| | Barriers to increasing native hawaiian, samoan, and filipino nursing students: Perceptions of students and their families☆☆☆Abstract This article presents the results of an innovative approach to increase the numbers of native Hawaiian, Samoan, and Filipino students who enroll in and complete the bachelor of nursing in science degree. The approach used 2 methods to obtain input. The first was a series of focus groups comprising current and potential students in the nursing program. The second method was a survey of community elders, parents, and high school students in schools with large enrollments of native Hawaiians, Samoans, and Filipinos. The results made clear that Asian Pacific Islanders are composed of distinct groups that have many diverse concerns that need to be addressed in the recruitment and retention phases. One surprise was the low interest in incorporating traditional healing into the curriculum. It was clear that high school students should be given information on nursing early and effectively because this is a key component of their interest in a nursing career. Nurs Outlook 2003;51:25-30.
The current nursing shortage is well documented,1 but unlike previous nurse shortages this one will be more difficult to resolve because of the underlying structural problems that are causing the shortage (aging of the workforce and women choosing other professions).2, 3 Most proposals to deal with the shortage fall into 2 categories—retention of the current workforce and/or recruitment from new sources. Workforce retention approaches revolve around workplace issues. Workforce recruitment strategies are aimed at increasing the numbers of nurses as well as their quality—to ensure that they are capable of working in today's highly technologically based workplace— without losing the caring touch.
One key recruitment strategy has been to attract those groups who might otherwise not consider nursing as a career, especially among ethnic minorities. For more than 25 years there have been federal, state, and private initiatives to increase the numbers of minority health professionals, including programs such as Health Careers Opportunities Program. However, despite these efforts, minorities are still under-represented among the health professions. Researchers have long realized that initial recruitment of minorities is not the end of the endeavor but rather the beginning of a period of retaining the student through a long sequence of academic barriers that become the rocks on which fledgling professional careers can be wrecked.
A recent initiative by the School of Nursing and Dental Hygiene (SONDH) at the University of Hawaii at Manoa (UHM) sought to identify the causes of academic success and failure among minorities as perceived by the students themselves, their parents, and their community elders/leaders. In the process, the participants in the study also provided recommendations on improving recruitment and retention strategies. The study focused on 3 large minorities in the state—native Hawaiians, Filipinos, and Samoans.
Background  UHM is the main campus for a statewide system of 10 campuses of higher education. UHM functions as the major comprehensive research campus, offering curricula leading to baccalaureate degrees in 88 fields of study, master's degrees in 87 fields, and doctoral degrees in 53 fields. UHM also offers professional degrees and in law, medicine, nursing, social work, architecture, education, and librarianship and a variety of professional certifications. Approximately 20,000 students are enrolled at the Manoa campus. The UH system has a single board of regents and a president who currently serves as a semiautonomous entity from the state legislature. UHM, which is classified by the Carnegie Foundation as a research-intensive university, is one of a dozen universities or consortia in the United States designated as Land, Sea and Space grant colleges. Designated institution status For the 1996-1997 academic year, UHM ranked among the top 100 educational institutions in the nation for producing ethnic minority graduates with advanced degrees.4 UHM ranked third nationally in awarding ethnic minority students with master's degrees (after New York University and Webster University) and doctoral degrees (after the University of California at Los Angeles and University of California at Berkeley). UHM was first overall in awarding master's degrees (including those in business administration, education, English literature, and ethnic studies) to Asian Americans and was second overall for awarding doctorate degrees to Asian Americans, after the University of California at Los Angeles. In medical education, UHM ranked second for awarding master's degrees in health professions and related sciences (after South Baylor University) to ethnic minority recipients and tied for 12th for awarding doctorate degrees in health professions and related sciences to Asian Americans. UHM's predominantly minority enrollment reflects the multiethnic composition of the state's population (Table 1).
In the fall 2000 semester, UHM had a student enrollment of 17,263. Caucasians represented 23% of the total UHM enrollment. Asian Americans comprised the largest ethnic group at 48%, which included Filipinos, at 9%. Native Hawaiians/Pacific Islanders comprised 15% of the student body. Since the student enrollment of under-represented minorities is greater than 11.6%, UHM qualifies as a “designated minority institution.” The indigenous people of Hawaii, the native Hawaiin population, were the first known inhabitants to claim the island chain of Hawaii as their homeland, dating back more than 1500 years ago. However, today, the state is now considered “home” to 1.2 million people composed of 5 major ethnic groups (native Hawaiians, Japanese, Caucasians, Filipinos, and other non-Hawaiians). According to the 2000 Census, Caucasians comprised the largest group (24%), followed by Hawaiians/part-Hawaiians (20%), other and mixed but not Hawaiians (20%), Japanese (17%), Filipinos (14%), and Chinese (5%). This makeup provides a rich mixture of ethnic groups, including native Hawaiians and Pacific Peoplesto compare health disparity risk. Hawaii also is the only state in the United States that is strategically located at the crossroads between Asia, Pacific Island nations, and the North American continent. It is the most geographically isolated population of considerable size on earth and yet a focal point where Asian influences of the Pacific Rim countries meet with Western influences of the United States. These cultural and geographic factors provide opportunities to both study and develop solutions to address racial/ethnic health disparities in the nursing shortage. Hawaii's population of 1,215,940 is relatively small compared with many other states, but it is one of the most varied states ethnically in the United States. However, the student population at UHM and SONDH do not reflect that generalized breakdown; especially under-represented are native Hawaiians and Samoans, as seen in Table 2.
Hawaii has several communities that are designated Health Professional Shortage Areas as well as Medically Underserved Areas or Populations.The paradox of these communities is that the state has one of the highest rates of health-insured individuals. These communities simply lack the appropriate ratio of health care providers. Thus Hawaii provides another unique opportunity to explore issues related to the nursing shortage as it relates to racial/ethnic disparities. Even though the university is a 12-campus system spread over the major islands of the state, most of the campuses and the students are found on the main island of O'ahu. Approximately 16,500 students attend UHM, which is regarded as the flagship campus. Housed at UHM are the School of Nursing and Dental Hygiene and the John A. Burns School of Medicine, which include a variety of health disciplines at departmental levels such as medical technology, speech pathology, and public health. There is 1 other small bachelor degree–granting campus on the island of O'ahu as well as 4 geographically spaced associate degree–granting institutions. One of these is Kapi'olani Community College, which also was involved in this research because it offers an associates degree in nursing. Also involved in this study were initially 4high schools on O'ahu whose catchment included districts with large numbers of native Hawaiians, Filipinos, and Samoans. Methods The following 2 qualitative approaches to disciplined inquiry that were both systematic and verifiable were used in this study: (1) focus group interviews of college students and (2) surveys administered to high school students, their parents, and community leaders. The original timetable and strategies for the recruitment of students for the focus groups were severely affected by a statewide strike of university faculty. Following Institutional Review Board guidelines, potential participants for the groups were identified by college and university instructors; counselors; registrar offices; and campus Hawaiian, Samoan, and Filipino study programs and student organizations. Students were recruited through posted fliers, informational materials distributed during classes, campus meetings, personal invitation, and telephone invitation. After an extensive recruitment process, 34 students participated in the focus group interviews—18 native Hawaiian students were interviewed in 3 groups (2 groups at Kapi'olani Community College, 1 at UHM); 8 Samoan students in 1 group at UHM; and 8 Filipino students in 1 group at UHM. All students who volunteered to participate were included in the focus groups. Focus groups were conducted by a medical anthropologist with extensive experience as a moderator; a nurse from an ethnic minority group who possesses a master's degree; and a nursing student, also a member of a minority cultural group in Hawaii. Respect for participants was a major value guiding the conduct of the group; active listening, empathy, and positive regard supported the generation of the responses. Because food is an essential part of community gatherings across cultural groups in Hawaii, snacks and beverages were always provided. The format for the groups included the welcome, the overview of the topic, explaining and obtaining consent, the ground rules, and the questions. Interview participants included students in nursing, allied health professions, and other academic programs. At the conclusion of each focus group, participants were given a $20 gift certificate, a scholarship, and financial aid information. The questions presented during the interview were developed by the multiethnic research team (Japanese, native Hawaiian, and Caucasian) on the basis of an extensive review of the literature in accordance with the interests of the funding agency. During the interviews, the following questions were presented to the each group to stimulate discussion:
1.Who or what has helped you most to get in school and stay in school? Who are your role models? What programs or people have helped?
2.What has been the most difficult aspect of your college education? What were the greatest obstacles to getting in school, and what are the obstacles to staying school?
3.What is your opinion of the health professions (especially nursing)? Is nursing a good profession to get into? Have you ever considered going into health care? How do family and friends regard nursing?
4.Name 3 ways that the University of Hawaii system can recruit students to nursing and other health professional programs.
5.Name 3 ways that the University of Hawaii system can help students stay in nursing and other health profession programs.
Extensive notes as well as tape recordings were made during each session. The responses shared by the participants from the different groups reflected their different but sometimes overlapping perspectives. Following the completion of the interviews the data were analyzed through constant-comparative analyses, and themes were generated. Items for the questionnaires were developed to reflect each theme. In some instances, the focus group participants themselves provided specific questions to include in the questionnaires for the high school students and elders/parents. The questionnaires were pilot-tested with groups of at least 5 respondents for readability and cultural competence. To conduct the survey portion of the study, 200 questionnaires were to be distributed to the 4 local high schools with large numbers of native Hawaiian, Samoan, and/or Filipino students. The delay in the setup of the focus groups was echoed in the distribution of the survey. A statewide strike of kindergarten through 12th-grade teachers that coincided with the university faculty strike meant forms could not be distributed until the beginning of the fall semester. As a result, 1 school had to withdraw from the study because of personnel reasons, and distribution in the other 3 high schools could not be as extensive as originally planned. Nevertheless, 200 questionnaires were distributed throughout the high schools with instructions on obtaining parental and student consent. Ninety-two usable questionnaires were returned from the 200 that were distributed to native Hawaiian, Samoan, and Filipino students. One hundred surveys were distributed to parents and guardians of high school students and community leaders and elders. Forty-five usable forms were returned. Both questionnaires used a simple “check 1 box” system and ended with 1 open-ended question inviting the respondent to add comments and/or suggestions. Results of the 2 surveys were analyzed with version 10 of SPSS (Statistical Package for the Social Sciences). Results Focus group interviews of college and university students Discussion about postsecondary education There were a few themes common to all of the focus groups. The most salient constraints to getting in school and staying in school were “money” and “time.” All groups stressed the importance of financial assistance, scholarships, and a flexible class schedule that accommodates students' work and family demands. Students expressed frustration in making a smooth transition from high school to college. Freshmen had problems managing college level course work, and negotiating campus bureaucracy was a primary concern to new students. There was a lack of available courses that fulfill departmental requirements, and often it was difficult to transfer credits from community colleges to the university.5 Participants discussed the need for more high school outreach programs and guidance to attract under-represented student populations to higher education. Assistance to students and parents with filling out school and financial aid applications is especially valuable. In their focus groups, native Hawaiian students concentrated on issues of low self-esteem, whereas Filipino students were more concerned with parental pressure that conflicted with the students' interests. Samoan students brought up issues of homesickness and environmental stress. Discussion about nurses and nursing education The general opinion of nursing as a profession was positive across all focus groups. Participants viewed nursing as a profession that commands respect “like doctors and lawyers.” It is seen as a high-paying and humanitarian profession that provides useful skills for contributing to “family and community” and offers job security and mobility. Prehealth and nursing students were overwhelmingly optimistic and positive about their field. Some students described how they had overcome initial fears about nursing, such as “dealing with blood,” and said that the rewarding aspects of their work outweigh the negative ones. However, participants outside the health field saw many deterrents to becoming a nurse. Nursing was viewed as a physically and emotionally demanding job that requires long and odd hours. The students commented that nurses take their work home with them, and they viewed nursing as a burn-out profession. A few participants stated that they do not like the idea that nurses are subservient to doctors. Male physicians in particular are still regarded by some students as treating female nurses in a chauvinistic way. The native Hawaiian focus group discussions centered on how Hawaiians often do not consider entering a health profession because of their reticence to use Western biomedical care as opposed to indigenous health protocols. At the same time a number of native Hawaiian participants noted that they wanted to enter the nursing profession to help their families manage health conditions prevalent in their community, namely diabetes, heart disease, and asthma. Discussion in the Filipino focus group centered on the support and encouragement that students receive from family and community to become nurses. The Samoan focus group stressed that Samoans—women especially—bring experience as family caregivers to their nursing practice and that nursing skills are valued in the home. They noted, however, that in American-Samoan nursing has been seen in a negative light and, until recently, nursingwas viewed as a low-paying profession and the vocational refuge of those without access to higher education. Discussion of beneficial people and programs Participants in all groups cited family above all other influences in their decision to pursue higher education. A few students credited teachers and academic counselors for contributing to their academic advancement. Some students receive financial support from their families, especially the students interviewed in the Filipino group. Others receive financial support from their church or community (eg, participants in the Samoan group). Overall, interview participants noted that they had benefited from a wide range of guidance support programs. Advice from students Focus group participants made the following general recommendations to promote greater postsecondary educational access and success:
1.Capture students when they are young. Career awareness and outreach programs should begin early on in a student's education!
2.Offer more financial aid and scholarship programs.
3.Offer more or strengthen current community outreach to attract young people to higher education, and assist students and parents with enrollment and financial aid applications.
4.Offer more or strengthen current high school and college mentor programs to ensure successful transitions.
5.Offer more or strengthen current tutorial programs to aid students with difficult course work.
6.Provide freshmen more assistance with negotiating administrative procedures, more guidance with selecting a course of study and establishing good study habits, and easier access to professors.
7.Offer distance-learning courses and other strategies such as independent study and weekend and evening courses to better accommodate students' extracurricular time constraints.
8.Broadly, design assistance and guidance strategies that are family-oriented, acknowledging the essential role families play in encouraging and sustaining a student's path in postsecondary education.
Participants made the following suggestions to improve recruitment and retention of nursing students:
1.Address misconceptions about the nursing profession. Recruitment programs should do the following: a. Emphasize the rewarding aspects of the profession. Stress that nursing is more than “emptying bedpans and wiping noses” and that it is possible to get over the “fear of blood and giving people shots.” Nurses receive a unique opportunity to do exciting and meaningful humanitarian work and achieve leadership positions as clinicians and researchers. b. Demonstrate the range of different types of nurses and environments in which nurses work.
Establish and/or strengthen clubs, cohort groups, and career shadowing for nursing students.Provide the kind of funding and academic support that a person with an athletic scholarship would receive. To paraphrase a comment made by a few respondents, “If nursing students were treated like football players, you wouldn't be asking us these questions.” Specific recommendations from the native Hawaiian focus group included:
1.Address problems of low self-esteem among native Hawaiians by creating and strengthening high school and college outreach and mentor programs.
2.Use native Hawaiian nurses as role models in recruitment efforts.
3.Appeal to the health concerns and epidemiologic conditions of native Hawaiians. Emphasize the contribution that nurses can make to family and community by learning about prophylactic and therapeutic care of diabetes and cardiovascular diseases.
4.Promote nursing curricula that teaches Hawaiian and other forms of native and holistic healing and allow nurses to integrate native therapies into their practice.
5.Feature a more ethnically diverse student body in television commercials for UH campuses.
6.Develop a more ethnically diverse nursing faculty.
The Filipino focus group participants recommended the following:
1.Use Filipino role models in recruitment efforts.
2.Emphasize the good pay and respect that nurses receive in recruitment efforts.
3.Ease the transition from high school to college through advising and counseling programs.
4.Use Filipino campus clubs to provide social, academic, and financial support for students.
The Samoan participants recommended the following:
1.Use Samoan role models in recruitment efforts.
2.Use Samoan radio and television shows and church groups in reaching out to the Samoan community.
3.Offer orientation programs for students and their families held in Samoa, and once students arrive on O'ahu, prepare them for college life in Honolulu. Orientation should alert students about what to expect when moving from a small community in Samoa to a big city, including practical topics such as dorm life, shopping, and budgeting. Provide language and paperwork assistance for applying for college, financial aid, and scholarships.
4.Create or strengthen current clubs or networks for students from Samoa to help them adjust to life in Honolulu.
5.Offer recognition awards for Samoan students that would bring successful students to the attention of the Samoan community and create more role models.
6.Recruitment programs should address the misconception, once common in Samoa, that nursing is menial labor.
Surveys of high school students, parents, and elders Parent/elder survey Eighty percent of the respondents to the parent/elder survey were parents. Nearly 15% were native Hawaiian, 4% were Samoan, 72% were Filipino, and 2% represented other ethnic groups. Forty-five usable responses were received. The results indicate that the opinions from the focus group were affirmed by the parents. It is interesting to note that the only area receiving less than a majority of agreement was the inclusion of content about traditional healing. Promoting nursing curricula that teaches Hawaiian and other forms of native and holistic healing and allowing nurses to integrate native therapies into their practice was an issue of high salience for students participating in the Hawaiian focus group interviews and was mentioned to a lesser extent in the Filipino and Samoan groups. Student surveys Forty-six percent of the students who responded were native Hawaiian, 9% were Samoan, 39% were Filipino, and 3% represented other ethnic groups. A total of 92 usable responses were submitted. Of this group, 87% were female students and 5% were male students. Table 3
depicts the results of the survey. Again the issues identified by the focus groups were supported. Interestingly, courses in traditional healing and the need for instructors representing the students' ethnic groups received less support than did other issues. Most families indicated that they would like a nurse in the family. Clearly, attitudes toward nursing as a career in Hawaii are positive. The community also is aware and supportive of the need for additional nurses. Visits by nurses to schools and the community to describe their jobs are reported to be useful. Visits to university campuses and additional information about financial resources would also be useful. Even though availability of classes that use distance education methods was valued, the degree of support was not as strong as that for the availability of guidance and weekend and evening classes. Issues related to the ethnicity of instructors and availability of courses on traditional healing, while important, were significant to only slightly more than half the group of respondents. Strategies that should be implemented for high school students as soon as possible because they were rated as needed by at least 90% of respondents include the following:
•Visits to schools and communities to talk about the nursing profession.
•Arranging students to visit hospitals and health care centers.
•Arranging for campus visitations.
•Provision of additional information on financial aid to those interested in health careers.
•Provision of course work to assist students improve their grades so that they can compete successfully for admission to programs.
•Provision of additional guidance for students who enter programs to help them succeed.
Overall, the results indicate that the opinions from the focus groups were affirmed by the parents. It is interesting to note that the only area receiving less than a majority of agreement was the inclusion of content about traditional healing. The provision of courses in traditional healing and need for instructors representing the students' ethnic groups received less support than did other issues. Conclusion As the nursing shortage continues to complicate health care, attention to the interventions documented in this study is essential to resolving current health care delivery concerns. Increasing the numbers of minority health professionals is not only a simple question of justice, but can also help decrease health disparities among minorities6 and, from a practical perspective, swell the ranks of those health professions that are facing decreasing enrollment (Table 3). References 1.
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Washington (DC): US Government Printing Office; 1999;. Rosanne C. Harrigan is a professor and Frances A. Matsuda chair, John A. Burns School of Medicine, University of Hawaii, Honolulu. Lisa X. Gollin is a researcher in the Division of Ecology and Health, John A. Burns School of Medicine, University of Hawaii, Honolulu. John Casken is an assistant professor in the Department of Nursing, School of Nursing & Dental Hygiene, University of Hawaii, Honolulu ☆ This investigation was funded in part by the College Board. ☆☆ Reprint requests: Rosanne C. Harrigan, University of Hawaii, John A. Burns School of Medicine, 1960 East-West Road, Biomed T101E, Honolulu, Hawaii, 96822. PII: S0029-6554(02)05455-6 doi:10.1067/mno.2003.3 © 2003 Published by Elsevier Inc. | |
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