Incorporating an Equity Agenda into Health Professions Education and Training to Build a More Representative Workforce

Academic success in undergraduate nursing education: An integrative review

AIMS

The aim of this review was to synthesize and appraise the available literature regarding academic success in undergraduate nursing education.

DESIGN

We used Whittemore and Knafl's five-stage framework for integrative reviews. Toronto and Remington's step-by-step guide to integrative reviews provided practical guidance in the review process.

DATA SOURCES

A search was employed to retrieve relevant scholarly, peer-reviewed, English-language articles published between 2003 and 2023 using the databases APA PsycINFO, CINAHL, ERIC, Education Research Complete, and MEDLINE.

REVIEW METHODS

The initial search located 2599 articles. After duplicate screening at title and abstract and full text levels using predefined inclusion and exclusion criteria, 40 articles were selected for inclusion. All included articles were critically appraised using the Mixed Methods Appraisal Tool for empirical studies and the Joanna Briggs Institute critical appraisal tools for the reviews and the theoretical papers.

RESULTS

A review and synthesis of the articles revealed preadmission factors can impact academic success in undergraduate nursing education. However, most authors used narrow measures of success such as on-time graduation and exam performance. In most articles performance in the clinical environment was not considered measured as part of academic success. Few empirical studies used a theoretical framework, and the overall methodological quality of the included articles was mixed.

CONCLUSION

Our findings suggest a gap in the literature regarding more inclusive approaches to measuring academic success in undergraduate nursing education. The dearth of qualitative studies and limited attention to how academic success is measured in the clinical learning environment suggest future research should focus on exploring student nurses' perceptions of success. Furthermore, researchers examining this topic are encouraged to utilize suitable theoretical frameworks to guide empirical studies.

Thirty Years of Midwifery Education in the Rural and Diverse State of New Mexico

The purpose of this article is to discuss the evolution of the University of New Mexico (UNM) Nurse-Midwifery Education Program, its impact on New Mexico communities, and the vision moving forward for the program in a rural and culturally diverse state. New Mexico has a rich history of community-based midwifery and the UNM Nurse-Midwifery Education Program, founded in 1991, is rooted in this tradition. Graduates are prepared to practice in rural and underserved communities, advance birth equity, and decrease perinatal health disparities. Faculty have advanced the program mission to improve the health and well-being of New Mexico families through diversifying the midwifery workforce, growing community collaboration, and engaging in research and scholarship activities aimed at promoting access to care. Program faculty recognize the critical need to address factors underpinning the rising maternal morbidity and mortality crisis, including rurality, poverty, and structural racism. These efforts have yielded positive results, with 60% of program graduates serving New Mexico communities and increasingly diverse midwifery student cohorts (70% of currently enrolled students). Efforts to support midwifery student success are bolstered through a recently awarded Health Resources and Services Administration Maternity Care Nursing Workforce Expansion grant. Through such endeavors, the program will continue to strive toward social justice and human dignity.

Midwifery Students' Experiences of Bias in the Clinical Setting: Prevalence, Types, and Impact

INTRODUCTION

Exposure to bias in clinical learning environments may undermine students' confidence, cause emotional harm, impede learning, and potentially delay graduation. However, little is known about the prevalence of bias experienced by midwifery students in the United States. This cross-sectional, descriptive study aimed to quantify clinical midwifery students' experiences of bias based on 7 self-identified characteristics (gender identity, race or ethnicity, body size, age, sexual orientation, religion, and occupational background). Additionally, this research explored the impact of bias on student well-being, learning, and professional commitment.

METHODS

The survey consisted of 39 items addressing (1) prevalence and types of bias, (2) emotional impact and influence on clinical learning, (3) ways students coped, (4) whether anyone spoke up at the time bias occurred, (5) whether students reported bias to faculty, and (6) impact of bias on commitment to midwifery. The survey was distributed to midwifery students and recent graduates in 2022 via American College of Nurse-Midwives email discussion lists and social media. Participants were eligible if they were in a clinical rotation in an Accreditation Commission for Midwifery Education-accredited midwifery program between 2019 and 2022.

RESULTS

Surveys were returned by 383 participants, with 301 meeting inclusion criteria. Most participants (66.5%) reported personally experiencing or witnessing bias against at least 1 of 7 personal characteristics. The most commonly reported biases were related to gender, occupational background, age, and race or ethnicity. Only half of the participants reported these occurrences to someone with academic authority, and nearly a third considered withdrawing from their educational programs.

DISCUSSION

In this study bias was common and significantly impacted students. These results underscore the need for creative and bold interventions at personal, educational, and institutional levels to prevent and mitigate bias. Safeguarding clinical learning environments will enable students to thrive, graduate with confidence and competence, and thereby contribute to the diversification and strengthening of the midwifery profession.

A Practical Guide to Identifying a Supportive Work Environment for Underrepresented Faculty in Academic Medicine

Much has been added to the literature to better characterize and define the experiences of faculty who are underrepresented in medicine and other health professions. Additions include approaches for faculty development and suggestions for institutions on how to create equitable environments that promote the success and advancement of this group. Despite all these additions to the literature, health professions educators still lack practical approaches to determine supportive academic health center environments that are receptive to their needs and resourced to promote their career success. To the authors' knowledge, there has not been a paper that uses a validated framework and practical approach to advise underrepresented faculty in the health professions on how to evaluate an academic health system. Adapting criteria used to determine the rigor of qualitative research, the authors propose such an evaluative approach.

Transformative justice to support truth and reconciliation within nurse-midwifery education

Nursing education holds a history framed in white supremacy and whiteness. Efforts to employ antiracist strategies have been hindered, largely due to an inability for faculty to acknowledge and hold accountability for racialized harms that occur within nursing educational structures. A nurse-midwifery program in the Pacific Northwest United States uncovered harm that impacted students and identified a need to respond and hold accountability. Guided by the framework of Transformative Justice, a truth and reconciliation process was implemented as a first step to better address racism within nursing and nurse-midwifery education. This paper describes the process to support other institutions in their work to address harms within nursing education.

Financial hardship and Australian midwifery students: A scoping review and thematic analysis

PROBLEM

Despite the pressing need to grow the Australian midwifery workforce, the rising cost of living is making midwifery education programs unaffordable for many. Understanding of the financial hardships faced by Australian midwifery students is currently limited.

BACKGROUND

Attrition from midwifery programs is high and rising. In Australia, this is further compounded by the financial pressures brought about by the cost-of-living crisis. Attending compulsory unremunerated clinical placements and being 'on call' for continuity of care experiences contributes to the financial challenges of midwifery students.

AIM

To identify and synthesise available literature addressing financial hardship faced by Australian midwifery students during their studies.

METHODS

Arksey and O'Malley's framework guided this scoping review. Six databases were searched between January 2020 and April 2024. The key findings of eight included papers were thematically analysed.

FINDINGS

Four themes were identified; "Attending placements and supporting COCE's as key contributors to financial hardship", "Impacts of financial hardship on midwifery students and their wider family", "Impacts upon the future growth and diversity of the profession" and "The need for universal financial support".

DISCUSSION

The findings highlight the nature of financial challenges, causational factors and the consequences of financial hardship associated with completing midwifery programs in Australia. Appropriate universal financial support is urgently needed if we are to grow and sustain the midwifery workforce.

CONCLUSION

With no primary studies specifically exploring financial hardship faced by Australian midwifery students, further research is required to understand the challenges they face and evaluate the efficacy of funding initiatives.

Prescriptive Authority for Direct Entry Midwives in Washington State: Increasing Client Access to Contraception

Improving health and achieving health equity includes access to sexual and reproductive health care for all populations, especially those most in need. However, access to life-saving and life-affirming contraception with an individual's chosen perinatal provider can be impeded by restrictive regulations that limit scope and practice authority. This is especially true for the majority of community and direct entry midwives in the United States who have historically been unable to legally provide effective contraceptive methods. Recently, licensed midwives in Washington state were the first in the nation to achieve prescriptive authority, enabling their clients to directly obtain contraception and access to medications for common prenatal and postpartum conditions. Sustained advocacy efforts in the state's capitol enabled the Midwives' Association of Washington State to build relationships over time with legislators and government agencies to achieve this long-term goal. We present a successful midwifery-led innovation that achieved scope expansion for licensed midwives whose practice authority was limited by restrictive laws. Lessons learned are described and strategies offered to aid midwives and their advocates in other locales who want to improve health equity and access to contraception. Midwives are well positioned to provide this essential care to individuals living in underserved rural and urban areas and those from historically marginalized communities, but their ability to do so is limited by restrictive legislation.

Nursing student perceptions of racism and health disparities in the United States: A critical race theory perspective

BACKGROUND

Limited research has been done on nursing students' awareness of racial disparities and their readiness to address bias and racism in clinical practice.

PURPOSE

This study investigated nursing students' perceptions of how racial disparities affect health outcomes, including maternal outcomes, in the United States.

METHODS

Interpretive description was used and supported by the critical race theory as a framework to guide the data collection, analysis, and interpretation to understand participants' perceptions surrounding racism and health disparities.

DISCUSSION

Nurse educators should guide students to look beyond individual behavioral and risk factors and consider systemic issues as a leading contributors to health disparities.

CONCLUSION

The most critical finding was the lack of participants' understanding of systemic racism and its impact on health disparities. While they often attributed racial disparities to low socioeconomic status and lack of education, they did not understand the relationships between social determinants of health and systemic racism.

'Only for the white'. A qualitative exploration of the lived experiences of Black, Asian and Minority Ethnic midwifery students

BACKGROUND

An ethnically diverse workforce has been identified as a key component of safe, compassionate maternity care, and yet midwifery remains a predominantly White profession across the Global North. Understanding the experiences of Black, Asian and Minority Ethnic midwifery students is key to addressing this disparity.

OBJECTIVE

To capture the university and placement experiences of Black, Asian and Minority Ethnic midwifery students in a culturally White environment.

METHODS

A qualitative approach underpinned by a feminist, inductive, interpretivist paradigm informed a study undertaken with student midwives studying at three separate universities in South East England. Five virtual focus groups and two semi-structured interviews were conducted with thirteen current student midwives and one preceptee (recently graduated) midwife self-identifying as Black, Asian or Minority Ethnic. Analysis was inductive, data-driven and thematic. Standards for Reporting Qualitative Research recommendations have been used to formulate this report.

FINDINGS

Although some participants reported positive experiences and felt well-supported, an overarching narrative emerged of midwifery as an exclusive and White profession. Institutionalised Whiteness was experienced in university, in placement and within individual student cohorts. Four themes were identified: 'being an outsider', 'prejudice, discrimination and racism', 'nowhere to turn' and 'positive forces'.

CONCLUSIONS

Racist and discriminatory beliefs and practices in some midwifery education and placement settings negatively impact student experience and are likely to result in poorer care being provided to Global Ethnic Majority women and families. An unwillingness among some White educators and students to recognise the presence and impact of inequitable and racist environments, and a lack of clear, acceptable, and effective pathways for students to use to raise and discuss concerns, makes it difficult to challenge and change this injustice.

Structural and social determinants of mental health inequities among collegiate athletes during the COVID-19 pandemic

OBJECTIVES

To characterise psychological distress during the COVID-19 pandemic among collegiate athletes and assess whether racial and ethnic differences in psychological distress are attenuated when accounting for inequitable exposure to structural and social determinants of health.

METHODS

Participants were collegiate athletes on teams competing in the National Collegiate Athletic Association (n=24 246). An electronic questionnaire was distributed by email, open for completion 6 October to 2 November 2020. Multivariable linear regression models were used to assess the cross-sectional associations between meeting basic needs, death or hospitalisation due to COVID-19 of a close contact, race and ethnicity, and psychological distress.

RESULTS

Athletes racialised as Black had higher levels of psychological distress than their white peers (B=0.36, 95% CI 0.08 to 0.64). Psychological distress was higher among athletes who had more difficulties meeting basic needs, and who had a close contact die or be hospitalised with COVID-19. After adjusting for these structural and social factors, Black athletes experienced less psychological distress than white peers (B=-0.27, 95% CI -0.54 to -0.01).

CONCLUSIONS

The present findings provide further evidence of how inequitable structural and social exposures are associated with racial and ethnic differences in mental health outcomes. Sports organisations should ensure the mental health services available for their athletes are appropriate for meeting the needs of individuals experiencing complex and traumatic stressors. Sports organisations should also consider whether there are opportunities to screen for social needs (eg, related to food or housing insecurity), and to connect athletes with resources to help meet those needs.

Social Justice in Nursing Education: A Way Forward

BACKGROUND

Systemic racism and inequity are embedded in higher education, especially in nursing. By disregarding health disparities and inequities, a hidden curriculum is endorsed, implicitly letting both instructors and students know that not addressing these subjects is acceptable.

METHOD

Needs assessments were performed to assess faculty and student attitudes about the needs for justice, equity, diversity, and inclusion (JEDI) concepts. Using the Plan-Do-Study-Act model, the School of Nursing leadership, faculty, and students created taskforces to implement anti-oppression curricula throughout prelicensure courses.

RESULTS

Anti-oppression curricula and workshops were piloted successfully in the first semester of prelicensure nursing. Student feedback was positive with constructive suggestions. JEDI curriculum mapping was completed across the prelicensure nursing curriculum.

CONCLUSION

JEDI concepts must be integrated across nursing curricula to identify gaps. Forming a collaboration between leadership, faculty, and students is an optimal way to proceed as they all are invested and accountable for change. [J Nurs Educ. 2022;61(8):447-454.].

Addressing racism in respiratory therapy educational programs: An integrative literature review

INTRODUCTION/BACKGROUND

The impacts of racism on the experiences of under-represented minorities in health education programs such as respiratory therapy can impede the ability of these students to succeed in these programs and in the healthcare workplace. This can exacerbate the discrepancy between the racial diversity of the healthcare workforce and that of the population that they intend to serve.

METHODS

An integrative literature review was conducted to examine and integrate the published literature that describes how racism is expressed and addressed in health education programs and in healthcare workplaces.

RESULTS

Thirty-one studies were reviewed that included a variety of allied health professions. Racial discrimination in these programs is characterized as racial stereotyping, micro-aggressions, significant cognitive and emotional burdens, socio-economic challenges, and organizational impediments. Individual coping strategies such as confronting racism directly or minimizing its existence and seeking and offering social and cultural supports are reported. At an institutional level, policies to address racism, foster an inclusive culture, and develop programs that enable and support diversity and career progression have been described.

DISCUSSION

A conceptual model that frames the factors that enable racism (both extrinsic/societal and intrinsic/individual) against strategies that mitigate the effects of racism (both institutional and individual) is proposed and applied to respiratory therapy programming.

CONCLUSION

Respiratory therapy programs must acknowledge, prioritize, and address racism consistently and systemically. Targeted research is required to explore the specific experiences of this profession, and to validate the effectiveness of the strategies described to redress the inequities unmasked by racism.

Strategies to Reduce Bias and Racism in Nursing Precepted Clinical Experiences

BACKGROUND

Nursing programs are tasked with ensuring diverse, equitable, and inclusive (DEI) learning environments for all student learners. With calls to diversify the nursing workforce, engaging nursing preceptors in program-wide DEI initiatives are crucial. Preceptors lacking commitment to DEI could result in poor patient-preceptor communication, tense learning environments, or biased evaluations of students.

METHOD

Suggestions for successful strategies to include the preceptor in nursing program's antiracism initiatives are based on the current literature.

RESULTS

Best practices include providing antiracism training for preceptors, decreasing potential for bias in student evaluations, inquiring about observed racism in clinical sites, and equipping students to be upstanders for antiracism and DEI interventions.

CONCLUSION

Dismantling racism and bias in nursing education requires a multilevel strategy. Nursing programs and nurse educators have a responsibility for ensuring a bias-free learning environment and should include the preceptor in antiracism strategic planning. [J Nurs Educ. 2021;60(12):697-702.].

Midwives Mentoring Midwives: A Review of the Evidence and Best Practice Recommendations

Mentoring involves a reciprocal relationship between a more experienced person (mentor) who offers guidance and counsel to a less experienced person (mentee). Reported benefits of mentoring among students of varying health professions include skill acquisition, understanding of the professional role, acclimation to the culture of the health profession, and personal and professional development. Globally, the midwifery profession has a long-standing history of mentoring students and new graduate midwives. However, only one study has described a formal mentoring program within the US midwifery profession. Therefore, to inform best practice for both formal and informal mentoring programs, current mentoring programs are summarized and a state of the science review on mentoring within midwifery in the United States and internationally was conducted. Three types of mentoring relationships are discussed: (1) student to student (peer), (2) midwife to student, and (3) midwife to new graduate midwife. Effective models and recommended approaches for the development and expansion of mentoring are discussed, to sustain, diversify, and scale up the midwifery workforce. Personal attributes and action steps of effective mentors and mentees are provided.

Essential components of midwifery ethics education: results of a Delphi study

OBJECTIVE

Ethical dilemmas are an inevitable part of a midwife's experience in clinical care. Midwifery educational programs have an obligation to provide students the opportunities to acquire the skills and knowledge to recognize and negotiate ethical dilemmas. Implementation of strategies for imparting ethical competencies and clinical ethics decision-making skills in formal midwifery curricula have been challenging and inconsistent. The purpose of this study was to gather information and opinions from midwifery educators and clinical preceptors about the essential components of ethics education for midwifery students in the United States (U.S.), aiming for consensus on key content, competencies, learning outcomes, and teaching strategies.

DESIGN

This is an online Delphi study conducted in three rounds. Round 1 consisted of open-ended questions to explore and identify key content, competencies, learning outcomes, and teaching strategies for midwifery ethics education. In Rounds 2 and 3, experts rated statements on a 1 to 7 Likert scale, with positive consensus defined as 70% or more of the experts scoring ≥6.

PARTICIPANTS

The panel included midwifery educators (midwifery program directors, faculty, and clinical preceptors) from the United States.

FINDINGS

Of the 12 statements on key content of ethics education, midwives emphasized that content promoting an understanding of shared decision-making is essential for inclusion. Of the statements regarding competencies, learning outcomes, and teaching strategies, 20 of 21 statements met consensus, including those related to shared decision-making and ethical decision-making, as well as attributes such as compassion and courage. Midwives did not agree that an essential teaching strategy includes a validated assessment tool for evaluating students on any component of ethics learning (knowledge, skills, behaviour).

KEY CONCLUSIONS

This Delphi study reveals what midwifery educators consider essential components of ethics education for midwifery students, with a particular focus on the professional attributes of shared decision-making.

IMPLICATIONS FOR PRACTICE

Initial insights about optimal ways to incorporate the essential ethics education components into midwifery program curricula are provided, and more research is needed.

Social, Demographic, Spanish Language, and Experiential Factors Influencing Nursing Students' Cultural Competence

BACKGROUND

Development of culturally competent nursing students is a core objective in nursing education.

METHOD

One hundred sixty nursing students completed an online survey assessing sociodemographic information, Spanish language, service-learning participation, and cultural competency.

RESULTS

Degree of participation in the multidisciplinary farmworkers clinic (r = .374, p = .013), federally qualified health center (FQHC) (r = .387, p = .032), and short-term international medical mission trip (r = .433, p = .021) was associated with higher cultural competency. Furthermore, several demographic factors including being a native Spanish-speaker (p = .022), female (p = .004), Latino (p = .045) or a student of low socioeconomic status (p = .026) were associated with higher cultural competency.

CONCLUSION

Participation in service-learning opportunities involving care for minority and disadvantaged communities, whether required or voluntary, was correlated with higher cultural competency scores, as long as the students' experiences involved direct patient care responsibilities. These findings highlight the need for identifying more diverse opportunities for service-learning and more diverse direct patient care opportunities to foster students' cultural competence. [J Nurs Educ. 2021;60(1):29-33.].

Perceptions of support by nursing faculty of color

BACKGROUND

Racial and ethnic minority faculty members within nursing academia are critical to the recruitment and training of a diverse health care workforce. Effective strategies and opportunities for the success of minorities within nursing faculty must be identified and explored.

PURPOSE

The purpose of this paper is to identify strategies for support being utilized by nursing faculty of color, and support systems that practicing faculty of color believe would aid their success in academia.

METHOD

This descriptive survey used an 18-item online survey distributed to faculty of color in nursing academic institutions throughout the United States. Of the completed surveys, 116 responses met inclusion criteria.

RESULTS

Common themes from faculty of color emerged regarding the importance of mentorship, faculty development, networking and acknowledgement.

CONCLUSION

Respondents noted their experience with successful support systems and strategies and support systems they found to be lacking. Strategies were recommended for promoting faculty of color in schools and colleges of nursing.

Investigating cognitive holding power and equity in the flipped classroom

In recent years, the flipped classroom has been proposed as an alternative paradigm of teaching, and has been demonstrated to improve the students' knowledge and skills, engagement, and self-efficacy. At the same time, as the number of students seeking higher education is growing and the needs of these students are rapidly evolving, it has become necessary to improve their cognitive holding power and enhance equity among them. The goal of this study is to investigate the impact of the flipped classroom on improving the students' cognitive holding power and enhancing equity.

For this study, the flipped classroom was implemented for teaching undergraduate university students' course “An Introduction to Instructional Technology”. In the class, whiteboard and Smartboard were used to discuss and clarify ambiguous ideas related to the topic and to present the model answers for the tasks. Outside the class, video files and Google applications (Word, PPT, Drive) were used for delivering learning materials. WhatsApp was used for communication and Google form was used for designing learning activities and assessment. The results of the study indicate: (1) to some extent flipped classroom can be a solution for improving students' cognitive holding power, especially in performing learning tasks and following teacher' instructions. (2) Equity among the students can be enhanced in the flipped classroom. These findings have implications for using the flipped classroom in managing the diversity of university students through enhancing equity among them and improving their abilities.