...calls for greater diversity are guided in part by research that demonstrated a link between healthcare workforce diversity and improved quality of care... For more than a decade, American nursing and health policy experts have called for increasing the diversity of the nursing workforce to better align with the nation’s demographics (Sullivan Commission, 2004; Institute of Medicine [IOM], 2011; Campaign for Action, 2018). These calls for greater diversity are guided in part by research that demonstrated a link between healthcare workforce diversity and improved quality of care (Alegria et al, 2013; Charlot et al., 2015; IOM, 2003; Jackson & Gracia, 2016; Murray & McCrone, 2014; Phillips & Malone, 2014; U.S. Department of Health and Human Services, [DHHS] 2006, 2016), and by a recognition of the opportunities and social benefits that a nursing career offers individuals from underrepresented backgrounds.

Underrepresentation in nursing is particularly notable among Hispanics and Blacks/African Americans (AA), who represent 31.8% of the United States (U.S.) population (U.S. Census Bureau, 2018), but in 2015 represented only 19.5% of registered nurses (Budden, Moulton, Harper, Brunell, & Smiley, 2016; DHHS, 2017). College enrollment statistics indicate that some progress has been made in the profession toward achieving diversity goals as Hispanic and Black/AA minorities comprised 21.1% of undergraduate nursing students in 2016 (American Association of Colleges of Nursing, 2017). However, continued aggressive efforts are needed if the nursing profession is to keep pace with demographic projections, which suggest that the United States will be a minority-majority nation by 2045 (Frey, 2018).

As the gatekeepers to a nursing career, colleges and universities are central to addressing the diversity challenge. In 2004, the Sullivan Commission on Diversity in the Healthcare Workforce spotlighted the importance of making education more attainable and affordable (Sullivan Commission, 2004) and called on academic institutions to remove cultural and logistical barriers to health professions education for minority students. Barriers faced by underrepresented (URE) minority students are many and include finances; a gap in academic preparedness; and feelings of isolation that students may experience in the college setting (Gipson-Jones, 2017; Page & Scott-Clayton, 2016; Seidman, 2005).

College enrollment statistics indicate that some progress has been made in the profession toward achieving diversity goals...Research has identified strategies to address many of these barriers. For example, pipeline and academic enrichment programs targeting URE and disadvantaged high school students have been shown to enhance academic preparation for college and increase the likelihood students will enroll in a health professions program (Brooks Carthon, Nguyen, Chittams, Park, & Guevara, 2014; Loftin, Newman, Gilden, Bond, & Dumas, 2013; Relf, 2016; DHHS, 2016). Scholarships and financial aid are also effective in improving recruitment as well as retention of URE students (Ferrell, DeCrane, Edwards, Foli, & Tennant, 2016; Gates, 2018; Singell, 2004; Swail, Redd, & Perna, 2003), and summer bridge programs offered after high school graduation have been found to help students transition to the college environment and prepare for its academic, social, and financial demands (Ashley, Cooper, Cala, & Brownell, 2017; U.S. Department of Education, 2016; Noone, Carmichael, Carmichael, & Chiba, 2007; Pritchard et al., 2016; Sablan, 2014).

In 2013, the College of Nursing at the University of Cincinnati implemented a multi-faceted program designed to improve the recruitment, academic performance, and retention of URE racial/ethnic minority and disadvantaged nursing students. URE is defined by the program as groups underrepresented in nursing according to race/ethnicity (i.e., Alaska Native, American Indian, Black or African American, Hispanic/Latino, native Hawaiian or Pacific Islander) as well as gender (male). Disadvantaged students include first generation college students and economically disadvantaged students (defined as students eligible for Pell Grants and/or with a family income at or below 200% of the federal poverty level).

Disadvantaged students include first generation college students and economically disadvantaged students...The Leadership 2.0/Nursing’s Next Generation program incorporated a range of strategies to aid students in overcoming known barriers to obtaining a bachelor of science in nursing (BSN) degree. The program initially focused on recruiting and supporting students through the sophomore year of college. However, after realizing marked improvements in the retention rate and grade point average (GPA) of Leadership 2.0 students, the College of Nursing secured a continuation grant, which allowed it to support students throughout all four years of the BSN program. In this article, the Leadership 2.0 program’s key components are described as well as lessons learned about factors that have contributed to its success.

Key Components of the Leadership 2.0 Program

The Leadership 2.0 program consists of nine integrated components (see Table) addressing academic, social, and financial factors that impact the recruitment, performance, and retention of URE and disadvantaged students. The first component consists of several pipeline programs, through which the College partners with community groups and schools to introduce middle and high school students to health professions careers and help prepare students for college. Promising students identified through the pipeline programs are invited to meet with Leadership 2.0 faculty and scholars and are encouraged to apply to the College of Nursing.

...the College partners with community groups and schools to introduce middle and high school students to health professions careers and help prepare students for college.Underrepresented and disadvantaged students who are accepted to the College of Nursing are invited to apply to the Leadership 2.0 program. Leadership 2.0 applicants must complete a written application. They and their parent(s)/guardian(s)/significant other(s) also participate in an interview with Leadership 2.0 program personnel. The program personnel select Leadership 2.0 students using a holistic review process, in which they consider life experiences and personal qualities along with more traditional measures of academic achievement when determining whether to accept a student (Glazer, Clark, & Bankston, 2015).

Table 1. Leadership 2.0 Program Components

Parents and significant others are invited to attend sessions...For students accepted into Leadership 2.0, participation in the program begins during the summer after high school graduation when students attend the Summer Bridge component. This six-week experience provides academic support and socialization opportunities that are designed to help with the transition from high school to college (Pritchard et al., 2016). Students live on-campus throughout the Summer Bridge experience, where they are introduced to campus resources and participate in activities, including daily classes in which freshman course content is presented in a nursing context, evening study tables, personalized academic advising, and social and cultural events. Parents and significant others are invited to attend sessions that describe academic and social programs, financial aid, and academic support services available to students.

Leadership 2.0 continues to focus on academics and socialization throughout the four years of the nursing program. However, over time the emphasis shifts from helping students transition to the college setting and manage the nursing curriculum, to supporting them in developing leadership skills and a professional nursing identity. Leadership and a professional nursing identity are promoted through research and professional development components in which students are introduced to the research process and complete a research project, shadow nurses in diverse clinical and community settings, are aided in developing a resume and honing interviewing skills, and serve as mentors to other students in the program. Students also participate in service learning projects, as well as campus activities that promote cultural self-awareness and an understanding of vulnerable populations. Additionally, throughout the four years, the financial needs of students are addressed through tuition and stipend support, individual financial aid check-ins, and financial literacy workshops.

...over time the emphasis shifts from helping students transition to the college setting and manage the nursing curriculum, to supporting them in developing leadership skills and a professional nursing identity.Advising is a key element threaded through all four years of Leadership 2.0. Although all students in the College of Nursing are assigned an academic advisor, the advising process for Leadership 2.0 students differs from the advising provided students outside the program in a number of important ways. For students not in Leadership 2.0, advising is predominantly conducted in a group setting. Within the Leadership 2.0 program, the ratio of advisors to students is much higher than for the College of Nursing in general, and advising is conducted primarily using a one-to-one rather than group format. Leadership 2.0 students are required to meet with their advisors at least once per month from the time they enter the program.

The academic advisors practice “intrusive” advising by closely monitoring their students’ academic progress, as well as their participation in study tables and use of other resources that support academic progression. Students also meet regularly with the Leadership 2.0 program coordinator, who fills a vital role as the students’ single point of contact to whom they can turn for help in addressing personal and financial challenges. The program coordinator works to get to know students, understand their needs and interests, and link them to appropriate campus programs and resources. For many students, the program coordinator becomes their “go-to” resource, to whom they turn whenever they encounter questions or problems.

The program coordinator works to get to know students, understand their needs and interests, and link them to appropriate campus programs and resources. Program evaluation is another important component of Leadership 2.0 with data collection and analyses procedures approved by the University of Cincinnati Institutional Review Board. Since its creation in 2013, Leadership 2.0 has admitted 56 students. The majority of students (87.5%) are female; 62.5% are from URE racial/ethnic minority groups, 12.5% are male, 46% are first-generation college students, and 55% are economically disadvantaged. After the program’s first two years, the first-year grade point average (GPA) and retention rate of participating students surpassed the GPA and retention rate for first-generation and URE students not in Leadership 2.0 and for all first-year nursing students (Pritchard et al., 2016). The mean first-year GPA of Leadership 2.0 students after the program’s first two years was 3.45, while that of URE students not in Leadership 2.0 was 3.06, and that for the entire student body was 3.40 (Pritchard et al., 2016). The retention rate and average GPA among participating students remains high and student ratings of the program have been consistently favorable.

Many students note that the program has had a profound impact on their social and emotional wellbeing and academic performance, as evidenced by the following comments obtained as part of the program evaluation:

Leadership 2.0 has helped shape my plans because it taught me how to push myself. It let me know that there is always someone there to help me, talk to me, encourage me when I need it. Leadership 2.0 was more than the friendships and scholarships and connections, it helped me realize that I can do anything I set my mind to.

Without Leadership 2.0, I genuinely believe that I wouldn't have made it this far in the [nursing] program. Without the guidance of [program coordinator] and the rest of the College of Nursing faculty I wouldn't have made it academically, financially, or emotionally through my first three years of college. I completely owe any success that I have achieved to this program, and for that I'm extremely thankful.

Program leaders have reflected on their experiences with the first four years of Leadership 2.0 and identified the following ten lessons learned about factors that have contributed to the program’s success.

Lessons Learned

The Importance of Intentionality
When designing Leadership 2.0, we used an intentional and purpose-driven approach to ensure that each program component contributes to Leadership 2.0 goals and adds value to the student experience. The Leadership 2.0 program structure is evidence based and supported by research on strategies to enhance student recruitment, academic performance, and retention of URE and disadvantaged students. Additionally, when developing each component, our decisions were guided by two questions: How does the component contribute to the program goals? and, how can we make it better?

This deliberate approach led us to make innumerable refinements. Examples include deciding to teach Summer Bridge content in the context of healthcare delivery to enhance its relevance for students; including parents and significant others in multiple aspects of programming; using intrusive rather than more passive forms of student monitoring and counseling; and designing social events to foster a sense of belonging and community. Such decisions resulted in a more integrated program structure and ensured that each component advanced one or more program goals.

Intentionality also guides our interactions with studentsIntentionality also guides our interactions with students. For example, the program coordinator seeks to advance program goals by identifying and meeting the needs of individual students. When meeting with students, she purposefully explores factors that influence student resiliency and performance, such as family structure and support, income and finances, and other social determinants, and then uses this information to match students to appropriate mentors, identify university groups that offer opportunities for socialization, and determine whether additional financial support might be needed. The value of this intentional and personalized approach is reflected in student evaluations and comments. For example, one student noted that the most helpful aspect of the Leadership 2.0 program was “...having staff and faculty and mentors who cared and would listen to my emotional and spiritual problems because I needed that more than academic help.”

Pipeline Programs Work but Require Ongoing Attention and Resources
There is ample evidence demonstrating that pipeline programs increase applications and enrollment in health professions programs by URE students (DHHS, 2016; Brunson, Jackson, Sinkford, & Valachovic, 2010). Given their track record of success, it behooves colleges and universities to incorporate pipeline programs into their diversity strategies. Although working with high school students is essential, we believe that efforts to introduce URE students to the health professions through a pipeline program ideally should begin well before the junior year in high school so that students can factor college readiness and admission requirements into course selections.

The University of Cincinnati College of Nursing has directly benefited from the pipeline programs it maintains through partnerships with high schools and middle schools in the Greater Cincinnati area. In 2015, high schools participating in the college’s pipeline programs accounted for 37 applicants to the College of Nursing. After working to strengthen the programs, the number of applicants from pipeline schools jumped to 57. We have learned that pipeline programs stand a better chance of success and survival when they are integrated into the fabric and business of a college or university and become a core part of recruitment, admissions, and diversity practices.

Pipeline programs also require a sustained commitment by university leadersPipeline programs also require a sustained commitment by university leaders. Leaders should view pipeline programs as long-term investments out of fairness to the students and schools that participate in the program, as it takes several years to establish the relationship(s) required for a pipeline program to yield results such as an increase in URE admissions. Program developers must think about sustainability from a program’s inception and cultivate multiple funding streams, including university sources, federal programs, and philanthropic entities.

Tailor Programs to the Target Population
When developing Leadership 2.0, we expected the majority of participants would be Black/AA students from the Cincinnati area. In preparing for the first student cohort, we selected Black/AA nurses to serve as mentors and identified AA student groups as social and supportive resources. As it turned out, the first cohort did indeed include a number of Black/AA students; however, the majority of students were first generation White students and economically disadvantaged students from the Appalachian region. These students found it difficult to identify with Black/AA mentors and, except for a Gen-1 House (to support first-generation students), few campus programs were designed to meet their needs. This experience challenged us to examine our own implicit bias about the population of URE and disadvantaged students served by Leadership 2.0 and tailor strategies to better meet the needs of actual program participants.

This experience challenged us to examine our own implicit bias...and tailor strategies to better meet the needs of actual program participantsFor the developers of diversity programs, our experience highlights the importance of understanding the make-up of the student population served by the program, and building in the capacity to evaluate and respond meaningfully to the needs of every student. By definition, most students in a program will come from environments with marked social and economic instability; however, supports that work for one student may not be appropriate for another. Rather than taking a one-size fits all approach, program developers should build in flexibility and anticipate drawing upon a diverse range of resources to meet student needs for guidance, socialization, and support.

Income: A Central Predictor of Need
Although race, ethnicity, and first-generation status can present significant barriers to academic advancement, we have found that socioeconomic status or income is the central predictor of need and whether students will be able to complete the nursing program. Economic need is not always easy to discern as students who have grown up poor can be skillful in compensating for and hiding their strained economic circumstances. For example, it was not until our program coordinator met with one student that we realized that both of the student’s parents were unemployed and the student was on her own financially. In another example, we discovered that two students were sharing shoes and socks to save money.

...socioeconomic status or income is the central predictor of need and whether students will be able to complete the nursing programSuch examples have heightened our awareness of the steady stream of expenses outside of tuition that accompany the college experience, as students are asked to pay for items such as scrubs, books, nursing supplies, caps and gowns, and NCLEX fees. Such expenses place an enormous financial burden on economically disadvantaged students, creating stress and potentially impacting the student’s ability to stay in the program. We have found that directly addressing questions of economic need as part of our initial and ongoing communications with students often comes as a relief to students and enables us to identify those who need additional help with expenses.

Parents and Significant Others also Need Support
Prior to implementing Leadership 2.0, the College of Nursing collaborated with other University of Cincinnati programs to examine best practices for helping minority and disadvantaged high school students pursue a career in the health professions. Our investigation included reviewing the literature, interviewing leaders of successful pipeline programs, and dialoguing with high school students, parents, teachers, and interested community leaders in town hall-style meetings. A key theme that emerged from our investigation concerned the importance of involving parents and significant others in programs for URE students. For many students, parents and significant others are a crucial source of emotional support throughout the high school and college years.

...for parents and significant others to fill this role, they need help...However, for parents and significant others to fill this role, they need help, as many are juggling multiple jobs and have additional children at home and other obligations. While we make a point of inviting parents and significant others to activities such as financial aid workshops and events recognizing student progress, we vary the time at which we hold these events and, in some cases, repeat them multiple times so that parents and significant others can fit them into their schedules. When needed, we have also signed notes validating a parent’s attendance at a program for sharing with an employer. These simple accommodations are often enough to facilitate participation by parents and significant others, and ensure that students benefit from the unique kind of support that only their family can offer.

Leverage Data to Maximize Program Effectiveness
Recognizing that data drives improvement, we identified metrics for each program goal and monitor them on an ongoing basis. For example, for our goal to recruit more URE and disadvantaged students, we track the number of URE and disadvantaged students that apply to the College of Nursing, the number admitted, and the number who accept. To assess student retention, we track the number and percent of Leadership 2.0 students who complete each year of study and progress to the next year. We track each student’s GPA as well as student assessments of program quality and satisfaction. We also conduct surveys, one-on-one interviews, and focus groups with students to evaluate each component and its underlying strategies at a deeper level.

...we identified metrics for each program goal and monitor them on an ongoing basisIn addition to tracking program-level data, we monitor individual student participation in each program component, recording whether students complete self-assessments, attend Lunch and Learn sessions (informational sessions offered during the lunch hour that address topics related to academic and nursing professional success), participate in service learning projects, and fulfill other required elements. In combination, the program-level and student data provide us with a comprehensive view of program effectiveness and where improvement might be needed, while also aiding us in identifying students in need of additional guidance and support.

Re-Think the Definition of Success
It makes sense that the success of a program like Leadership 2.0 would be defined by the percentage of students who successfully complete the program and obtain a BSN degree. However, after working with many students, including some who face seemingly insurmountable challenges, we have learned that success can manifest itself in other ways, and have broadened our definition of success to include whether we have helped students move toward a desired career. For the vast majority of students, this equates to achieving a BSN. For a small number of students, it has meant modifying the journey toward a BSN by transferring to a community college to obtain an associate degree in nursing.

...we have learned that success can manifest itself in other ways, and have broadened our definition of success...Other students have realized that nursing is not their calling and transferred to another program at the university. Realizing that many students are not sure what they want to do in life when they enter college, we make it a priority to assess fit early in the Leadership 2.0 program so students do not spend too many of their valuable tuition dollars pursuing a career in which they have little interest. Although having a student transfer to another college may be unwelcome news from the College of Nursing budgetary perspective, when viewed from the perspective of the student, it may represent a first step toward realizing a career that better matches their needs and interests.

Anticipate Spillover Effects
Diversity programs can have a far-reaching impact on a university’s culture and infrastructure and yield benefits to students not enrolled in the program. For example, as part of Leadership 2.0, the College of Nursing adopted holistic admission strategies. This action has benefited a great many students who apply to the College of Nursing, not just students in Leadership 2.0, and has strengthened the College of Nursing’s learning environment by ensuring it reflects a diversity of culture, ideas, talents, and perspectives.

...Leadership 2.0 has made College of Nursing faculty more attuned to every student’s need for academic support...In other examples, Leadership 2.0 has made College of Nursing faculty more attuned to every student’s need for academic support, more aware of academic resources offered by the university, and more mindful of the financial burden carried by students. The program has also benefited the PhD student pipeline by prompting at least one Leadership 2.0 student to pursue a PhD in nursing. Perhaps the greatest spillover effect is the way in which Leadership 2.0 has raised awareness within the College of Nursing about academia’s responsibility for enhancing nursing workforce diversity and supporting URE and disadvantaged students.

The Role and Importance of Leadership
The program leadership team must be skilled in program design, implementation, and operationsAmong all of the factors impacting a program’s success, leadership by program leaders and within the College of Nursing is perhaps the most important. The commitment and involvement of the College of Nursing dean is especially critical for gaining the support of university leaders and departments, and for setting expectations and securing buy-in among College of Nursing faculty and staff. The program leadership team must be skilled in program design, implementation, and operations.

Beyond this, team members must have a passion for working with URE and disadvantaged students and be committed to supporting students in overcoming challenges and achieving their goals and dreams. We have found that such passion and commitment is infectious and will inspire and drive the actions of faculty and staff as well as students, as evidenced by the following student comment:

Leadership 2.0 gave me everything I needed to succeed. They funded me, taught me, gave me experience, gave me support, but most importantly they cared about me. It hasn't always been easy, but everyone involved with Leadership 2.0 has always been there for me... I feel like I gave them every reason and every opportunity to give up on me, and yet they persisted... I will honor what has been done for me in whatever way I can with this life of mine.

Disseminate Results
We call on our academic colleagues to make dissemination of their work to enhance student diversity a priorityAlthough many colleges and universities have implemented programs to enhance student diversity, published reports describing program structure and outcomes and factors contributing to program effectiveness are lacking. As a result, institutions seeking to implement a program for URE and disadvantaged students for the first time, or to improve a program that is already in place, are at a disadvantage and may waste time and resources on strategies that do not work. We call on our academic colleagues to make dissemination of their work to enhance student diversity a priority. Such dissemination is essential if the nursing profession is to make progress in addressing this pressing issue.

Conclusion

Colleges and universities are critical to ongoing efforts to increase the diversity of the nursing workforceColleges and universities are critical to ongoing efforts to increase the diversity of the nursing workforce. The Leadership 2.0 program at University of Cincinnati College of Nursing has achieved noteworthy gains in the recruitment, retention, and academic advancement of URE and disadvantaged students and offers a model for schools of nursing that are seeking to do the same. The program uses a multi-pronged approach to meet student needs for academic support, socialization, and financial security. Lessons learned by program leaders highlight factors that determine a diversity program’s ability to meet the needs of individual students and contribute to the development of a nursing workforce that is responsive to ever changing patient and societal needs.

Acknowledgement. This work was supported by the U.S. Department of Health and Human Services, Health Resources and Services Administration (D19HP25914) and Interact for Health.

Authors

Tracy J. Pritchard, PhD
Email: tracy.pritchard@uc.edu

Tracy J. Pritchard has a PhD in Systems Biology and Physiology. Dr. Pritchard was part of the team that designed the first summer bridge offered at the University of Cincinnati College of Nursing in 2013. She was also part of the team that developed the Leadership 2.0: Nursing’s Next Generation program. She was involved in the program by coordinating and providing research experiences for the students as well as leading evaluation of the program. Dr. ritchard’s research focuses on the impact of social determinants on access to education and student retention and academic success. She is now Director of Medical Education at the University of Cincinnati College of Medicine.

Greer Glazer, RN, CNP, PhD, FAAN
Email: glazergr@UCMAIL.uc.edu

Greer Glazer is the Dean of the University of Cincinnati College of Nursing and is a certified nurse practitioner and Fellow of the American Academy of Nursing. Dr. Glazer has extensive experience in building training programs for underrepresented and disadvantaged students. In 2013, she developed and implemented the Leadership 2.0: Nursing’s Next Generation program, funded by HRSA (Health Resources and Services Administration), to support underrepresented and disadvantaged students to successfully transition to college. Dr. Glazer has published about minority underrepresentation in nursing and health disparities. She has also completed U.S. Department of Education, HRSA, and NCI grants that educated underrepresented nurse scholars.

Karen D. Bankston, RN, MSN, PhD, FACHE
Email: bankstkd@UCMAIL.UC.EDU

Karen D. Bankston, former Associate Dean for Clinical Practice, Partnership and Community Engagement at the University of Cincinnati College of Nursing, co-lead the establishment of the HRSA funded Leadership 2.0 program. Currently, she is an adjunct professor in the college’s PhD program, and focusing on her research interests. Specifically, she is examining the influence of the social determinants on student success and health outcomes, as well as the impact of stress on the lives of African American women who live in poverty. She sits on numerous boards including The Children’s Home, The Southwest Ohio Council on Aging, The LiveWell Collaborative, and Beyond Civility. She is a certified health care executive and is a fellow in the American College of Health Care Executives and the American College of Nursing. She has provided consultation nationally on the topics of leadership, implicit bias, and organizational change management.

Kimberly McGinnis, MA
Email: Kimberly.mcginnis@cchmc.org

Kimberly McGinnis has a master’s degree in Community Counseling from the University of Cincinnati. As a student affairs professional with 20+ years of experience and social justice advocate, she has served various roles at the University of Cincinnati. As Associate Director of Student Affairs in the Lindner College of Business, she taught first year experience courses and advised students across the curriculum. She also created Business Fellows to support first generation and ethnic minority students through academic, social and professional programming. In 2013, Kimberly joined the University of Cincinnati College Nursing to be the Program Coordinator for the Leadership 2.0: Nursing’s Next Generation program. In 2019, Kimberly joined Cradle Cincinnati, an organization committed to reducing infant mortality in Greater Cincinnati.