The Sullivan Commission report in 2004 has identified a lack of minority nurses in health professions as a major factor contributing to health disparities among minority populations . Many health care professionals are concerned with this issue, as evidenced by the plenty of articles published since the Sullivan Commission report that are related to diversity, recruitment and retention of minority nursing students, and the importance of cultural competency as an integral part of nursing curricula .
The health of the nation's population depends on an adequate supply of health care providers such as nurses that reflects the racial/ethnic composition of the population . A recent census report predicting that by midcentury, racial and ethnic minorities will make up over half of the United States' population . But according to a 2013 survey conducted by the National Council of state Boards of Nursing (NCSBN) and The Forum of State Nursing Workforce Centers, nurses from minority backgrounds represent 19% of the registered nurse (RN) workforce. Considering racial/ethnic backgrounds, the RN population is comprised of 83% White/Caucasian; 6% African American; 6% Asian; 3% Hispanic; 1% American Indian/Alaskan Native; 1% Native Hawaiian/Pacific Islander; and 1% other nurses . A culturally diverse nursing workforce is critically needed to meet the healthcare needs of increasing diverse population of the nation. Recruiting and retaining minority nursing students continues to be an important component of this process because it can directly lead a change to the nursing workforce. As the composition of the US population changes, the demand for culturally diverse nurses at all levels will increase . A variety of strategies have been incorporated into different nursing programs. Compared with all the other strategies, minority faculty can play a vital role in the retention of minority nursing students. For this article, minority group is defined as African American, Hispanic, Asian-American and other underrepresented racial/ethnic groups. Retention is defined as remaining enrolled in a licensure nursing program and graduating from the program.
Many barriers have been documented in the literatures to explain the retention and graduation of nursing students from different racial and ethnic groups. These barriers include inadequate academic preparation, financial problems, poor social adjustment, a lack of faculty and institutional support, language, communication styles, writing skills, isolation and self-esteem [7,8]. Compared with the nursing shortage, nursing faculty shortage is at crisis level. The National Advisory Council on Nurse Education and Practice (2002) indicated that less than nine percent of all full-time nursing faculty are minorities in the United States. Minority nursing faculty is important in creating a diversity of thinking and reality within nursing education . According to 2013 data from AACN's annual survey, only 13.1% of full-time nursing school faculty come from minority backgrounds, and only 5.5% are male . Because of a shortage of qualified nursing faculty members and a shortage of clinical sites for student clinical placement, many baccalaureate nursing programs are unable to admit all of the qualified individuals who apply. The lack of minority nursing faculty in education is often cited as a barrier for minority nurses and minority nursing students . According to Beard and Volcy (2013), Increasing minority faculty representation is a crucial step in making nursing a more diverse profession. Minority faculty could serve as role models and strengthen their school's ability to deliver culturally competent health care education to nursing students . The lack of diversity in nursing issues must be addressed and resolved.
Davis suggestions and recommendations for nursing programs emphasized that if a minority part of the community or nation is in distress, left unattended, the problem will spill over into the larger community . Unless significant progress is made in the next 10 years to meet the need for a diverse nursing workforce, the growth of minority populations in the United States could result in a higher burden of poor states of health.
The theoretical framework of this analysis of the literature is based on Tinto's theory of student retention. Tinto (1993) asserted that institutional commitment is a major factor in the retention of students at a university; the greater the allegiance to the institution, the greater the likelihood of student retention and graduation from the university. Students must be integrated into the social and intellectual life of the university. Students experience the character of institutional life through interactions with their peers and faculty. Institutional life may also be expressed informally through the daily interactions between the faculty and students inside and outside the classroom. Students' failure to establish significant personal ties to faculty or other students at the institution will feel isolated and strongly affects their willingness to persist at the institution. This absence of close contact with other students or faculty is thought to be the largest factor affecting the retention of students in higher education. Many strategies created for minority student retention projects were based on Tinto's assertion that frequent contact with faculty is vital to student retention in higher education.
According to Tinto, the informal encounters with faculty outside the classroom that are viewed by students as warm and caring are strongly associated with retention and graduation from the learning institution .
This paper used an integrative literature review to explain out the minority faculty role in retention of minority nursing students. An integrative review is a specific review method that summarizes past empirical or theoretical literature to provide a more comprehensive understanding of a particular phenomenon . The integrative literature review followed the five stages of review as proposed by Whittemore and Knafl (2005). The five stages of review include problem identification, literature search, data evaluation, data analysis and presentation . A comprehensive search of the literature was performed to locate articles published between 1995 and 2015. The following online databases were utilized in this search: Cumulative Index of Nursing and Allied Health Literature (CINAHL), PubMed, EBSCO, and Google Scholar. The following search terms were sed alone and in combination: minority, nursing faculty, nursing student, retention, nursing workforce, diversity, nursing education. Once an article was identified, the author(s) were added as additional search terms. Additional article were identified through a hand search of reference lists. This search strategy yielded 670 articles.
Titles and abstracts of articles were reviewed in depth to determine studies' relevance for inclusion in this paper based on the following criteria. Exclusion criterial included studies published prior to 1995, studies conducted in the other countries, or studies that were not published in English. Studies that were limited to minority nursing student experiences in graduate nursing programs were not included. Commentaries, expert opinion pieces were also excluded. Sixteen publications met the selection criteria and were included in this review. Once identified, results of the researches were carefully reviewed and analyzed.
The work already done
To release the continued pressure to enroll, retain and graduate increasing numbers of nursing students from minority backgrounds, a variety of retention strategies targeted toward helping minority nursing students are embedded into many nursing programs. Basically, those strategies include mentoring, tutoring, remedial courses and financial support.
Formal, structured mentoring programs that pair students with more knowledgeable individuals, such as upper-level nursing students, professional nurses, or nursing faculty have been incorporated into nursing programs to effectively improve retention rate of minority students . To improve the retention and graduation rates of minority nursing students, an educational environment supporting the needs of all students from different culture, ethnic or gender background must exist.
To achieve this goal, the Mentorship Model for the Retention of Minority Students (MMRMS) was developed by using supporting concepts identified from themes that emerged in the literature review. The supporting concepts include: academic support, financial support, self-development, professional/leadership development, and faculty and institutional awareness. All these concepts identified in the MMRMS model contribute to minority nursing student success. Faculty and institutional awareness is defined as continuous and active support of both recruitment and retention initiatives for minority nursing students. This support include being aware of cultural differences among diverse students, the provision for faculty development addressing cultural awareness and sensitivity, and provision of financial and academic support for minority students. Research showed that nursing needs to become more aggressive and be proactive in the recruitment, retention and graduation of students from different racial and ethnic groups . To increase the diversity of individuals who enter and practice in the nursing profession, the Diversity Pyramid plan was used as a strategy to retain minority students. This plan includes a three-pronged approach focused on securing and demonstrating organizational ommitment, providing financial support to minority students in need and targeting resources to meet the needs of a diverse student population, all of which include measurable objectives in the plan. The Diversity Pyramid plan played important roles in building a sustainable diversity initiative to retain minority students . The reviewed studies are summarized in Table. Strategies that worked to help with minority nursing student retention. Although lots of current research focused on the strategies an institution or faculty can apply to help the retention of minority nursing students. A few researches have been done to focus on the minority faculty role in the retention of minority nursing students. According to Velez-McEvoy (2010), the following are some examples of the many models in recent literature that worked to help with minority nursing student retention: model of institutional support, relationship-based mentoring, caring curriculum, care group model. The model of institutional support addressed perceived barriers and thus supported retention rate of Hispanic students in baccalaureate nursing program. The relationship-based mentoring is based on Watson's Caring Theory.
The Caring Theory builds a healing nursing practice and a more empowering, positive society, and transforms behavior through modeling. By mentoring minority nursing students, faculty can build trusting relationships and encourage student development. Bevis and Watson (1989) proposed the Caring Curriculum based on a position of human freedom, echoing nursing's traditional humanistic, existential philosophy. The principal idea of Caring Curriculum is that knowledge is constructed; teachers have the opportunity to reflect, to go to the "inner teacher to connect with students' life experiences and integrity of care. Faculty address wholeness, health and healing, self-respect, and self-care while engaging with nursing students in a moral, scientific manner.
Faculty and nursing students share effective skills, have hope, and develop a trusting, nurturing relationship. The Care Group Model emphasizes caring relationships, adult learning, and acquisition of knowledge and skills. This model involves reflection, analysis of the problem, and evolution of caring groups. This model focuses on the acquisition of skills within a caring environment . Including the interview as part of the admission procedure has helped improve the diversity profile of the prelicensure admissions with regard to ethnicity . According to Gardner (2005), strategies used in the minority retention project include: increase the positions of retention coordinator to expand the ability to develop a supportive network among nursing and pre-nursing students; the retention coordinator established a mentoring network with working minority RNs from the community and minority nursing students in the program; language partnerships build between Englishas- a-second-language student and English-as-a-first-language student. The retention coordinator organized a potluck dinner and information meeting at the beginning of each semester for nursing students to bring their family together in one night; to increase cultural knowledge, the retention coordinator invited a nursing practitioner to give a health care seminar. The retention coordinator held minority support group meetings so minority students could voice concerns, determine effective interventions and provide emotional support; the retention coordinator acted as an informal advisor to other faculty regarding cultural competence issues and retention strategies; the retention coordinator met often with the minority pre-nursing students. This minority retention project was proved to be extremely successful . Regarding the perceived barriers to success for minority nursing students, increase minority faculty will increase emotional and moral support, decrease isolation and loneliness, decrease discrimination assumption to minority nursing students. Lack of minority faculty to serve as mentors and role models was identified as challenging for minority nursing students. Mentoring programs and opportunities for professional socialization can become facilitators of success and achievement for minority nursing students. The institutional need create a learning climate that is welcoming and caring for minority students .
What can minority faculty do to help?
Retention as a function of faculty-student interaction is the most compelling strategy addressed in lots of articles [19,7,20,21,17,8,11,6]. This indicated that nursing faculty must become aware of the problems that minority nursing students face and work to fashion a new, friendly educational paradigm. Faculty can reach this goal by incorporating existing frameworks or building their own framework to support and retain minority nursing students. Research showed that if we want to effectively address disparities in health care, we need to have minority nursing faculty members in the nursing program to teach students, serve as role models, interface with patients, and conduct research relevant to health care needs of minority underserved populations. Minority faculty and practitioners are more "knowing" about the health care issues and needs of minority groups and individuals and that they are more likely to assume positions in places that serve minority nursing students . Lack of diverse faculty is repeatedly cited by nursing researchers as a barrier to recruitment and retention of minority students. Except working as a role model for minority students, it is easier to establish a relationship between minority faculty and minority students. To examine African American baccalaureate nursing students' (BSN) perceptions of the absence of minority nursing faculty in their nursing program, a query packet was sent to the randomly selected BSN students to collect data. The result showed that more than fifty percent of students felt that the absence of minority faculty was very important for their success in classroom and clinical area. The presence of minority nursing faculty provide an opportunity for minority nursing students to observe such faculty members in leadership roles in class room, in clinical area, and in other related university and community roles . The minority nursing students expressed a desire for role models and the need to be understood by somebody from the same ethnical background . Minority students who have more interactions with minority faculty in their higher educational experiences reported a sense of pride, feeling more encouraged, a renewed sense of motivation and increased confidence in their abilities to become professional nurses . Increasing minority nursing faculty members will decrease attrition rate of minority students and increase graduation rate (7,17,8]. The intervention of increasing minority faculty will effectively impact and facilitate successful program completion for underrepresented minority nursing students .
Additional avenues to help with recruitment and retention of minority nursing student
Some other avenues that can be used to encourage minority nursing students to stay in nursing include: 1) Education of faculty in transcultural concepts in nursing as well as continuing education in successful methods and learning strategies to retain minority nursing students. 2) Educational presentations in elementary, middle, and high schools to students, their families, and friends to create a positive image of nursing as a career choice. 3) A campaign to support students with English-as-a-secondlanguage, including assistance with NCLEX-RN preparation .
4) Recognizing the need to enhance the diversity of nursing is critically important to provide funding, as well as create and support policies, to ensure that we continue to enhance workforce diversity in the nursing profession .
Efforts to diversify the nursing workforce should include a robust and measurable strategic plan for recruiting and retaining racial/ethnic minority nursing students. Minority nursing students have the potential to be leaders, but faculty must empower them by reaching out to them and enhancing their educational experience. Minority nursing faculty has a major role to play in retaining minority nursing students. The lack of qualified nursing faculty and the inability to recruit new nurses into the faculty role are significant factors contributing to the overall nursing shortage. Ensuring workforce diversity and leadership development opportunities for minority nurses must remain a high priority if we are to realize the goal of eliminating health disparities, and ultimately achieving health equity.