Addressing the Nursing Shortage: The Role of Maryland Community Colleges in Alleviating the Nursing Shortage Lauren Brown, Howard Community College
Abstract: As the national nursing shortage continues, and the long-term trajectory of demand for new nurses shows no end in sight, nursing programs must evaluate nursing student recruitment and retention. Community colleges and four-year university nursing programs offer different programs and resources that may affect nursing program completion. Highlighting the role of community college nursing programs, this study aims to determine why students choose community college nursing programs and why faculty choose to teach at community college nursing programs. The study also aims to identify how community colleges may promote student success in order to alleviate the nursing shortage. Current nursing students at a community college were interviewed regarding their choices to attend a community college and their opinions on how programs can promote student retention. In addition, current community college faculty were interviewed regarding their choices to teach at their institution and also regarding their opinions on how nursing programs can promote student retention. These interviews were analyzed and compared in order to identify common themes. Based on these themes, this study suggests strategies to promote community college nursing student success and explain why some students select community college nursing programs.
Introduction
As the nursing shortage across the United States continues to expand, the demand for new graduate nurses continues to rise. The causes of the nursing shortage are complex and multifaceted. The aging workforce and population combined with lack of nursing faculty and nursing burnout places strain on the nursing workforce (Haddad et al., 2020). In order to train more nurses, nursing programs must determine how to increase nursing student recruitment and retention.
Nursing students at a community college in Maryland may earn an associate degree in nursing. These programs allow graduates to take the National Council Licensure Examination - Registered Nurse (NCLEX-RN) in order to become a registered nurse. Students at four-year institutions may earn a bachelor’s degree in nursing (BSN) that also allows graduates to take the NCLEX-RN in order to become a registered nurse. Therefore, students of either two or four-year nursing programs are prepared to take the licensure exam and become registered nurses (Maryland Board of Nursing, n.d.). While many employers require that associate degree nurses commit to earning a BSN within a certain number of years, the associate degree nurses can work as a registered nurse.
Although community colleges and four-year universities can both train registered nurses, there are differences between the types of institutions. Community colleges are unique in their ability to provide overall affordable education. One might assume that graduates of four-year nursing programs would score higher on the NCLEX-RN exam; however, the data refutes this misconception. Specifically in Maryland, community college nursing programs have demonstrated success regarding NCLEX-RN scores of their graduates. Indeed, according to the Maryland Board of Nursing (2020), from July 1, 2019 to June 30, 2020, associate degree nursing programs had higher NCLEX-RN pass rates than four-year institutions. Additionally, associate degree nursing programs had more students pass the NCLEX-RN than BSN programs. This is primarily due to a greater number of associate degree nursing students taking the exam, though the passing rates for associate degree programs were higher (MBON, 2020).
In the state of Maryland, some community college programs have different program formats for associate degrees. Schools offer a variety of pathway programs, evening/weekend programs, and accelerated programs. The different programs allow students to complete their programs over different durations, and pathway programs transition students from one career, such as an Army medic or paramedic, to nursing. This study aims to identify why students preferentially select community college nursing programs and how community colleges in Maryland can increase nursing student recruitment and retention. In addition, the study aims to address how community colleges in Maryland can promote diversity and how this impacts student recruitment and retention.
Literature Review
Nursing Student Recruitment
In order to address the nursing shortage, student recruitment should reach a large group of potential students. Some groups that may have not been included in the past offer significant potential for the nursing workforce. For example, Army and Airforce medics and Navy corpsmen have clinical training, diverse experiences, and a broad array of backgrounds that would be beneficial when transitioning into nursing. Recruiting veterans would have benefits for the veteran population including increased income, decreased unemployment, and reduced rates of homelessness. Additionally, veterans are likely to provide quality care to fellow veterans and understand common health issues that veterans face, such as PTSD (Keita et al., 2015).
Another way to expand recruitment includes providing materials about nursing and nursing programs to people in their native languages so that communities may gain more of an understanding of nursing and the programs that are available. When more people understand the educational requirements and resources, community members may encourage each other to consider or pursue nursing (Colville et al., 2015). Reaching out to people with a native language other than English would not only raise awareness of the nursing profession in those communities; it would have the potential to increase language diversity and cultural competency of the nursing workforce.
Nursing Student Retention
Nursing student experiences are impacted by a wide range of intertwined factors, and student populations may face unique challenges to retention. Diefenbeck et al. (2015) reported that, for racial and ethnical minority BSN students, the program’s proximity to home and having a family member in the healthcare field were factors that played a role in their decision to pursue a nursing degree. Conversely, minority students reported that barriers to their retention included lack of adequate financial support, the necessity to work while in school, lack of experience with computer programs, feelings of isolation, insufficient number of role models, and feelings of being unwelcome (Colville et al., 2015). Also, minority nursing students report valuing clear communication from all members of a nursing program, including students, faculty, and non-faculty instructors (Williams et al., 2018).
Second-career nursing students, meanwhile, may be faced with a sense of loss due to becoming a student again, fear of failure in a new field, and feeling overwhelmed by multiple responsibilities and possible lack of resources. Dela Cruz et al. (2013) identify that second-career nursing students may benefit from faculty mentoring, class cohorts, and class representatives that meet with faculty. Students enrolled in an associate degree nursing program that participated in a student success program cited faculty mentoring as a highly positive experience (Harris et al., 2014).
Nursing students identify many factors that contribute to stress. During clinical experiences, students feel stress due to lack of knowledge and fear of poor grades, making mistakes, interacting with professionals, and being watched by clinical instructors. Outside of clinical instruction, students cite tests and work overload as sources of stress (Pulido-Martos et al., 2011).
Materials and Methods
Participants
Eight current nursing students and three current faculty from a community college in Maryland participated in the study. After receiving approval from the college institutional review board, the researcher recruited participants using convenience sampling through a personal network within the nursing program.
The researcher sent an email with the informed consent form to each participant. All participants were 18 years of age or older. At the start of each interview, the participants were reminded of the measures put in place to protect their privacy. All interview audio recordings were stored on a password-protected device that only the researcher had access to.
Individual interviews were conducted via Zoom with each participant. The interviews ranged from approximately 20 minutes to approximately 50 minutes. The participants were asked a combination of closed and open-ended questions including follow-up questions as needed (see Appendix).
Results
Students identified that they selected community college nursing programs for a variety of factors. Students voiced that four-year options were less affordable options when compared to community colleges. Program reputation was also a deciding factor, and students reported selecting the program with the best reviews and most positive word of mouth. In addition, students valued school environment. They discussed wanting a school and nursing program that felt caring. Students also considered how students are selected for enrollment as a deciding factor, since students want to be accepted into the program. The type of program also impacts student decisions. Students may specifically be drawn to evening or night programs. Lastly, students identified location as a reason for selecting a nursing program. Students wanted to be near the school; however, some students were willing to attend an out-of-county school.
Students identified cost, anxiety, and other personal barriers as obstacles to student success. Students want their nursing program to acknowledge their obstacles and work with them to overcome these hardships. Faculty and students specifically discussed the potential that faculty-student relationships have to promote student success. Therefore, students believe that nursing programs must promote positive faculty-student relationships, decrease student anxiety, and address additional student barriers in order to increase nursing student retention.
Students and faculty noted that nursing programs can promote diversity by adopting more flexible enrollment requirements and offering a wide variety of programs, such as accelerated programs, evening or night programs, or pathway programs.
Discussion
Interview data suggests that in order to ameliorate the nursing shortage, community colleges must take advantage of their unique capabilities and opportunities. In order to expand student recruitment and promote student success, nursing programs must understand why students select certain programs and what students believe makes them succeed.
Program Selection
Students overwhelmingly report affordability as justification for choosing community college nursing programs. Multiple students did not consider four-year programs for that reason specifically. For example, one student explained, “Community college was the only way for me. It doesn’t make sense to me to get a BSN on such a high price when community college offers the same thing.” In addition, students that already have a previous college degree noted not wanting to incur additional student loans. One student explained that a family member was paying her loans, and she did not want to increase that burden. Another student with a previous degree stated, “I already have college loans, so I didn’t want to take any loans out.” Overall, affordability was mentioned most frequently and emphatically by students as the factor guiding their selection of community college nursing programs.
While community college nursing programs are more affordable than four-year options, cost still remains as an obstacle. One student explained that after not passing a class for the first time, it was mandatory to purchase the latest editions of books when retaking the class. In addition, the student had to purchase an access code for a required assignment. Furthermore, another student noted that paying for parking for some clinical sites is a barrier. Students are also responsible for purchasing uniforms and some equipment. While community college options are overall more affordable, textbooks and additional fees must be minimized in order to decrease financial barriers for nursing students. Minimizing these costs would promote diversity, reduce financial burden, and decrease student anxiety.
Students also identify program reputation as a factor for selecting their nursing program. Students consider word of mouth and school reviews from various websites when considering which nursing program to select. The students interviewed for this study discussed hearing about their college’s program through friends, coworkers, and family members and placed importance on the nursing program’s reputation for high quality education and a caring environment.
In addition, students cited the school atmosphere as a reason for program selection. One student revealed that, “I was going to go to [], because they had nights, but for some reason, I didn’t get a good feeling from it. But, when I went to [], everything was in line for me to take the right steps to actually become a nurse. The advisors were awesome. Everybody was friendly. They work with you, so I said, ‘This is the type of school I want to attend.” Another student compared the selected nursing program to another school when stating, “I went to [] and took a science there, and it seemed like the science teacher didn’t really care.” The student went on to explain that the selected school had a caring environment that seemed more supportive than another school. Community college nursing programs should be well-known in their communities. In order to create and maintain a good reputation, nursing advisors must be available to prospective students and the community. Community colleges should consider sending nursing advisors to local high schools and other relevant community organizations in order to demonstrate the friendly and caring atmosphere of the school and increase access to information regarding nursing programs.
Students identified how the school determines who is in the program as a factor to consider when selecting a nursing program. Some schools may consider previous degrees and if a student lives in the county when admitting students. For example, one student described, “I loved that it was a lottery, because they didn’t really look at my grades. They looked at the fact that I had a point for a bachelor’s, that I completed all these credits, and it wasn’t really that big of a deal that I didn’t get stellar grades.” Different programs may employ GPA restrictions which automatically disqualify some students from getting the chance to succeed in nursing school. This lottery system also contributes to diversity. One faculty member explained, “I think the fact that we don’t have a drop dead, you have to have this grade point average to get in here- that is one big way that we promote diversity. I think we understand that the grades don’t really tell the whole story. We know that as educators. At [], we don’t just know that; we act that by not having that as a barrier.” The lack of a strict GPA cutoff is crucial for promoting diversity and recruiting students, and community colleges should consider adopting this practice. Although some evidence suggests a positive correlation between GPA and NCLEX-RN passing rates, there are varying results regarding specific type of GPA. Some studies identify that only certain classes, such as anatomy and physiology, have a significant correlation to NCLEX-RN pass rates (Sears, 2015).
Students also discussed the importance of school location when selecting a nursing program. One out-of-county student explained that the selected program was the closest school with a night program. Although there are multiple community college night programs in Maryland, this student highlighted location as an important factor. In-county students value their close proximity to the school which facilitates class attendance and using the school’s resources. Since community college nursing students value the close location of the school, community colleges should focus recruitment within the community that they are located and nearby counties. Community colleges should also evaluate what languages are present in their communities and provide materials about the program in those languages and increase awareness of the nursing program in the communities that speak those languages (Colville et al., 2015).
Faculty reported that reputation was an important factor when selecting a school to work at. One faculty member described wanting to work at the school and waiting until a position opened up. The faculty member had a family member attend the college that enjoyed their experience. Therefore, community reputation and personal connection to the school influenced the faculty member’s decision of where to work. Another faculty member was recruited from a colleague when working at a hospital. One faculty member reported working at four-year institutions and highlighted the more individualized resources for students in the community college environment.
Student Retention
Both students and faculty reported student-faculty relationships as a factor that contributes to student success. Through these relationships, students may develop resilience, which is beneficial to academic performance (Froneman et al., 2016). Students report that feeling supported by faculty is beneficial; however, students discussed some caveats. One participant described that some faculty, “... had a negative impact on my learning experience, so I did not go to them or anything, but other faculty, when I feel comfortable, I definitely utilize them.” While it is beneficial to have faculty members available to students, students must want to communicate with the faculty to maximize the benefits of the student-faculty relationship.
Students consistently reported wanting to feel comfortable with faculty members rather than intimidated. When students feel comfortable with faculty members, they report using office hours and communicating with faculty outside of class. For example, a student explained, “I actually called Professor [] … and it was nice to hear someone actually care… and say I hear you, I see you.” Another student revealed, “I feel like me seeing them outside of class helped me be successful. I feel like they made me feel comfortable. I felt like they were really easy to talk to.” Another student described valuing relationships with clinical faculty, stating, “When we were on campus, I felt more connected with the clinical instructors. They just seemed so approachable- like I could ask them anything.” When students feel comfortable with clinical faculty and do not feel anxious and intimidated when being observed by them, the clinical instructors become an invaluable source of experience and advice (Pulido-Martos et al., 2011). In addition to receiving help with class materials and the nursing program, one student explained, “I would go to their conference hours and actually talk to them. I asked for advice on getting a job, BSN programs, and stuff like that, not just questions about class.” This example highlights that the relationship is based on support and not solely teaching material. Faculty-student bonds, therefore, can also promote student success in the workforce. This feeling of support encourages students as they progress through their nursing program and into their nursing careers. In order to ensure positive faculty-student relationships, college evaluations of the faculty should include evaluating how the faculty members support students. In addition, when recruiting faculty members, the nursing program must emphasize the importance of working to create positive bonds with students. Taking these actions would encourage students to take advantage of the opportunity to interact with faculty.
Overall, students mentioned that having assigned faculty mentors promoted student success. One student explained, “By nature of that [assigned mentor] being part of the program speaks to them wanting students to succeed.” Another student identified that creating a remediation plan with the assigned mentor after not meeting a predetermined benchmark on an exam increases student success. However, some students identified negative assigned mentor interactions and explain that required meetings with faculty members were not helpful. When students described negative mentorships, the reason was due to feeling intimidated and demeaned by faculty mentors. Also, one student acknowledged that the required meeting after an exam was inconvenient to attend. Community college nursing programs should have assigned faculty mentors for students; however, these relationships should not rely on required meetings. Assigned faculty mentors should be available to support students when desired. Again, these faculty-student relationships depend on trust and respect in order to successfully empower students and promote success.
Faculty members all reported that community colleges have the unique ability to promote personalized relationships and resources. The faculty feel more available to students and believe that this is a major factor that strengthens student success. One faculty member expressed that, “It’s more personalized for the students. Even though we have so many students, we have a small faculty, and so students know who we are. They know where to find us. I think we make ourselves more available to students than four-year college faculty.” Another faculty member describes that, “I think we understand our population a little bit better, because we’re not getting students from all over the place. It’s usually students in the community, so we kind of understand what their needs are upfront.” This supports that community college faculty are able to truly understand and help their students. This also connects to the student value of school location. Since students value close proximity to their nursing programs, they are likely to come from the communities that the schools are located in. Students and faculty must work together to form meaningful and beneficial relationships to promote student success. Overall, students are looking for approachable faculty who voice their desire for student success, encourage students, and remain accessible to students.
Students also discussed several barriers that impacted their nursing school experiences. One student described that it had been many years since last going to school. The student explained, “I have a gap also between my education, my past schooling and now. That was also a barrier.” In addition to affecting program selection, cost also impacts student retention. As discussed earlier, extra fees may place financial strain and anxiety on a student. In order to promote retention, schools must minimize extra costs. Nursing programs should explore ways to ensure that students do not have to pay extra costs for transportation and additional supplies. Students who are parents, meanwhile, revealed that lack of time is challenging. For example, one student stated, “I have kids, and they have extra activities, and I have to drive them to their sports and to their other stuff, and then I have to find the time for me to study.” Finally, one faculty member noted, “What I would like to see is more support for the ESL students.” The faculty member went on to explain that English as a Second Language (ESL) students take more time during examinations and when learning material. One study suggests that nursing programs should coordinate peer support among ESL students, provide extra time on examinations, and provide ESL tutoring to support ESL students (Hansen & Beaver, 2021). All of these barriers have the potential to decrease retention, so students need faculty to acknowledge their obstacles and collaborate to find possible solutions.
In order to promote student retention, community college nursing programs must also address nursing student anxiety. Although this issue is not specific to community colleges, these schools have the opportunity to further increase student success. One specific anxiety producing event that was discussed by multiple students is the dosage calculation examination. In the nursing program reviewed for this study, students must pass this examination each semester to progress through the program. In addition to the anxiety of the examination being a course requirement, mathematics in general is a large stressor among nursing students (Johnson et al., 2020). While dosage calculation is a crucial skill to promote patient safety, community colleges ought to investigate a broader array of approaches for evaluating student knowledge in different ways. For example, nursing programs should consider having the dosage examination impact the student grade rather than allowing the examination itself to determine whether students pass or fail the course. Barra (2013) identifies that there is a gap between minority and non-minority nursing students when it comes to mathematical performance; however, that study reports that nursing students performed significantly better on a dosage examination after participating in weekly mathematics tutoring sessions. Although community colleges may offer additional tutoring, community colleges should incorporate one-on-one or small group tutoring specific to dosage calculation for nursing students. Also, community colleges should consider offering a dosage calculation class that can be completed before or during the program. Increasing time spent teaching and reviewing dosage calculation and rethinking how to test student knowledge should be implemented to decrease student anxiety, improve job readiness, and promote student success.
In order to increase nursing student retention, community colleges must work to decrease anxiety among students. Although colleges cannot eliminate anxiety or decrease anxiety outside of school, nursing programs should create a culture that supports the whole student, inside and outside of the classroom. To achieve this goal, faculty and students must work together to form supportive bonds. One faculty member suggests sharing resources, such as food bank locations, with all the students. Although this does not directly relate to the nursing program, providing information about different resources may make the students feel supported, and some students may use the resources.
As noted above, recruitment and retention of students from diverse backgrounds, such as non-traditional students or second-career students, is critical for addressing the current needs of the nursing workforce, and different groups of students may need different resources. For example, students who work full- or part-time may benefit from a nursing program during evenings or nights. One student expressed, “For me, the nights and weekends were really the driving force. When I saw how limited my options were, that cemented the deal.” In addition, second-career students specifically may benefit from an accelerated program that includes summer semesters. Some careers, such as Army medics and Licensed Practical Nurses (LPNs), may also be attracted to pathway programs that transition those careers to be RNs. A faculty member stated, “... especially the people who are looking for a different career, the summer accelerated program helps with that, because those people already have a career; they want to just switch their career, so they come to the accelerated program, and they become nurses in a year.” Therefore, a variety of program offerings will promote diversity. Community college nursing programs must work to increase the availability of non-traditional programs. For example, evening programs should be offered starting in Fall and Spring semesters. Dos Santos (2020) identifies that non-traditional students enroll in associate degree nursing programs due to family considerations and the goal of higher social status in the future. In order to meet the needs of these students, nursing programs must understand that these students will often need different programs, such as night and evening or accelerated programs.
Conclusions and Future Directions
The nursing students interviewed for this study strongly consider price, location, reputation, school environment, and the school’s enrollment process when selecting a nursing school. They also stated that assigned faculty mentors, faculty support, early alert programs, and exam preparation sessions as ways that the nursing program promotes student success. The interviewees noted that lack of time, anxiety, additional costs, and not feeling comfortable with all faculty as potential obstacles to student success.
Community colleges have unique abilities and opportunities regarding student recruitment in retention. Community colleges must take advantage of their smaller populations to maximize faculty-student relationships. Also, community colleges should invest in non-traditional programs to accommodate more diverse students. Lastly, community colleges should evaluate their enrollment requirements and consider adopting more flexible GPA requirements to give students a higher chance to succeed in nursing school. Community colleges may increase nursing student retention by facilitating beneficial faculty-student relationships, decreasing nursing student anxiety, and working with students to address personal barriers.
Students from the evening and night program at the school may be more likely to have jobs and not have the time to participate in the study. Also, the researcher had less connections to students in the evening and night program. Additionally, the study did not have any participants that were students in an accelerated nursing program. Future research should make additional efforts to include students in these specialized programs, given their potential strategic interest for recruitment and retention. A larger sample size, expanded to include four-year nursing program students to yield comparisons, would also yield valuable perspectives. Finally, investigating clinical faculty recruitment and retention would contribute further to this important line of inquiry for nursing education and the nursing profession.
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Appendix
Student and Faculty Interview Questions
Student Questions
How old are you?
How do you describe your race or ethnicity?
What is your gender identity?
What county do you live in?
Do you have children?
Do you work outside the home?
How many hours?
What is your occupation?
Do you have any college degrees?
When did you earn your last degree?
Do you have a family member that works in health care?
What types of social support do you have inside and outside of the nursing program?
Do you feel welcomed and accepted by the nursing program? How so?
Please describe your relationships with the faculty and other instructors in the nursing program.
Why did you decide to apply for the [] Community College nursing program?
What factors impacted your decision to attend a community college?
Why did you ultimately select [] Community College?
Did you consider four-year programs? Why or why not?
Why did you choose [] Community College over these schools?
What are some barriers or obstacles that you and/or students in the program face?
What resources are you aware of that the school/program provide to address these barriers?
What, if any, resources do you use or have you used to help with these barriers?
How does the program promote student success?
Is there anything that the nursing program and/or school could do to help you?
What resources do you think could have prevented that?
What grade did you receive?
What resources do you think could have prevented that?
How can the school/program prevent failing a class?
Did any of the barriers discussed earlier contribute to you needing to retake a course?
Is there anything else you can think of regarding your choice of the [] Community College nursing program and your experience in the program?
Faculty Questions
Could you describe your educational background?
Can you describe your background as a nursing educator?
Why did you choose to work at [] Community College?
Did you consider working at a four-year school?
Why did you pick [] Community College over those schools?
(If they have worked at a four-year school) What advantages or disadvantages do community college nursing programs have as opposed to four-year schools?
What resources do the program and school provide to support nursing students and promote student success?
How does the program promote diversity?
Could you describe some obstacles to allowing more students into the nursing program?
Are there any services or programs that could be implemented in the future to increase the number of students in the program?