553) = 4.332, p< .014. Therefore, the null hypothesis was rejected. The mean difference, MD and p values f or NUR 1213 were as follows: White Black/African American ( MD = .312, p = .016), White Hispanic ( MD =.144, p=.513), and Black/African American Hispanic ( MD = .169, p=.518). Therefore, the null hypothesis was rejected for White Bla ck/African American comparison However, it is important to note that there was no significant difference between the WhiteHispanic NGPA (Table 4 5). Hypothesis 1.b states: There is no significant relationship between mean NGPA (NUR 1023 and NUR 1213) and NCLEX RN s uccess (Tables 46 and 4 7). An independent samples t test was conducted to compare the mean NGPA for NUR 1023 between students who passed the NCLEX RN ( N =423, M =2.47, SD =.718) and those who failed the NCLEX RN ( N =67, M =2.03, SD =.627). There was statistical significant difference between the two groups [ t (488)= 4.696, p=.000]. For NUR 1213, the difference in mean NGPA between students who pass ed the NCLEX RN ( N =423, M =2.57, SD =.797) and those who failed ( N =67, M =1.96, SD =.638) was also found to be statistically signifi cant [ t (488)= 5.966, p=.000]. Therefore, the null hypothesis was rejected Th e second research question asks : Is there a significant relationship between the HESI exit exam (E2) scores and the academic and NCLEX RN success of racial/ethnic minority nursing students? Of the students admitted to the program, 79.6% (n=491) had progressed to the last clinical course (NUR 2943L) and took the HESI E2 exam as required for successful completion of this course. The HESI E2 exam scores for these students ranged fro m 525 to 1147 with a mean score of M =839.21 ( SD =103.821).
80 Hypothesis 2.a states: There is no significant difference in HESI E2 scores between racial/ethnic minority and White nursing students Tables 4 8 and 4 9 show the results of this analysis. A cros s tabulation analysis of the HESI E2 examination scores for this sample per race/ethnicity revealed that White students earned scores from 577 to 1111 with the highest mean of 854.81 ( SD = 100.650); Black/African American earned scores from 525 1147 with a mean of 804.50 ( SD = 108.440); and Hispanic students earned scores from 6211028 with a mean of 814.07 ( SD = 96.043). A one way ANOVA test was conducted to compare the three racial/ethnic groups on their performance on the HESI E2 examination. The results showed significant differences in HESI E2 scores between racial groups, F(2, 488) = 11.603, p< .000. Therefore, the null hypothesis was rejected Scheffe multiple comparisons found that Black/African American nursing students HESI E2 scores were statistically significant ly lower than the White group (p difference ( MD ), and p values for HESI E2 were as follows: White Black/African American ( MD =50.313, p =.000), White/Hispanic ( MD =40.738, p=.012), and Black/African AmericanHispanic ( MD = 9.575, p =.838). Ther efore, the null hypothesis was rejected However, it is important to note that there was no significant difference between Black/African American Hispanic nursing students HESI E2 scores (Table 4 10) Hypothesis 2.b states: There is no significant differe nce in HESI E2 scores between nursing students who passed and those who fail the NCLEX RN exam. Tables 4 11 and 412 show the results of this analysis. ). In this study, the HESI E2 mean score for nursing students ( N =423) who passed the NCLEX RN was M =84 8.27, SD =103.184 compared to a mean score of M =784.00, SD =89.818 for those who failed ( N =67). An independent samples t test was used to determine whether a significant difference existed between HESI E2 scores for students who
81 passed and those who failed t he NCLEX RN. There was a statistical difference between the two groups [ t (488), M = 64.267, p=.000]. Therefore, the null hypothesis was rejected Question three asks: Is there a significant relationship between financial support (financial aid) and the a cademic and NCLEX RN success of racial/ethnic minority nursing students? Hypothesis 3.a states: There is no significant difference in financial support (financial aid) between racial/ethnic minority and White nursing students Nursing students belonging to racial/ethnic minority groups have reported finances as a major struggle interfering with their nursing educational experience. The data from this sample revealed that Black/African American nursing students (n= 110, 80.3%) were more likely to receive s ome form of financial a id. On the other hand, only 57%, (n=49) of Hispanic nursing and about 59% of Whites nursing students (n=234) were recipients of some form of financial aid. The Chi square test showed significant difference between race/ethnicity and financial support/aid, X2 ( 2, N = 617) = 21.16, p < .001. The percentage of students who received financial aid differed by race/ethnicity; t he refore, the null hypothesis was rejected. The percentages of financial support/aid by racial/ethnic group are dis played in Table 413. Hypothesis 3.b states: T here is no significant difference in academic success between nursing students who were financial aid recipients and nonfinancial aid recipients. Table 4 14 shows the results of this analysis. About 61% (n=77) of the 127 students who did not complete the ADN program were financial aid recipients compared with 63.6 % (n=262) of those who completed on time and 69.2% (n=54) belonging to the group delayed graduation. Overall, the majority (64.5%, n=316) of nursing students (n=490) who completed the ADN program on time or late received some form of financial aid. The Chi square test showed no significant difference between academic success and financial support/aid, X2 ( 2, N = 617) = 1.55, p < .460. The
82 percentage of students who received financial aid did not differed by academic success. The refore, there was failure to reject the null hypothesis. Hypothesis 3.c states: T here is no significant difference in HESI E2 mean scores, NGPAs for NUR 1023 and NUR 1213 betwe en nursing students who are financial aid recipients and those who were nonfinancial aid recipients. Results for this analysis are displayed in Tables 415 and 416. An independent samples t test was conducted to compare the HESI E2 mean scores for students who were financial aid recipients ( N =317, M =836.55, SD =106.774) and those who were non financial aid recipients ( N =174, M =844.06, SD =98.328). There was no statistical significance between the two groups [t(489)= .767, p=.444]. Likewise, an independent s amples t test was conducted to compare the NGPA for NUR 1023 for students who had financial aid ( N =393, M =2.12, SD =.959) and those who did not have financial aid ( N =224, M =2.17, SD =.1.035). There was no statistical significance between the two groups [ t (61 5)=.582, p=.561]. Therefore resulting in the failure to reject the null hypothesis. An independent samples t test was also conducted to compare the NGPA for NUR 1213 for students who received financial aid ( N =358, M =2.22, SD =1.019) and those who did not receive financial aid ( N =198, M =2.37, SD =.998). There was no statistical significance between the two groups [ t (554) =1.683, p=.093] resulting in the failure to reject the null hypothesis. Question four asks: Is there a significant relationship between race/ethnicity and the academic and NCLEX RN success of racial/ethnic minority nursing students? Hypothesis 4.a states: T here is no significant difference in academic success between racial/ethnic minority and White nursing students Additional data was obtained on the racial/ethnic representation for academic success. Tables 4 17 and 418 show results for this analysis. Of the 412 students who completed the ADN program within 4 semesters, 67.2% (n = 277) were White, followed by
83 19.2% (n = 79) Black/Afric an American, 13.6% (n = 56) Hispanic. The total number of students who graduated from the program within 6 semesters came to N = 490 (79.4%) when taking into consideration the 78 students who completed the ADN program late. This figure ( 79.4%) represents the program graduation rate, which is pe r centage of students who completed the ADN program in 150% of the stated program length. Of the 79.4% t of nursing students who completed the ADN program, 52.7 % (n=325) were White, 15.9% (n=98) were Black/African Ame rican and 10.9% (n=67) were Hispanic. The ADN program attrition rate by racial/ethnic group was as follows: 11.2% White, 6.3% Black/African American, and 3.1% Hispanic. But when looking at percentage within racial/ethnic group, Black/African American nurs ing students had the highest percentage (28.5%, n=39) of noncompleters, followed by 22.1% (n = 19) of Hispanic, and only 17.5% (n= 69) of White nursing students. First semester failure attrition rate accounted for 13% of the sample. When considering each racial/ethnic group separately, the highest percentage of students who completed/graduated from the ADN program in time was predominantly from the White group with 70.3%, followed by Hispanics with 65.1%, and Black/African Americans with only 57.7%. The graduation rate for each racial/ethnic group was as follows: 82.5% White, followed by 77.9% Hispanics, and 71.5% Black/African American nursing students. The overall graduation rate for the program was 79.4%. According to the National League for Nursing NL N Data ReviewTM for year 20082009, the graduation rate for racial/ethnic minority students from pre licensure registered nursing programs (both ADN and BSN programs) was 24.5 percent in 2006. In this sample, 26.7% of racial/ethnic minority nursing student s completed/graduated from the ADN program This graduation rate exceeds the national average by 2.2%. The Chi square test showed no significant difference between academic success and race/ethnicity, X2 ( 4, N = 617) =
84 8.74, p < .068. However, it is important to note that students from Black/African American racial/ethnic background were less likely to successfully complete/graduate from the ADN program than those who belonged to White or Hispanic race/ethnicity. Hypothesis 4.b states: T here is no significant difference in the NCLEX RN success between racial/ethnic minority and White nursing students. Four hundred and ninety students from the original cohorts of students (N=617) admitted in to the ADN program had met the curriculum requirements and were eli gible to sit for the NCLEX RN licensure examination. Of the 490 students who took the exam, 423 (86.3%) passed on their first trial and 67 (13.7%) failed. First time pass rates per racial/ethnic groups were very close with 86.6% (n=58) for Hispanic nursin g students followed by 86.5% (n=281) for White and 85.7% (n=84) for Black/African American nursing students. The Chi square test showed no significant difference between NCLEX RN first time pass rate and race/ethnic ity X2 (2, N = 490) = 0.04, p < 980. T he percentage of students who passed the NCLEX RN on their first trial did not differ by race/ethnicity. As a result, there was failure to reject the null hypothesis. Table 419 provide the results for this analysis. Summary The findings and analysis pr esented in this chapter generated answers to the research question in this dissertation. Descriptive and inferential statistical analyses were used. The results of this study provided pertinent data about the relationships between selected individual and i nstitutional variables and the academic and NCLEX RN success of racial/ethnic minority nursing students in an ADN program. This study offers new data for mean HESI E2 scores comparisons by race/ethnicity, financial aid recipients and nonrecipients groups and NCLEX RN success. The results provided evidence for assumptions and can be used to guide nursing
85 faculty as they strive to enhance the educational experience of racial/ethnic minority nursing students.
86 Table 4 1. Nursing course grade (NUR 1023) by race RACE Total White Black/AfAm Hispanic NUR 1023 grades F Count 36 28 15 79 % within 1023 45.6 35.4 19.0 100.0 % within RACE 9.2 20.9 17.6 13.0 C Count 181 78 41 300 % within 1023 60.3 26.0 13.7 100.0 % within RACE 46.4 58.2 48.2 49.3 B Count 158 26 27 211 % within 1023 74.9 12.3 12.8 100.0 % within RACE 40.5 19.4 31.8 34.6 A Count 15 2 2 19 % within 1023 78.9 10.5 10.5 100.0 % within RACE 3.8 1.5 2.4 3.1 Total Count 390 134 85 609 % within 1023 64.0 22.0 14.0 100.0 % within RACE 100.0 100.0 100.0 100.0 X2 ( 6, N = 609) = 29.986, p < .000 Table 4 2. Nursing course grade (NUR 1213) by race RACE Total White Black/AfAm Hispanic NUR 1213 grades F Count 36 17 8 61 % within 1213 59.0 27.9 13.1 100.0 % within RA CE 10.1 14.9 10.1 11.1 C Count 147 61 40 248 % within 1213 59.3 24.6 16.1 100.0 % within RACE 41.3 53.5 50.6 45.2 B Count 139 33 28 200 % within 1213 69.5 16.5 14.0 100.0 % within RACE 39.0 28.9 35.4 36.4 A Count 34 3 3 40 % within 121 3 85.0 7.5 7.5 100.0 % within RACE 9.6 2.6 3.8 7.3 Total Count 356 114 79 549 % within 1213 64.8 20.8 14.4 100.0 % within RACE 100.0 100.0 100.0 100.0 X2 ( 6, N = 549) = 14.989, p < .020
87 Table 4 3. Descriptives for NUR 1023 and NUR 1213 NGPAs by race/ethnicity N Mean Std. Deviation NUR 1023 White 394 2. 30 .918 Black/AfAm 137 1. 81 1.029 Hispanic 86 2.01 1.063 Total 617 2. 15 .985 NUR 1213 White 362 2. 38 1.018 Black/AfAm 114 2.04 .999 Hispanic 80 2.2 3 .933 Total 556 2.29 1.010 T able 4 4. One way ANOVA for NUR 1023 and NUR 1213 NGPAs by race /ethnicity Sum of Squares df Mean Square F Sig. NUR 1023 Between Groups 25.961 2 12.981 13.96 *** .000 Within Groups 563.441 606 .930 Total 589.402 608 NUR 1213 Between Groups 10.043 2 5.021 4.99 ** .007 Within Groups 548.486 546 1.005 Total 558.528 548 *p 0.05; **p 0.01; ***p 0.001
88 Table 4 5. Post Hoc tests NGPAs by race/ethnicity Multiple Comparisons Scheffe Dependent Variable s (I) RACE (J) RACE Mean Difference (I J) St d. Error Sig. NUR 1023 White Black/AfAm .491 ** .097 .000 Hispanic .286 .115 .047 Black/AfAm White .491 ** .097 .000 Hispanic .206 .134 .307 Hispanic White .286 .115 .047 Black/AfAm .206 .134 .307 NUR 1213 White Black/AfAm .335 .108 .008 Hispanic .151 .125 .479 Black/AfAm White .335 .108 .008 Hispanic .184 .147 .456 Hispanic White .151 .125 .479 Black/AfAm .184 .147 .456 *p 0.05; **p 0.01; ***p 0.001 Table 4 6. Group S tatistics : Means NGPA for NCLEX RN NCLEX N Mean Std. Deviation NUR1023 Failed NCLEX 67 2.03 .627 Passed NCLEX 423 2.47 .718 NUR1213 Failed NCLEX 67 1.96 .638 Passed NCLEX 423 2.57 .797
89 Table 4 7. Independent Samples Test (NGPA) for NUR 1023 and NUR 1213 Levene's Test for Equality of Variances t test for Equality of Means F Sig. t df Sig. (2 tailed) Mean Difference NUR 1023 Equal variances assumed 33.08*** .000 4.696 488 .000 .436 NUR 1213 Equal variances assumed 35.73*** .000 5.966 488 .000 .610 *p 0.05; **p 0.01; ***p 0.001 Table 4 8. Descriptive s : HESI E2 examination scores by r ace/ e thnicity N Mean Std. Deviation White 326 854.81 100.650 Black/AfAm 98 804.50 108.440 Hispanic 67 814.07 96.043 Total 491 839.21 103.821 Table 4 9. One w ay ANOVA for HESI E2 scores by race/ethnicity Sum of Squares df Mean Square F Sig. HESI E2 scores Between Groups 239763.259 2 119881.629 11.603*** .000 Within Groups 5041824.713 488 10331.608 Total 5281587.971 490 *p 0.05; **p 0.01; ***p 0.001
90 Tale 4 10. Post Hoc tests HESI E2 scores by race/ethnicity Multiple Comparisons Scheffe HESI E2 (I) RACE (J) RACE Mean Difference (I J) Std. Error Sig. White Black/AfAm 50.313 ** 11.710 .000 Hispanic 40.738 13.634 .012 Blac k/AfAm White 50.313 ** 11.710 .000 Hispanic 9.575 16.113 .838 Hispanic White 40.738 13.634 .012 Black/AfAm 9.575 16.113 .838 *p 0.05; **p 0.01; ***p 0.001 Table 4 11. Group Statistics: HESI E2 examination mean scores by NCLEX RN status NCLEX N Mean Std. Deviation HESI Failed NCLEX 67 784.00 89.818 Passed NCLEX 423 848.27 103.184 Table 4 12. Independent Samples Test HESI E2 by NCLEX RN status Levene's Test for Equality of Variances t test for Equality of Means F Sig. t df Sig. (2 tailed) Mean Difference HESI Equal variances assumed 1.385 .240 4.816 488 .000 64.267 *p 0.05; **p 0.01; ***p 0.001 Table 4 13. Financial support (aid) by race/ethnicity RACE Frequency Percent Valid Percent Cumulative Percent White Valid No FinAid 160 40.6 40.6 40.6 Has FinAid 234 59.4 59.4 100.0 Total 394 100.0 100.0 Black/AfAm Valid No FinAid 27 19.7 19.7 19.7 Has Fin Aid 110 80.3 80.3 100.0 Total 137 100.0 100.0 Hispanic Valid No FinAid 37 43.0 43.0 43.0 Has FinAid 49 57.0 57.0 100.0 Total 86 100.0 100.0 X2 ( 2, N = 617) = 21.16, p < .001
91 Table 4 14. Financial support (aid) by academic success ACADSUCCESS Total No Grad Delayed Grad OnTime Grad FAID No FinAid Count 50 24 150 224 % within No FinAid 22.3% 10.7% 67.0% 100.0% % within ACADSUCCESS 39.4% 30.8% 36.4% 36.3% Has FinAid Count 77 54 262 393 % within Has FinAid 19.6% 13.7% 66.7% 100.0% % within ACADSUCCESS 60.6% 69.2% 63.6% 63.7% Total Count 127 78 412 617 % within FAID 20.6% 12.6% 66.8% 100.0% % within ACADSUCCESS 100.0% 100.0% 100.0% 100.0% X2 ( 2, N = 617) = 1.55, p < .460 Table 4 15. Group Statistics : Financial aid by HESI E2 scores NUR 1023NUR 1213 FAID N Mean Std. Deviation HESI No FinAid 174 844.06 98.328 Has FinAid 317 836.55 106.774 1023 No FinAid 224 2.17 1.035 Has FinAid 393 2.12 .959 1213 No FinAid 198 2.37 .998 Has FinAid 358 2.22 1.019
92 Table 4 16. Independent Samples Test Financial aid by HESI E2 scores NUR 1023NUR 1213 Levene's Test for Equality of Variances t test for Equality of Means F Sig. t df Sig. (2 tailed) Mean Difference HESI E2 Equal variances assumed 1.217 .271 .767 489 .444 7.514 NUR 1023 Equal variances assumed 3.458 .063 .582 615 .561 .048 NUR 1213 Equal variances assumed .123 .726 1.683 554 .093 .151 *p Table 4 17. Academic success by race/ethnicity Race Academic Success Frequency Percent White No Grad 69 17.5 Delayed Grad 48 12.2 OnTime Grad 277 70.3 Total 394 100.0 Black/AfAm No Grad 39 28.5 Delayed Grad 19 13.9 OnTime Grad 79 57.7 Total 137 100.0 Hispanic No Grad 19 22.1 Delayed Grad 11 12.8 OnTime Grad 56 65.1 Total 86 10 0.0 X2 ( 4, N = 617) = 8.74, p < .068
93 Table 4 18. Comparison of e nrollment a ttrition g raduation rates by race/ethnicity White Black/AfAm Hispanic Total Percent Racial/Ethnic Minority Total Enrollment Frequency 394 137 86 223 617 Valid Percent 63.9 22.2 13.9 36.1 100 Attrition Frequency 69 39 19 58 127 Valid Percent 11.2 6.3 3.1 9.4 20.6 % within race 17.5 28.5 22.1 25.3 Graduation Frequency 325 98 67 165 490 Valid Percent 52.7 15.9 10.85 26.7 79.4 % within race 82.5 71.6 77.9 74.8 Valid Percent 100 100 100 100 Table 4 19. NCLEX RN Pass rates by race/ethnicity RACE Frequency Valid Percent Cumulative Percent White Valid Failed NCLEX 44 13.5 13.5 Passed NCLEX 281 86.5 100.0 Total 325 100.0 Black/AfAm Valid Fail ed NCLEX 14 14.3 14.3 Passed NCLEX 84 85.7 100.0 Total 98 100.0 Hispanic Valid Failed NCLEX 9 13.4 13.4 Passed NCLEX 58 86.6 100.0 Total 67 100.0 X2 ( 2, N = 490) = 0.04, p < .980
94 Figure 4 1. Grade distribution for NU 1023 by race/ethnicity
95 Figure 42. Grade distribution for NUR 1213 (12131) by race/ethnicity
96 CHAPTER 5 DISCUSSION The purpose of this study was to examine the relationship between the selected individual and institutional factors that influence the acade mic and NCLEX RN success of racial/ethnic minority nursing students enrolled in an ADN program. The individual factors explored in this study were race/ethnicity, nursing course grades (NCG), nursing grade point average (NGPA) and HESI exit (E2) examinat ion scores. The selected institutional factor was financial support /aid The variables were selected based on a review of the literature and Marianne Jeffreys theoretical framework the NURS model. The study used demographic and academic data to compare an d contrast various educational outcomes between racial/ethnic minority and White nursing students. In particular, t he study compared these groups in performance areas such as nursing course grades ( NCG), nursing grade point average ( NGPA), and HESI exit (E 2) examination scores academic success (graduation) and NCLEX RN pass rates. This chapter will present a brief description of Jeffreys model and its relationship to this studys key findings along with interpretation in relation to the literature revie w. Finally the chapter will conclude with a summary of the findings. Jeffreys NURS (Nursing Undergraduate Retention and Success ) model (Figure 2 1) formed the theoretical framework for this study It is a very comprehensive model and exceeds the scope of this study. For this reason, variables were selected from Jeffreys' NURS model and led to the proposition of a smaller conceptua l model (Figure 2 2). Drawing from Jeffreys' NURS model and the literature review, these key individual and institutional vari ables were used to illustrate the ir relationship with the academic and NCLEX RN success of racial/ethnic minority nursing students This study is unique in that it primarily focuses on specific groups of nursing students ( Black African American, Hispanic & White )
97 Jeffreys earlier NURS (Nontraditional Undergraduate Retention and Success ) model primarily focused on the retention and success of nontraditional nursing students (2004) The new NURS model is geared toward the undergraduate nursing student (tr aditional and nontraditional) in general and is therefore applicable to this study sample. In developing the model, Jeffreys (2004) considered global and national immigration trends, the traditional and nontraditional student, the issue of attrition, the multifaceted process of nursing student retention and the complex interaction of influencing variables, and the lack of diversity in the nursing workforce. Jeffreys (2004, p.277) maintains, The NURS model is flexible enough to be used to guide assessment at the individual, subgroup, course, program, institution, or multisite level. The author also recognizes that the NURS model is tentative and would need revision as new empirical data become available (ibid). Relationship between Race/Ethnicity and A cademic and NCLEX RN Success Jeffreys NURS model proposed that a students decision to withdraw from or remain in a nursing program can be predicted by the interaction of student profile characteristics (i.e. race/ethnicity) student affective factors, academic factors, environmental factors (i.e., financial aid) professional integration factors, and outside surrounding factors. These interactions are predictive of academic outcomes (course grades /nursing grade GPA, HESI exit exam (E2) scores ) and psychological outcomes (Jeffreys, 2004). Jeffreys (2004, p.10) asserts that : The voluntary and/or involuntary decision to remain in a course, persist in the nursing program, graduate, take the RN licensing exam, and enter the nursing workforce and/or begin a m ore advanced nursing program occurs during and at the conclusion of eac h nursing course. ( p.10 ) As seen in the results of this study, 20.6% of all the students included in this study voluntarily or involuntarily withdrew.
98 According to Jeffreys NURS mo del, each students profile characteristics (i.e., race/ethnicity) may have direct and/or indirect impact on retention ( Jeffreys 2004, p.30). Jeffreys (2004) further emphasizes that contrary to attrition, which may be voluntary or involuntary, retention is a voluntary decision. A student makes the decision to continue in the nursing program, graduate and take the NCLEX RN. Jeffreys (2004) considers the NCLEX RN as a component of retention, since the student has to make the choice to persist on the educ ational pathway toward becoming an RN. In this study, race/ethnicity was found to be significantly related to students academic success which supports Jeffreys model that postulated race/ethnicity directly or indirectly impacts student retention Blac k/African American nursing students had a higher attrition rate (28.5%), a lower ontime completion rate (55.7%), and took longer to complete the ADN program than the other racial/ethnic groups (versus White and Hispanic) included in the sample. This findi ng is consistent with a recent study by Jeffreys (2007) who noted that Black nursing students had the highest percentage of voluntary attrition, took longer than Asians and Whites to complete the nursing program, and had the highest percentage of nongradu ates Similarly, Seago and Spetz (2005) found that African American nursing students had lower ontime completion rates than the statewide average and the lowest rate of success with only approximately 50% graduating. Delayed graduation rate for Black/Afr ican American nursing students in this study mirrors earlier research studies. For example, Endres, (1997) found that African American graduates who passed the NCLEX RN were more likely to require significantly more semesters to complete the nursing curr iculum. Also Byrd et al. ( 1999) found that White students were more likely to graduate than racial/ethni c minorities Conversely, Higginss (2005) study of 213 ADN
99 students yield ed no statistical significance between race and academic success. Gardner (200 5) ascertained that the high attrition rate of ethnic/racial minority nursing students is a contributing factor to the underrepresentation of these individuals in the nursing profession. An additional finding of interest in this study was the 20.6% attrition rate of the overall sample with more than half (54.4%) of these students being White, 30.6% being Black/African American, and 15.04% being Hispanic nursing students. Although this finding is close to the national figure (17.0%) reported by the NLN for ADN programs during academic year 2006 2007 (NLN 2008), it is still a great concern in light of the current and projected shortage in the RN workforce, especially in racial/ethnic minority communities, where this shortage is even more pronounced. The issue of retention is across the board within nursing education and deserves to be a priority because of the negative effects the shortage may cause on the U.S. healthcare system. In this study, race/ethnicity was not found to be significantly related to stud ents NCLEX RN success The first time NCLEX RN pass rate for all three racial/ethnic groups in this study was nearly comparable. Hispanic nursing students had the highest NCLEX RN first time pass rate (86.6%), followed by White (86.5%) and Black/Africa n American (85.7%). Additionally, the overall ADN program first time pass rate was closely related to the national NCLEX RN pass rate for the time period of the study (fall 2006 to fall 2010). This finding of no significance between race/ethnicity and NCL EX RN success may not support Jeffreys theory of race/ethnicity directly or indirectly influencing retention. One explanation could be that as racial/ethnic minority nursing students progressed through the ADN program and adapted to the rigor of the curriculum In due course, t hey developed the necessary skills (study and critical thinking skills) enabling them to perform at
100 comparable level as their White counterparts. Another argument could be that those racial/ethnic minority nursing students who we re underprepared had already failed out of the ADN program during the first year Those who remained and took longer to complete the curriculum requirements (by having to repeat one course), were able to academically i mprove, and as a result, were successf ul in the NCLEX RN. Based on the data from this study, researchers must use caution regarding drawing conclusions about the direct or indirect influence of race/ethnicity on the academic success of students. As suggested by Jeffreys NURS model, researc hers must take into account the interactions among the variables (in the model) leading to attrition or retention. Previous studies support the findings of this study. These researcher s found no correlation between race/ethnicity and first time pass rate i n the NCLEX RN (Briscoe & Anema, 1999; Endres, 1997; Hardin, 2005; Higgins, 2005; Jeffreys, 2007; Washington & Perkel, 2001; Yin & Burger, 2003). For instance, Endres (1997) conducted a retrospective study to look at the strongest predictors of NCLEX RN success. In line with the results from this study, Endres (1997) concluded there were no significant differences between the passing and failing rates among African American, Foreign born, and Caucasian nursing students. Similarly, Jeffreys (2007) and Higg ins (2005) did not find race/ethnicity to be a significant predictor of first time NCLEX RN pass rate. Contrary to this studys finding, a number of prior studies had demonstrated consistent association between race/ethnicity and NCLEX RN first time pas s rate. Crow et al. (2004) found that programs with higher percentages of White students were more likely to have higher passing rates than programs with smaller percentages; additionally, programs with higher percentages of Hispanic students reported low er pass rates (p. 184). This was not the case in this study. Regardless of higher percentages of Whites in this ADN program, Blacks and Hispanics
101 comparatively succeeded in passing the licensure exam on the ir first attempt. Sayles, et al. (2003) found that African American students were less likely to be successful in the NCLEX RN than their White counterparts. Harris (2006) found that White nursing students were 0.48 times more likely to pass NCLEX RN the first time than racial/ethnic minority students These conflicting findings regarding NCLEX RN the firsttime rates were independent of program type (ADN or BSN) or sample size. The results may have been influenced by other factors such as: cultural values and beliefs, self efficacy, absence of enrich ment program, satisfaction with the ADN program and stress In order to yield results portraying the whole students, further research must be undertaken to examine variables such as: student affective factors, professional integration factors and psychol ogical outcomes that may be influencing these students retention and success. Relationship between NCG/NGPA and Ac ademic Success Jeffreys NURS model identifies NCG and NGPA as essential academic outcome measures (2004). The model proposes that persiste nce and attrition decisions occur during and after each individual nursing course (Jeffreys, 2004, p.125). The data from this study revealed that Black/African American nursing students were more likely to earn a failing grade (F) in both NUR 1023 and NUR 1213. These low grades may partially explain the higher attrition rate and lower ontime completion/graduation rate for this group of students. Students often are unaware of the rigor of the nursing curriculum and may be often challenged by the required academic workload. Unfortunately, too many encounter academic failure due to these academic demands. The literature provides clarification for this phenomenon. Childs et al. (2004) wrote that ...many African American students are unaware of and unprepared for the amount of study required in college courses. Amaro et al. (2006) discovered study workload as a barrier to success for ethnic minority nursing students. Another reason for the low NCG and NGPA may be the
102 socioeconomic status of the Black/African American students pursuing nursing degrees versus Whites. In addition to the academic workload, many of these students need to work in order to support themselves and/or their families. The employment responsibilities or hours represent a significant sourc e of stress and competitor of time commitment for study Regrettably, often times, their academic outcomes ( NCG and NGPA ) succumb to the other demands. The data for this study revealed statistical difference in NCG between White and racial/ethnic minority nursing students for NUR 1023. However, analysis of NCG for NUR 1213 revealed no statistical difference between White and Hispanic nursing students, but the difference persisted between White and Black/African American nursing students. This result reve aled that, as Hispanic nursing students progressed through the ADN program, their academic performance (outcome) greatly improved compared to their White counterparts. For this reason, the need to explore their lack of success during the first semester (NU R 1023) in the ADN program is warranted. Relationship between NGPA and NCLEXRN Success The re was statistical significant relationship between NGPA (for NUR 1023 and NUR 1213) and NCLEX RN Success Students with lower NGPA were more likely to fail the NCLEX RN. These findings support Jeffreys assumption that academic outcomes (NCG & NGPA) impact a nursing student attrition and retention. Several earlier studies presented similar findings. Byrd et al. (1999) concluded that the NUR 101 (nursing fundamental) course average was predictive of successful completion of the nursing program. Likewise Jeffreys (2007) reported grades in MS1 (introductory nursing course and included contents from fundamentals and medical surgical nursing) to have significantly in fluenced the type of retention, progression, graduation, and licensure. Similarly, Alexander and Brophy (1997) noted statistically significant differences in nursing course grades between graduates who passed and those who failed the
103 NCLEX RN; and Stuenke ls (2006) research further echoes that those who passed NCLEX RN held higher mean s cores for nursing theory grades. Uyehara et al. (2007) found significant correlations between NCLEX RN success and nursing GPA and course grades in Fundamental nursing c ourse. Additional supportive f indings by Seldomridge and DiBartolo (2004) indicated students who passed the NCLEX RN had higher mean test averages in both adult health I & II nursing courses compared to those who failed. These previous studies confirm thi s study s findings of the relationship between NCG/NGPA and academic and NCLEX RN success. Conversely, Horton (2006) investigated the predictors of graduation and NCLEX RN success of 351 students who attended a small Midwestern BSN program from 19942005. The author concluded that the number of C grades earned in nursing courses were identified as predictors of graduation or NCLEX RN success. It is important to note that other factors such as language, learning styles, academic preparation not explored in this study may affect nursing course grades, and subsequently students academic and NCLEX RN success. The study data showed higher academic failure rate for racial/ethnic minority students and yet almost equal to better first time NCLEX RN pass ra tes than their White counterparts. The reasons beyond the difference between the academic and NCLEX RN success for racial/ethnic nursing students are discussed in previous sections and deserve further scrutiny. As it now stands, there is compelling eviden ce and plea to increase the ratio of racial/ethnic diversity in the RN workforce. This goal will materialize only when ADN programs retain and graduate their enrolled racial/ethnic minority students. Relationship between HESI E2 Exam Scores and Ac ademic and NCLEXRN Success This study added HESI E2 exam scores as an academic outcome measure as depicted in Jeffreys NURS model. The results from this study revealed a higher mean score for White nursing students and significant differences in mean HESI E2 scores between White and
104 racial/ethnic minority students. Additional analyses also yielded significant differences in mean HESI E2 scores between nursing students who passed and those who fail the NCLEX RN. These findings support Jeffreys assumption that academic outcomes (HESI E2 exam scores) impact a nursing student attrition and retention. No earlier research has examined the difference between the mean HESI E2 scores between racial/ethnic groups. However, the previous E2 studies revealed significant differences in NCLEX RN failure rate between low sco ring and high scoring students (Lauchner, et al., 1999; Newman et al., 2000; Nibert & Young, 2001; Nibert et al., 2002). Also a multidimensional study by Hardin (2005) suggested ADN graduates with higher passing scores on the E2 had a higher NCLEX RN success rate. Once again, t hese findings support Jeffreys assumption that academic outcomes (HESI E2 exam scores) impact a nursing student attrition and retention ( NCLEX RN success). The HESI E2 examinati on is a standardized test used t o measure students preparedness for the NCLEX RN. The nursing program uses the HESI E2 exam t o measure students preparedness for the NCLEX RN. When examining the scores for the last cohort (fall 2008), only one student obtained a score below 700. This may due to the fact that the passing score was raised to 750 that same semester. It can only be assumed that students may be taking the E2 exam more seriously because of its impact on their academic status. This inquiry could only be explored with a survey or a qualitative study. Other nursing programs (ADN and BSN) have established similar progression policies based on students scores in standardized assessment exams. Students are often allowed to retake the HESI E2 mult iple times until achievement of the minimum sc ore set by the program. Nibert et al., (2003) reviewed 45 programs with progression policies where nursing students who did not meet minimal HESI E2 scores had either failed a key course, been denied eligibilit y for
105 graduation, or approval to take NCLEX RN. Likewise, Lewis (2005) retrospective research identified significant difference between HESI E2 scores of students in nursing programs with benchmark policies than those in programs without progression poli cies. In the same way, Spector and Alexander (2006) indicated that progression or exit exams are valuable tools in predicting NCLEX RN success. Conversely, Spurlock and Hanks (2004) questioned the ability of the HESI E2 to predict NCLEX RN failures; th erefore, recommending nursing programs to consider multiple aspects for progression beyond the HESI E2. Spurlock and Hanks (2008) further cautioned against the practice of multiple retakes of the E2, as they have found that only students first scores o n the E2 is significantly related to NCLEX RN outcomes (p.165). The additional scores decrease the strength of the relationship between the two variables. T his practice may also give schools a false sense of security, because the initial scores on the E2 are the most reliable in predicting NCLEX RN success. Base d on the existing policy at the ADN program for this study the racial/ethnic minority nursing students who scored low on the HESI E2 received additional remediation materials and were reassesse d with an HESI E2 to assure readiness for NCLEX RN. This may be the explanation for the comparable first time NCLEX RN pass rate among the racial/ethnic groups. One may conclude that when remediation is offered to low performing students, outcome results such as NCLEX RN first time pass rates are almost identical across all racial/ethnic groups. Relationship between Financial Support/Aid and Ac ademic and NCLEX RN Success Jeffreys NURS model incorporates environmental factors (i.e., family emotional su pport, family responsibilities, family crisis, financial status, etc) that are external to the academic process, but may significantly influence a students academic achievement and retention. The environmental factor explored in this study was financial support/aid. The data
106 revealed no significant relationship between financial aid and academic and NCLEX RN success No significant relationship was found between financial aid and the other independent variables either (race/ethnicity, NCG, NGPA, HESI E2 scores) However, in this study, only 57% of the Hispanic nursing students received some form of financial aid compared to 80% of the Black/African American and 59.4% of White nursing students. Previous studies offer some explanation for this trend. Long erbeam, Sedlacek and Alatorre (2004) reported that Latinos are more likely to be concerned about finances and more likely to work; which may cause them to be come ineligible for Pell Grant At the same time, t hey are also unwilling to take out loans for tui tion (Soroff, Rich, Rubin, Strickland & Plotnick, 2002), and many are unaware of additional financial options (Goetz, 2007). Unfortunately, the data from this study was unable to capture the related factors to this low percentage of financial aid recipien ts among Hispanics, and thus unable to present further discussion on this matter. Summary Most findings from this study correlated with Jeffreys NURS model. The NURS model served as a guide for this research study analysis and discussion. Students were tracked from ADN program entry to completion, as well as the NCLEX RN pass fail status. This discussion has also reflect ed on previously published studies that have addressed some or all of the variables explored in this study. There was significant a relationship between race/ethnicity and academic success, but none between race/ethnicity and NCLEX RN success. Therefore, the variable of race/ethnicity needs to be further explored along with other factors (i.e., academic factors, culture, socioeconomic s tatus, professional integration factors & psychological outcomes, etc) that may be inherent to racial/ethnic groups. Nonetheless, it is extremely important for administrators and faculty to pay close attention to underlying barriers to the academic succes s and retention of these groups.
107 The significance between NGPA and academic and NCLEX RN success was an expected finding, as previously proven. Students who earn a passing grade in their nursing courses or those with a high NGPA are more likely to gradua te from the ADN program and pass the NCLEX RN on their first trial. Although this study did not find statistical significance between financial aid status and academic and NCLEX RN success, other research have shown finances to influence racial/ethnic mi nority nursing students academic and NCLEX RN success (Amaro et al., 2006; Anders et al., 2007; Evans, 2007; Gordon & Copes, 2010; Nugent et al., 2004; Stewart, 2005; Taxis, 2006; Wilson, 2007); therefore, this variable should not be dismissed when deali ng with these students. One desired outcome for this study was to provide nurse educators with data that would disclose the relationships between selected individual factors (NCG, NGPA, & HESI exit (E2) exam scores), and institutional factor ( financial s upport/aid) and academic and NCLEX RN success for racial/ethnic nursing students It is anticipated that these findings will offer some guidance to college administrators and nursing faculty as the y ex amine and revise curriculum and instructional approaches to meet the learning needs and challenges of all at risk nursing students. As these adjustments are implemented, they will promote successful completion of the ADN program and success on the NCLEX RN may increase. Another desired outcome was to offer i nformation that would facilitate early recognition of atrisk students. This early identification would allow facultys provision of the necessary counseling and support to promote academic success and the probability of on time graduation.
108 CHAPTER 6 IMPLICATIONS Policy Recommendations The 2010 U.S. Census report provides evidence of a growing racial/ethnic minority population. Hispanics now account for about 16.0% and Blacks/African Americans make up 12.6% of the total U.S. population. While this inevitable demographic trend is occurring, the 2008 NSSRN reports a sustained homogeneous (83.2% White) RN workforce (HRSA, September 22, 2010) This disproportionate representation of racial/ethnic minorities in the RN workforce has been going on for deca des. If this problematic situation is not solved, it will have disastrous effects on the U.S. healthcare system. Research shows the lack of minority health professionals to be linked to the nations widening gap in the healthcare status between minority an d majority populations (Sullivan Commission, 2004). Ensuring equal representation of racial/ethnic minority in the RN workforce is not simply a matter of equal opportunity, but one of responsiveness to a major obligation to reduce healthcare disparities among racial/ethnic minority groups and consequently improve the healthcare of the nation. Hispanics continue to be the most underrepresented minority group in the RN workforce while experiencing the fastest growth within the general U.S. population. Unfortunately, the findings from this study do not offer much optimism for an impending change for the Hispanic population. The study results indicated they had the lowest enrollment rate, which means that even a 100% retention rate would not adjust the existing disproportion. Additional results from this study revealed high attrition rate for Black/African Americans, overall higher academic failure rates (Lower NCG, NGPA and HESI E2 scores) for both Blacks/African Americans and Hispanics, and yet they have com parable NCLEX RN pass rates to their White peers. It is important to note that while the Black/African American segment of the sample was reflective of
109 the local demographic, the high attrition rate is still alarming as it negatively affects not only the racial/ethnic RN workforce diversity, but also the current and projected RN workforce shortage. In order to improve the disparity in the RN workforce ADN programs need to enroll, retain, and graduate higher percentages of racial/ethnic minority students to compensate for the persistent underrepresentation. In this study, academic and NCLEX RN success are indication of retention, degree completion and considered positive outcomes for all stakeholders, from top college administrators, to deans and directors to faculty and most significantly students, especially those belonging to racial/ethnic minority groups. As mentioned earlier in this paper higher retention and graduation rates support President Obamas higher education reform for America to reclaim its leadership educational status in the world by 2020. Also, the Sullivan Commission and the IOM call to increase diversity in the RN workforce translate in higher number of awarded postsecondary degrees. Unfortunately, in spite of these recommendations by national leaders, the racial/ethnic minority underrepresentation in the RN workforce persists, as confirmed by the results of this study of one particular nursing program in South Florida. If this program is reflective of the national trends in nursing pr ograms, then nursing school administrators, policy makers, and local communities must recommit to improving the racial/ethnic representation in the nursing professionals. Many policy implications can be drawn from the results of this study. Higher educatio n administrators, nurse educators, policy makers, and the like, have an enormous obligation to partake in the preparation of the racial/ethnic minority registered nurses. Policies and initiative s to promote racial/ethnic minority students academic and NCLE X RN success are necessary to
110 achieve this goal. Based on the study findings and discussions the following policy recommendations are proposed. Institutional and departmental policies to use data in the decision making process. A policy recommendation would be for the college and the ADN program to make a commitment to establish data driven policies. The data generated by this study shed light on the obligation for the state college administrators and faculty to consider and address the challenges and nee ds of racial/ethnic minority nursing students. It is crucial to increase their participation in nursing education and consequently their representation in the RN workforce. It is anticipated that these results will prompt discussions and determine new cour se of actions. Moreover, the materialization of the proposed recommendations would only be made possible if the ADN program director and faculty receive support from college administrators. The implementation of any new program will have considerable impli cations for faculty workload, as additional time must be allotted for planning, implementation, and program evaluation. Institutional and departmental policies to recruit additional Hispanic students into the nursing profession. The overall underrepresenta tion of Hispanic students in the ADN program was related to low enrollment (13.2%). The College is strateg ically located in Southeastern United States where there is a high concentration (19%) of Hispanics and must seize the opportunity to attract and educate more students from Hispanic background into the nursing profession. The college needs to re examine its current recruitment and enrollment strategies, and employ innovative approaches to attract these students A policy recommendation would be to have a recruitment goal of 3.0% increase of Hispanic students per year for the next five years into the ADN program Research found that the lack of college/career guidance from
111 high school causes racial/ethnic minority nursing students to be underprepared for college (Gardner, 2005; Goetz, 2007; & Jones, 1992). The College could start with forming collaboration with two middle schools and two high schools that are located in areas with highest racial/ethnic minority in the County. This partnership would include the K 12 guidance counselors, the college s academic advisors, nursing program specialist and faculty, racial/ethnic minority nurses from the community, and a couple of healthcare facilities. The emphasis of the partnership would be on promoting racial/ ethnic minority (especially Hispanics) inclusion in nursing. The K 12 guidance counselors would assist students in course selection that would get them ready for college level work. The collaborative team could provide workshops for parents and students to educate them on opportunities in the nursing field at the college level. ADN program policies to retain and graduate additional Hispanic Black/African American and all at risk nursing students. T he data from this study revealed a 28.5% attrition rate for Black/African American nursing students and an overall attrition rate of 20.6% for all students in this study. These students represent the at risk group that did not make it through the ADN program. The higher attrition rates for the racial/ethnic minority students had a negative impact on their academic success especially Black nursing students The ADN program needs to set a goal to increase both retention and NCLEX RN first time pass rates by 5.0% for the next five academic year s for all racial/et hnic groups Although not captured by this study, the study sample included students from Haitian background who self identified as Black/African Americans and have English as a second language (ESOL) and face the same linguistic and learning styles chall enges as the Hispanic nursing students. Also, some of the Hispanic students were first generation in the U.S and are
112 ESOL students. The lack of mastery of the English language is a common barrier faced by many ESOL students aspiring to enter college (nursi ng school). These students may be fluent in the English language but still struggle with reading, comprehension and writing. Compounding the language issue is the variety in learning styles. Seago and Spetz, (2005) raised the questions about White nursing faculty not taking into consideration various learning styles and culture as they plan lessons and teach contents. Some teaching styles are more effective for some specific learning styles. Therefore, in order to promote student engagement and learning, al l faculty must take into consideration the different learning styles and incorporate various components in their classroom presentations. A potential policy recommendation to improve Hispanic Black/African American and all at risk nursing student s rete ntion rates could be to focus energy on the lowest quartile of students. This policy would benefit all students regardless of racial/ethnic background and would lead to several programmatic initiatives. For example the ADN nursing department could establis h an enrichment program for the at risk group. A literature review on current best practices related to retention in nursing education revealed the significance of professional integration factors (i.e., nursing faculty advisement/helpfulness, peer men toring/tutoring, professional events & memberships, enrichment programs, etc...) to an undergraduate nursing students reten tion and success as described in the NURS model (Jeffreys, 2004) Gardner (2005a ) developed and implemented the Minority Retention Project at California State University School of Nursing. The purpose of the project was to enhance the integration of racial/ethnic minority students into a supportive learning environment. The following strategies were used: 1) A mentoring network compri sed of working minority RNs from the community who worked with minority nursing students. These nurses served as role models, friends,
113 confidant s, and a support system for the students. 2) A program coordinator who provided students with information about additional educational support services (library tours, writing centers, and financial services) on campus. 3) Classes on study and test taking skills. The retention rate was 100% for the 20032004 academic year as a result (Gardner, 2005a ). Symes, Tart, Travis, and Toombs (2002) reported c lose to similar results as Gardners (2005). The implementation of their retention program yielded an 89.0% retention rate for at risk students. Nursing f aculty identified at risk students early and provided academic support, which ranged from teaching a student how to highlight a text to assisting in dealing with family issues or facilitating a peer support group. Faculty also noted that some students did not seek early assistance and ended up with a failing grade in th e course. This lack of initiation toward faculty, from racial/ethnic minority students, is an expression of some cultural norms that consider it rude to speak up or ask questions of someone in a superior position (Symes et al., 2002). This finding is supported by Amaro et al. (2006) who reported that ethnic minority students felt they did not get the assistance they needed to be successful. Taxis (2006) conducted an investigation of the experiences of nine Latina/Hispanic senior students and graduates from a BSN program with regard to institutional factors that influenced their retention and graduation. E xperiencing caring relationships with institutional agents were among the key factors extracted from the data analysis of individual interviews, focus gro ups and questionnaire responses. In the same way, Amaro et al. (2006) studied the perceptions of 17 ethnically diverse nursing students regarding their educational barriers and how they coped with these barriers. The authors found nursing faculty who served as mentors, who tutored students, who were patient, and who provided encouragement were key players in
114 the success of minority students. The professional integration factors a re powerful influences on the academic and NCLEX RN success of racial/ethnic nursing students Consequently, the ADN director and faculty would either duplicate one of these program s or borrow components from each one that would best meet the specific needs of those at risk students. Such enrichment program would need to include policies such as: mandatory faculty mentoring, peer/faculty tutoring and/or learning groups, and workshops attendance for all students identified as at risk. The majority of these students are unfamiliar with rigor of nursing school and need to develop grea t study habits that incorporate critical thin king skills. The faculty mentoring would consist of mandatory one on one student/faculty meetings at different points in the semester, students would develop with facultys assistance a plan of success for the semester with follow up meetings. In order to engage the students in the learning process, classroom instructions would be delivered in ways to engage each of the learning styles. The learning group sessions would include review of lectures using additiona l instructional activities to facilitate comprehension of nursing concepts and promote study skills, along with critical thinking skills and test taking skills. The workshops would cover topics on time management, study and critical thinking skills. These approaches yielded effective outcomes in the aforementioned programs and the following ones: the Mentorship Model for the Retention of Minority Students (Nugent et al. 2004), The Coppin Academy for PreNursing Success (CAPS) at Coppin State University He lene Fuld School of Nursing (Gordon & Copes, 2010), the recruitment and retention project at UTEP SON for the economically disadvantaged Hispanic nursing students (Anders et al., 2007), the Minority Retention P roject (Gardner, 2005a ), and the NGN project f rom Clayton College and State University ( Wilson, 2007)
115 Another potential academic policy would be for racial/ethnic minority nursing students to have membership and be actively involved in racial/ethnic minority professional nursing organization, as this would be great source of inspiration for these students. This would also create an opportunity for students to find racial/ethnic minority nurse mentors who may have had similar experiences and able to provide guidance on how to navigate through nursing school. Such enrichment program would promote academic and NCLEX RN success. In light of the overall high attrition rate for the ADN program, the changing racial/ethnic demographic in the U.S. and the RN workforce shortage, it is imperative to prioritize the needs and challenges of not only the racial/ethnic minority nursing students, but also all those at risk students. With the right elements in place success can be achieved. Institutional commitment to establish an improved financial aid application pro cess. The data from this study showed that only about 57% of Hispanic nursing students received some form of financial aid Students qualification/eligibility for financial aid may affect their decision to attend college. A policy recommendation would be to have a mandatory financial aid workshop attendance for all high school students and their parents as a requirement for high school graduation. Since financial aid guidelines do change, a similar mandate would benefit new and returning college students. In order to increase awareness of financial aid opportunities, the college may partner with the K 12 system and organize workshops throughout the year for parents and students to inform them about all types of financial aid available for racial/ethnic min ority students and the financial aid processes. Also, some of these workshops could be designated to assist parents and students complete the financial aid forms prior to eligibility deadlines. Financial literacy about college affordability is an essential factor in enrollment and
116 retention of racial/ethnic minority nursing students. The lack of financial knowledge may be one of the reasons for the low enrollment of Hispanics in the ADN program. Institutional priority to allocate additional funds to the ADN program. The proposed recommendations would require both human and financial resources and must be supported by high level college administrators and State Legislature. A policy recommendation would be to make the enrollment, retention and graduation of r acial/ethnic minority in the ADN program a top priority for the next five years The need to achieve greater racial/ethnic minority diversity in the RN workforce greatly depends on nursing education. The current state of affairs might be an opportunity for top college administrators to partner with leaders from private and public health organizations to lobby for funds at the State level. Data from this study and evidence from the nursing industry could be presented, along with discussions on their impact on the health outcomes and the disparities between racial/ethnic majority and minority groups. In addition, the Dean would need to work closely with the college grant office to identify available grants geared toward student retention. Most importantly, any initiative that is instituted would need to plan for sust ainability when funds from the s tate or grants run dry. C ollege administrators and nursing faculty have the responsibility to establish the necessary programs to deal with the individual and insti tutional factors that are preventing the success of racial/ethnic minorities in nursing education and contributing to their persistent underrepresentation in the nursing workforce. Enrollment without a strategic retention plan is futile If these trends persist, it is unlikely that the ADN program will graduate the sufficient number of racial/ethnic minority nurses to respond to the nursing profession racial/ethnic diversity challenge. As the racial/ethnic minority population in the US continues to exponentially grow, especially the Hispanic segment of the population, their educational progress would not
117 only benefit the individual, but also the healthcare system within their residential communities, states, and the nation as a whole. For this very reason, it is imperative that top level college administrators, deans of nursing, nursing program directors and faculty focus on addressing the educational needs and success of the racial/ethnic minority nursing students. Future Directions for New Studies Under standing the factors relating to racial/ethnic minority nursing is of great significance. As a result, the following studies are proposed for further research This was a quantitative study that examined the records students, who have completed the ADN pro gram and passed the NCLEX RN, or have withdrawn voluntarily or involuntarily from the program. It would be worthwhile to conduct a prospective study that examines additional variables such as enrollment status, overall grade point average, income and nee d based, and immigration status as this may affect eligibility for financial aid, along with programspecific factors (i.e., The students would be tracked from admission into the ADN program through taking the NCLEX RN. This would allow early identification of at risk students as well as program specific factors that contribute to students academic success or failure. Additionally, the data would provide opportunities for curriculum change, implementation of innovative teaching methodologies, improved financial and academic advising and ultimately student success. Grades in nursing courses (NCG/NGPA) were an issue for Black/African American students. This represents a roadblock to the academic success of this particular group of students and a challenge for both nurse educators and students to overcome. A future study could be designed and based on a diversity model to examine the relationship between students learning styles primary language, cultural values and beliefs, academic preparation and acade mic success The results would provide evidence for both faculty and students as they engage in the teaching and learning process. In order to meet the educational needs of racial/ethnic minority
118 students, faculty would develop and implement innovative tea ching methodologies that provide equal learning opportunities. No significant difference was found in NCLEX RN pass rates among the different racial groups. This is evidence that once the students developed the required study and critical thinking skill s in the first year of the ADN program, they continued to grow and were ready for the NCLEX RN. However, one great concern remains regarding the higher attrition rates and lower performance (in terms of NCG and NGPA) of Black/African American and Hispanic nursing students in comparison with their White counterparts. A qualitative study that investigates the educational experience (reasons for exiting and/or stopping out) of racial/ethnic minority students in nursing school would provide valuable cues for c ollege administrators and nursing faculty. Cultural sensitivity and competency are taught to nursing students in relation to patient care. However, the practice of cultural sensitivity and competency in nursing education remains a challenge and may infl uence racial/ethnic minority students success and achievement. According to Wilson, Andrews, and Leners (2006), institutional barriers that hinder ethnic participation in nursing include lack of faculty sensitivity to cultural differences and institutiona l racism. A future study that explores the level of cultural sensitivity and competency of nurse educators and the influence of their interactions with racial/ethnic minority students would benefit both faculty and students. The disproportion of the racia l/ethnic minority in the registered nursing profession has been linked to the health disparities experienced by minority patients. It would be important to conduct a clinical study that would first survey the current racial/ethnic representation within the major local hospitals in addition to investigating the healthcare disparity index in the community.
119 The results may prompt modification in staffing and the healthcare delivery system. In order to ensure parity in health care delivery to racial/ethnic mino rity groups, it is imminent to increase their ratio within the registered nursing workforce. The demographic shifts in the U.S population present unique challenges and opportunities in nursing education.
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131 BIOGRAPHICAL SKETCH Louise Aur lien was born in Port au Prince, Hati to M. Jean Louis Aur lien and Sophana Calixte Aur lien After high school, she moved to the United States to pursue higher education. She started out as an LPN (Licensed Practical Nurse) and then obtained her Baccalaureate in Science Nursing (BSN) from the University of Massachusetts in Boston. She then we nt on to complete her Masters i n Science with a Primary Care focus (Family track) from Northeastern University in Boston, Massachusetts. She is a Family Nurse Practitioner. She has worked in different areas in Nursing, from longterm care, to m edical surgi cal, to maternal child health and school health centers (adolescent population), etc She has been a part of the Nursing profession for over 20 years. In 2003, Louise moved to Florida and first joined the faculty at Palm Beach State College (then Palm Be ach Community College) as an adjunct in October of 2003, and was subsequently hir ed full time in January of 2004. She earned tenure in 2007. In 2007, she was accepted into the LEAD (Leadership Educational Administration Doctorate) program at the University of Florida (UF ) (Concentration: Higher Education Administration) and completed in August 2011. Louise enjoys the beach, reading, spending time with her family and friends. After completing her Doctorate in Education at UF, s he hopes to have time to travel for leisure and volunteering.