Chapter 1 provided the review of the qualitative phenomenological study. It included the introduction, the background of the problem, nature of the study, research questions, theoretical framework, and definitions of terms, assumptions, limitations, and delimitations. The purpose of the qualitative phenomenological study was to understand the phenomenon of the continued shortage of Hispanic nurses from the viewpoint of young Hispanic female college students. Chapter 2 includes a historical overview of the nursing shortage and current literature pertaining to (a) society’s perception of nursing, (b) the supply and demand for nurses, (c) the nursing shortage and (d) cultural diversity in nursing. Further review of literature focuses on the Hispanic female (a) college students, (b) shortage of Hispanic nurses, (c) career theory, and (d) cultural influences on career choices.
To understand the nursing shortage, the importance of cultural diversity in nursing and the underrepresentation of Hispanics in the nursing workforce an extensive literature review were conducted. The study reviewed historical and current literature. Key word searches were used in the University of Phoenix Online library sources and databases. Major databases included EBSCOhost, Gale Power Search, and ProQuest. Specialized databases included the review of [email protected], ProQuest Nursing, and Sage full-text collections. Further review of the literature included such sources as books, academic journals, peer reviewed articles, empirical studies, and germinal writings. Additional literature searches included the review of related dissertations. Topics for review included (a) the nursing shortage, (b) perceptions of nursing, (c) cultural diversity, (d) Hispanics, and (e) career choice.
RNs are the largest single healthcare profession in the United States. Since World War II the United States has had to deal with the nursing shortage (Gerson & Oliver, 2008). World War II was the largest and most violent armed conflict in U.S. history. Army Corp nurses played a vital role in the support of military troops but the shortage of military nurses resulted in civilian nurses being called to duty because of the shortage of military nurses, creating a shortage of civilian nurses (Bellafaire, n.d.). After WW II the federal government continued peacetime support of nursing education. In 1964 the Surgeons General’s Consulting group on Nursing predicted a national shortage of RNs resulting in Congress passing the Nurse Training Act and the modification of nursing programs in an attempt to meet the projected demand (Newschaffer & Shocnman, 1990). Congress reauthorized the Nurse Training Act in 1979 amidst another projected nursing shortage under the supervision of the National Academy of Sciences’ Institute of Medicine (IOM). Among much controversy, the IOM concluded the supply of RNs was adequate and federal subsidies were not needed so no significant policy changes and no precautions were taken to guard against the nursing shortage of 1997-1980 (Newschaffer & Shocnman, 1990).
In late 1987, among reports of a potential nursing shortage, Congress incorporated the Nursing Shortage Reduction Act into the 1988 Omnibus Health Legislation and the Secretary’s Commission on Nursing promptly examined underlying causes and formulated recommendations (Newschaffer & Shocnman, 1990). One of the recommendations was the formation of nursing campaigns targeting minority students. In 2000 the national supple of RNs was estimated to be 1.89 million but the demand was estimated to be 2 million (Gerson & Oliver, 2008). Thirty states were experiencing a critical nursing shortage while the U.S. Department of Health and Human Services expected the shortage of RNs to grow to 44 states by 2020 (King, 2002). Surveys and studies conducted were published in the New England Journal of Medicine and the Journal of the American Medical Association. The Joint Commission confirmed the fact that the nursing shortage would have a negative impact of health care and patient outcomes (Gerson & Oliver, 2008). The nursing shortage has continued to develop over the last several years, a potential crisis that affects the United States and possibly the international nursing profession.
The nursing shortage has gained the attention of professional nurses, healthcare leaders, and policy makers. The U.S. population is aging as well as is the healthcare workforce. Nationally the average workforce age is 34.6 years. The decline in younger people choosing nursing as a career choice has resulted in a steadily aging registered nurse workforce. The average age of a registered nurse is 45 years thus RNs are, on average, approximately 10 years older than the nations workers (Williams, 2007) resulting in older individuals doing physically demanding work and that may not be safely done by those older nurses (Kimball & O’Neil, 2001). The U.S. General Accounting Office (2001) has identified several reasons for the continued nursing shortage. One major factor identified is job dissatisfaction. Key reasons cited include inadequate staffing, heavy workloads and increased use of overtime. Nurses have expressed dissatisfaction with their wages and the stress and physical demands placed upon them resulting in nurses retiring earlier due to heavy workloads. The lack of nursing school faculty has resulted in the restriction of nursing student enrollment (Doheny, 2006). The shortage of nurse educators will eventually affect the expansion of the knowledge base for nursing practice. The decline of nursing instructors and faculty has resulted in the decline of evidenced-based research and a decline in the participation of nurse leaders providing input that helps to shape healthcare policy (U.S. General Accounting Office, 2001). There has been a drop in nursing school applications as opportunities especially for women outside of nursing have expanded (Doheny, 2006). Efforts need to be undertaken to improve the workplace environment, decrease the number of nurses leaving the profession and encourage more young people to choose nursing as a profession.
The nursing shortage and reduced reimbursement from insurance companies along with managed health care have led healthcare administrators to rely on overtime to solve nurse staffing problems. Studies have shown a relationship between nurse to patient staffing ratios and patient outcomes. In a study of 799 hospitals in 11 US states, researchers found when nurses carried a heavy workload there was a higher prevalence of urinary tract infections, pneumonia, and cardiac arrest (Needleman et al., 2007). A second study of 168 Pennsylvania hospitals examined the mortality rates of post-surgical patients. Researchers found that for each additional patient assigned a nurse there was a 7% chance of a patient dying under his or her care (Aiken, Clarke, Sloane, Sochalski, & Sibar, 2002; Welton, 2007).
The nursing shortage is the reflection of changes in population demographics, career expectations and work attitudes. The result of a shortage of nurses can lead to nurse burnout and increased absenteeism (Garrett, 2008). Registered nurses see the nursing shortage as a threat to safe quality patient care. The continued shortage can hamper access to health care or timely medical care as well as the patient’s ability to play an active part in decisions affecting his or her health care and could prompt registered nurses to leave the profession (Evans, 2007). Taking a closer look at the effects of the nursing shortage on quality is important because a health service organization has the responsibility to exercise reasonable care of a patient’s safety.
The economics of health care affects us individually and as a society. For example if a hospital or the healthcare provider fails to exercise reasonable care of a patient’s safety, the hospital or the healthcare provider could be considered negligent. Patient safety is among concerns for a medical facility with patient safety issues including: hospital acquired infections, medications errors, and postoperative complications. Each of these events can result in a significant cost increase in patient care ranging from $3,344 to $10,700 or higher as the result of the increased length of hospital bed days of care (Rothberg, Abraham, Lindeauer, & Rose, 2005). Working conditions have been associated with the spread of infection, medication errors, falls, and increased deaths. Researchers have found a correlation among nurse-patient ratios, length of stay, and the prevention of adverse events. For example, hospital-acquired pneumonia could result in an additional 5.1-5.4 bed days of care and $22,390-$28,505 in hospital costs. An adverse drug event could add 2.2 hospital days at an additional cost of $3, 344. In a study of 404 California hospitals patients experiencing post-operative complications had, on average, an 8.1 day longer hospital stay cost totaling $10,700 and higher (Rothberg et al., 2005). These types of occurrences result in significant financial loss to a medical center.
The Centers for Medicare and Medicaid Services are working on reducing certain diagnostic-related groups on the National Quality forum list of near events, Payments for prolonged care and treatment of a patient as the result of a hospital acquired infection will be reduced. Reimbursement for procedures that were the result of negligence or harm to the patient such as the result of wrong site surgery, performance of the wrong procedure, or death associated with a fall during hospitalization will be stopped (CMS, 2010). The public wants and expects quality health care but the quality of our lives can be affected by the availability of healthcare providers. No national commitment presently exists to ensure that as the Baby Boomers reach retirement the nursing workforce will be ready. To strengthen the nursing workforce, strategies need to be identified and put into place (Donelan et al., 2008). As previously stated, there is a shortage of nurses needed to meet the demand. Nurses have simply become a commodity responding to market incentives. The nursing shortage affects the supply and demand of nurses as well as other areas such as academia, research, and policy.
An aging population, Baby Boomer nurses preparing for retirement, and the enrollment decrease in nursing schools in the late 1990s has created a critical need for nurses. In 2005 nursing schools began to recover but there continues to be a gap between nursing education and nursing practice. According to Valerio (2008), as far as supply verses demand there have been ups and downs but the present nursing shortage it is much more acute and long term. As of April 2006, the RN vacancy rate in the United States was 8.5%, the result of labor market factors. Several factors contribute to the high demand for registered nurses: longer life expectancy, medical advancements in the treatment of chronic conditions, aging Baby Boomers, rising wealth, and increased population growth. In contrast, factors contributing to the lower supply of nurses include: education, retirement, and job requirements. In the 1990s there was a decrease in nursing school enrollments. The average age of nurses currently is 45 year, and many nurses are approaching retirement age. Finally, the aging nurse population brings with it a decreased desire or ability to work long hours and a decreased ability to do hard physical labor such as lifting patients (OxResearch, 2007). As Baby Boomers age, healthcare organizations may begin to see the increased use of healthcare services. Increased usage will inevitably create a demand for additional healthcare workers (Kimball and O’Neil, 2001).
The future demand for nurses requires society to consider the public’s perception of nursing as a profession and the effect of the perception on recruiting and retaining an adequate supply of well-educated professional nurses. In an effort to identify factors that may help shape the future of the nursing workforce, Donelan et al. (2008) conducted a national survey to identify perceptions and attitudes about nursing, personal experiences, influence of societal demographics, and the influence of the media. The results revealed that the public attributed the nursing shortage to issues of benefits and salary. When the public was asked about their perceptions of nursing as a career choice, 70% viewed nursing as a positive career choice yet more than half believed nurses were underpaid. Twenty-five percent of those participating in the survey considered nursing as a career choice for them at some point but did not pursue a career in nursing because of conflicts of time, required commitment to studies, and educational as well as financial barriers.
Even though the overall US workforce is becoming more culturally diverse, the professional nursing workforce is 79% non-Hispanic Whites (Donelan et al., 2008). Vogt and Taningco (2008) acknowledged the current and projected nursing shortage and the lack of diversity within the profession. These researchers studied the significance of identified barriers as they related to nursing among Latinos in the Los Angeles who were considering nursing as a career choice. The study’s participants (N = 373) included nurses, assistant nurses (assistant nurses included licensed vocational nurses, certified nursing assistants, and medical assistants), and nonnurses who self-identified as of Hispanic or Latino descent. The majority of Latinos surveyed were first generation U.S. citizens, mostly female (60%) with a mean age of 40 years. The nurses, the assistant nurses, and the nonnurses displayed different socioeconomic characteristics. Financial support for their education consisted of financial aid, loans, employment, and scholarships. Parents provided additional financial support. The most common reasons to enter nursing among nurses and assistant nurses were the desire to care for people in need, job assurance, flexible scheduling, and an attractive compensation package. Barriers identified differed between nurses and nonnurses.
Nurses reported that family obligations resulted in a lack of time to study (72.4%), limited enrollment capacity made it difficult to enroll into a nursing program (61.8%) and lack of financial support (51.3%). Other challenges included lack of academic preparation (39.55%) and perception of lack of professional prestige (39.5%). Assistant nurses reported similar challenges. As many as 48.8% of the study’s participants expressed interests in other careers and 49.8% stated a nursing school was too far away. Among nonnurse participants, 69.6% of the participants pursued other careers, 58.7% lacked knowledge and understanding of nursing as a profession, 47.8% believed there was a lack of nursing role models, 42.4% perceived nursing to be too stressful and demanding with another 35.95% believing nursing lacked professional prestige. The results of the survey were used to determine that education on nursing as a profession could increase awareness and possibly attract Hispanic students who otherwise may not have consider it as a career option (Vogt & Taningco, 2008).
The workplace environment continues to make improvements and there have been an increased interest in nursing but the nursing shortage remains a problem. Vogt and Taningco’s (2008) survey results reinforce the fact Latinos in the United States face distinct barriers. Nursing offers both benefits and challenges. A youthful Latino population in the United States has the potential to improve nursing’s ranks. Establishing ways to increase Latino participation in nursing can improve and benefit a growing diverse healthcare system. The shortage of minority nurses can affect nursing education and training by limiting the number of role models (Xu, 2008) and mentors. The shortage of Hispanic nurses is especially acute. The next section includes the importance of cultural diversity in nursing.
The U.S. demographics have seen an increase in ethnic and cultural diversity. Organizational values dominate the workplace. Matton (2009) felt individuals carry their cultural values and perspectives with them into the workplace. These values include the following characteristics: a universal, individualistic orientation, an emphasis on peer-relationships, active mastering, orderliness, and a focus on the external world of things. “Culture influences the way in which people perceive, identify, define, and solve problems” (Matton, 2009, para. 13). Values may not be congruent with other cultural backgrounds and there is the potential for misunderstanding when cultural values conflict with organizational values.
A major concern in health care is the lack of cultural diversity in nursing because of the underrepresentation of minorities. Culturally diverse RNs bring their cultural constraints and values into the healthcare setting (Gardner, 2005). The U.S. census for 2000 reported that as few as 31% of U.S. citizens identified themselves as an ethnic or racial minority (U.S. Census, 2000). The U.S. Census Bureau further reports the number of non-White Americans is expected to rise by 50% between 2000 and 2020 (Gilchrist & Rector, 2007) but as few as 16.8% of all registered nurses reported as an ethnic or racial minority (HRSA, 2010). In 2000, the proportion of Hispanic Americans was 11.4%, yet the corresponding share in the registered nurse workforce was 2.0%. In 2004 that number fell to 1.8% (Xu, 2007). RNs self-identified as Hispanic increased 1.3% between 2004 and 2008. Compared to the U.S. population of Hispanics, Hispanic RNs remain one of the most underrepresented racial or ethical groups in the nation (HRSA, 2010).
As the U.S. population becomes more diverse there is an increasing need for a culturally representative nursing workforce (Gilchrist & Rector, 2007), as culturally competent nursing workforce can have positive effects in the elimination of health disparities (Xu, 2007). The Institute of Medicine (2002) reports healthcare provider and patient compatibility increases access to healthcare services and patient satisfaction. When caring for the Hispanic patient, personalized care is important. The patient’s diet, customs, and traditions will assist in culturally competent nursing care and result in effective interaction with the client. A nurse must understand the importance of another’s values or experiences so he or she can tailor and personalize nursing intervention and plan of care (Foronda, 2008).
The mission of the U.S. Bureau of Health Professions, a division of the U.S. Health Resources and Services Administration, is “to improve the health status of the population by providing national leadership in the development, distribution and retention of a diverse workforce that provides the highest quality of care for all” (Xu, 2007, para.1). With the ongoing nursing shortage Arkansas could benefit by increasing the number of minority nurses to keep in step with the states changing demographics. To serve the growing Hispanic population in Arkansas the number of registered nurses should be proportionally similar to the population. An increased understanding of factors affecting a minority college student’s perception of nursing can help healthcare educators and professionals more effectively meet the needs of the Hispanic student (Gardner, 2005). As our society moves from a Caucasian majority to a multicultural reality, future incentives need to consider nurses’ personal as well as professional development and the complexity of a diverse workforce. An example of a response by leadership is to target minority recruitment, a solution that involves cultivating loyalty and a long-term investment in people (Kimball & O’Neil, 2001). A diverse nursing workforce is achievable by promoting a positive image of nursing, supporting potential minority nursing students through the nursing school application process and seeking out ways to develop recruitment campaigns as well as retention efforts (Gilchrist & Rector, 2007). The shortage of Hispanic nurses is especially acute and can affect nursing education and training because of the limited number of role models (Xu, 2008) and mentors. To attain cultural sensitivity, individuals must be willing to gain a knowledge and understanding of cultural differences and values.
The United States has seen a dramatic shift in demographics. According to Lowe & Archibald (2009), “In 1900, one in eight Americans was of a race other than Caucasian. The current ratio is one in four, and by 2050, an estimated one in three Americans will be African American, Hispanic, Native American, or Asian/Pacific Islander” (para. 1). In 2000, the U.S. Census reported that 32.8 million Latino’s reside in the United States and that by 2035 there will be close to 75 million Hispanics living in the United States (Knoerl, 2007). The next section includes an examination into the complex issue of cultural diversity in health care, cultural influences, and the underrepresentation of Hispanic in nursing.
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Cultural diversity in healthcare has become a complex issue. A change in ethnic and cultural composition of the U.S. population has become a challenge for nurses. Nurses are striving to provide high quality nursing care and meet the diverse cultural needs of their patients while facing a shortage of adequate qualified staff to meet these needs (Lowe & Archibald, 2009). Health professional in the United States find it difficult to believe that individuals from other cultures are different. According to Glazner (2008), healthcare professionals need to understand how cultural groups view life processes, health and illness, and maintain wellness. Healthcare professional who are concerned about cultural diversity are more effective in achieving optimum outcomes.
Hispanic patients prefer to speak Spanish during medical encounters, “Language development within the cultural context becomes imperative in the education of RNs serving Spanish speaking populations in the United States” (Bernal de Pheils & Saul, 2009, p. 518). Culturally competent nurses have a better chance of eliciting information from patients regarding healthcare problems and concerns, explaining diagnosis and prognosis, and empowering the patient in his or her self-care. Language barriers can affect patient satisfaction and patient care outcomes (Bernal de Pheils & Saul, 2009). To ensure safe quality care and the appropriate use of the healthcare system nurses need to know and respect culturally grounded values (Foronda, 2008; Raines & Morgan, 2000), and the nursing profession will need to consider how to put cultural diversity into operation (Lowe & Archibald, 2009). To design and deliver individualized comprehensive care the nurse must look at the cultural influences such as communication styles, time perception, family, and religious values as well as health beliefs. Increased awareness of cultural or ethnic beliefs and practices demonstrates not only respect for the individual but also helps the nurse better understand health behaviors.
The ethnic minority population in the United States faces many health disparity issues. Minorities are more likely to have difficult births, higher rates of certain cancers, deaths from diabetes, and less adequate health care (Lowe & Archibald, 2009). Ethnic minorities die younger and faster than Caucasians in almost every type of illness. Nurses must be able to serve the ethnic minority population with culturally diverse knowledge, information, and resources (Lowe & Archibald, 2009). Understanding cultural influences can have a strong effect on the nurse patient relationship as cultural consideration helps the nurse learn more about the patient and build a trusting relationship.
The nations’ largest healthcare profession is nursing. The patient’s first point of contact in a healthcare system is often a nurse (American Nurse Association, 2008, Beacham, Askew, & Willliams, 2009). In caring for patients nurses must be conscious of factors that may influence a patient’s access to health and health care. Influential factors can include a patient’s beliefs, religion, culture, and individual values (Beacham et al., 2009). Nursing schools recognize the need to increase enrollment to reflect cultural demographics. The pool of qualified applicants is small. Many lack thinking, writing, and problem-solving skills. High school proficiency scores are low, and new high school graduates are often unprepared to continue their education. The lack of diversity in nursing schools includes several personal factors. For females a disinterest in nursing is attributed to the availability of more career options, poor financial compensation for nursing and a decrease in the number of adolescents as compared to past generation (Beacham et al., 2009).
Arkansas has become the home of one of the nation’s fastest growing populations. Arkansas’ Hispanic population has increased greatly since 1990. Between 1990 and 2000, Arkansas had a population growth of 196% with Hispanics being the fastest growing minority at 48% (Capps et al., 2007). In the last 8 years the Hispanic population in Arkansas has almost doubled. As of July 2007, the U.S. Census Bureau (2006) reported 2,834,797 Spanish speaking people living in the state. Approximately 5,400 or 5.3% of the population is Hispanic. The majority of the Hispanic population in Arkansas is immigrants who have moved to the area from Central America or Mexico (State 39 Capitol Week in Review, 2008). The highest foreign born population, 63%, lives in Washington, Benton, Sebastian, and Pulaski County (Capps et al., 2007).
According to Rural Healthy People 2010 poverty rates are two to three times higher for minorities living in a rural area. Twenty-nine percent of the rural Hispanic population is poor compared to 13% of rural Whites, live in a health professional shortage area and are less likely to report receiving preventive medical services (Marquand, 2008). Rural residents are often geographically isolated and lack reliable transportation, are less likely to have health insurance or Medicaid benefits and have a higher rate of chronic diseases as compared to n areas. Disparities in health and socioeconomic status are especially noticeable among minority groups. Many of the rural area suffer from a shortage of healthcare providers. Minority nurses are heavily recruited in urban areas resulting in a shortage of minority nurses in the rural setting. The rural nursing shortage provides employment opportunities for minority nurses. The demand is especially strong for emergency room nurses, nurse educators, nurse managers, and nurse practitioners. Minority nurses play an important role in rural health care. Rural healthcare nurses serve as role models increasing cultural awareness while providing cultural sensitive care (Marquand, 2008).
Healthcare disparities occur across all ethnic, racial, and socioeconomic levels. A diverse Hispanic nursing population can help overcome barriers and improve the quality of culturally competent nursing care. A diverse workforce is needed but the number of ethnically diverse registered nurses grows slowly. A recent study conducted by researchers at the University of Southern California identified a number of barriers related to the continued shortage of Hispanic nurses. Of the respondents interviewed barriers identified included the lack of study time due to other family obligations (74%), difficulty in gaining admission into a nursing program (61.8%), lack of financial support (51.3%), and the lack of academic preparation (39.5%; Martinez, 2008; Voght & Taningo, 2008). It has been predicted that the Hispanic population could triple by 2050 (Nasser, 2008). The nursing shortage will have a direct impact on the Hispanic population as an increased Hispanic population will result in increased healthcare needs and a decrease in available healthcare services. As the registered nurse workforce continues to age and shrink there is an increasing need to increase the education attainment of ethnically diverse students (Wong, Sengo, Keane, & Grumbach, 2008), particularly those of Hispanic descent. Wong et al. (2008) conducted a study examining students’ ethnic cultural background and characteristics influencing their perceptions about institutional factors. The goal of the study was to address California’s nursing shortage by providing assistance in career development to nursing students from diverse ethnical backgrounds. Students were asked to provide their perceptions of situational, dispositional and institutional characteristics, career values, and sociodemographic characteristics. The results of the study identified characteristics nursing schools should use when designing a comprehensive educational curriculum. A comprehensive curriculum would focus on the recruitment and retention of nursing students from diverse ethnical backgrounds. To provide society with a better understanding of these characteristics, it is important to look further at career theory.
Since 1964 there has been an increase in workforce participation and incomes of American women. In 1964 the reported percentage of women working outside of the home was 39%. These women face sex discrimination, pregnancy discrimination, and sex-based wage discrimination. By 2006, the reported percentage of women working outside of the home increased to 60%. Women made up 46% of the workforce at that time and the proportion continues to grow (Cocchiara, Bell, & Berry, 2006). A qualitative study conducted by Whitmarsh, Brown, Cooper, Hawkins-Rodgers, and Wentworth (2007) examined career planning and career decision making among women. The results identified six themes: career/family patterns, career encouragers, career obstacles, personal compromises, career changes, and career decision making. For the study the focus was on career encouragers, personal compromises, and career decision making.
Researchers estimate that up to 50% of college freshmen are undecided about their academic major, and as many as 70% will change their major at least once during college (Gordon & Steele, 2003, Lepre, 2007). During different developmental stages, career choice decisions occur. Research in career development has identified the importance of positive reinforcement by significant others in a person’s life. Ajzen’s theory of planned behavior will aid in providing an effective framework for studying the effectiveness of positive reinforcement on behavioral change and career decision making. Ajzen and Fishbein (2005) acknowledged that individuals who believe they have the skills and resources needed to perform the behavior or overcome barriers are likely to acquire a strong sense of self-efficacy. Given behaviors are affected by cultural, personal, and situational factors. Additionally, beliefs can be affected by physical and social environment, exposure to information, values, and prejudice (Ajzen & Fishbein, 2005). Using Ajzen’s theoretical model, Giles and Rea (1999) investigated if men were less likely to pursue sex-atypical careers than women and identified factors that would explain their reluctance. The aim of the research study was to employ Ajzen’s theoretical model of planned behavior by incorporating self-efficacy, measures of attitude, and subjective norms to better predict and understand behavior. The results of the study found men were less likely to pursue sex-atypical careers because men believed they lacked the qualities required (e.g., patience).
Three factors can influence readiness to perform a given behavior (behavioral intentions): one’s attitude toward behavior (behavioral beliefs), outside influences that may have an effect on one’s behavior (normative beliefs), and the amount of control an individual has over his or her behavior (control beliefs; Ajzen, 2006). Behavioral beliefs can produce either an unfavorable or favorable attitude toward a behavior (Ajzen, 2006). A student’s desire to become a nurse is based on his or her attitude toward nursing as a career choice, perceived social pressure to go into nursing, and perceived behavioral control. The greater the perceived amount of control, the more favorable the attitude and social pressure, the stronger the student’s intention to choose nursing as a profession (Hoke, 2006).
Ajzens’s theory of planned behavior has been used to explain the behavior of participants in studies involving career options. Students of middle-school age begin to investigate career options through discussion with guidance counselors and participation in career choice awareness programs. By the time students are in high school they have identified a profession (Matutina, 2008). Hoke (2006) noted that even if nursing as a career choice was not rejected during the middle-school years, without recruitment efforts nursing may not even be considered. Early recruitment efforts need to be geared to middle-school students. Educating the students about the many specialties in nursing may increase the public’s knowledge of nursing and the students may share information gained with friends and family (Matutina, 2008). Erickson, Holm, Cheliminial, and Ditomass (2005), conducted 800 telephone interviews to help determine what the most important reason for a career choice was. Among the students’ responses included “Happiness in the work place” and “good salary” (Erickson, 2005, p. 46). Some students believe nursing did not offer strong benefits in terms of job security. Other deterrents to choosing nursing as a profession included interested in another career and unappealing responsibilities. As many as 61% of the teens interviewed believed nurses were neither critical thinkers or capable of solving problems (Erickson et al., 2005).
Because high school students reject many career options because of perceptions, it is important to provide a positive impression of nursing during middle-school years (Matutina, 2008). Cohen, Palumbo, Rambure, & St. Mongeon (2004) compared middleschool student’s perception of nursing as a career choice. The students viewed nurses as being more hands on, making less money, and having less decision-making ability than the ideal career. Changing an individual’s perception of nursing, may result in nursing being viewed in a more favorable light (Matutina, 2008). A student’s interest in nursing must be motivated by a reassurance and knowing that nurses do make a difference and through a clear understanding of the fact that nursing as a profession is important. Among students who choose nursing as a profession only 10% had talked with a nurse. Personal communication with a nurse can have a powerful influence and provide an insight into day to day realities. As few as 9% had seen or heard something on the media that influenced their view of nursing with as many as 29% having heard or seen something in the media that actually changed their view (Erickson et al., 2005). According to the theory of planned behavior, individuals will behave in accordance with their beliefs. The theory of planned behavior implies the Hispanic female college student’s attitudes, subjective norms, and perceived behavioral control are related to their actual behavior concerning their perception of nursing as a career and career choices.
Research can offer individuals with the benefits of various types of creative approaches that can be taken into consideration to help encourage a student’s career choice. Ajzen’s theory can help to explain human action and the process of behavioral change. Success in promoting nursing as a career choice among a rapidly growing Hispanic population can be accomplished by designing interventions that may change one’s perception, understanding, knowledge of, and attitude toward nursing. As an example, women who chose a female-dominated profession make career decisions based on early developmental experiences, strong messages sent by their parents during early educational years and the strong influences of their mother and other female relatives. Those women who explored careers outside of gender specific roles received additional support and mentoring from teachers, professors, and guidance counselors (Whitmarsh et al., 2007). Many women involved in duel career marriages stressed the importance of spousal support, a strong marital partnership and shared responsibilities often necessitating personal compromises. Those women in female-oriented careers, faced with the demands of external reality, often made personal compromises and career adjustments to accommodate marriage and family responsibilities (Whitmarsh et al., 2007). Career counselors have the responsibility to help young women explore career options. Career counselors can organize career fairs, develop mentoring programs, provide educational materials and identify sources of psychosocial support to include professional women in the community and professional organizations. Whitmarsh et al. (2007) suggest that additional research is needed to fully examine the influence of career encouragers and career obstacles on a multicultural cohort of women.
In the past economic instability of the labor market and workforce participation rates has had an impact on the Latino population (Cocchiara et al., 2006). According to Cocchiara et al. (2006), Latinos in the workforce increased 73% between 1992 and 2004 and is projected to be 6.2% of the labor force by 2010. Society is seeing an inflow of Hispanic women entering the workforce as the number of working women of Hispanic descent is increasing. In 2002, 57% of Latino women worked outside of the home. Cocchiara et al. (2006) predicted the number would increase to 59% by 2012 (Cocchiara et al., 2006). In an exploratory qualitative study Hite (2007) examined the life and work experiences of Hispanic women. Factors that influenced career goals included persistence, family responsibilities and family values. Traditionally in Hispanic cultures family values have long been a critical reference point. Strong cultural expectations regarding marriage and motherhood complicated choices for Hispanic women. Additionally, language proficiency and employment opportunities showed a direct relationship and educational attainment was linked to economic stability (Hite, 2007). All of these factors affected career possibilities.
The presence of barriers in students’ lives may explain the discrepancy between Hispanics’ high career aspirations and low expectations (Rivera, Chen, Flores, Blumberg, & Ponterotto, 2007). To assist Hispanic women in achieving their goals, it is important to understand career decision making and intervene effectively. Rivera et al. (2007) identified possible barriers in pursuing career goals such as financial constraints ethnic discrimination, sex discrimination, and conflict between work demands and family obligations. Constantine (2005) found that ethnic and gender career barriers were related to Hispanic college students’ inclination to limit career options. The influences of mentors or role models were instrumental in the career decision making process as a source of support and encouragement in career pursuit among adolescents. Overall, the most common role model identified was mothers (Flores & Obasi, 2005).
The human capital theory stated that increased educational investment has the potential to lead to increased economic growth (Cocchiara et al., 2006). The underlying principle is that people are a form of investment. Education and training can be compared to any other type of economic resource. People in general are used as a form of investment as well as for growth and development. Individuals choose their level of education and advanced training while viewing these opportunities as investment in personal growth and development. Benefits derived from our investment include greater professional advancement and earning potential. There may also be cultural and nonmonetary gains (Cocchiara et al., 2006). Actions need to be taken to develop a workforce that compares to the United States ethnicity demographics. The following section includes an examination of cultural influences and the effect on educational attainment.
College students from ethnic and racial minority groups have unique stressors when they attend college (Winograd & Tryon, 2009). Research has identified several barriers related to cultural influences including financial needs, isolation and discrimination, and academic barriers (Noone, 2008). Cultural diverse students have reported feeling different and isolated from their White peers as they may experience different means of communication, lack of assertiveness, and different customs. Difficulty with the English language can further exacerbate the sense of isolation (Noone, 2008). Ethnically diverse students especially if English is not their first language, may not have the academic language comprehension needed to be successful in nursing school and may require additional time to read assigned text, write papers, and take tests (Gardner, 2005; Noone, 2008). Hispanics have a low educational attainment with only 61% having a high school diploma with 12.5% graduating from college with a bachelor’s degree (OMH, 2008).
Nursing programs are described as rigid and demanding with minimal availability of Hispanic role models in the academic and clinical setting. Some Hispanics view themselves and their capabilities in a way that interferes with their academic success (Alicea-Planas, 2009). As Alicea-Planas (2009) suggested, “For many Hispanic students, family and cultural heritage are essential and irreplaceable aspects of their life. There is often an intense and almost overpowering sense of family obligation felt by students” (p. 510). Many Hispanic students enrolled in a college or universities are first generation college attendees. Although families are proud of their student’s accomplishments they do not understand the level of difficulty or commitment involved (Aliciea-Planas, 2009).
In the United States many colleges offer opportunity programs. These opportunity programs provide personal, financial, and academic support to students from underrepresented backgrounds or who are financially disadvantaged. Students who are a member of an ethnic or racial minority group are often the first in his or her family to attend college (Winograd & Tryon, 2009). All college students must adjust to a variety of stressors: college schedules, academic requirements, increased independence, and the need to choose a career path or profession. Then there are stressors unique to minorities. Minority students are faced with family financial responsibilities (Phinney, Dennis & Osoria, 2005; Winograd & Tryon, 2009), academically underprepared (Miller, Oztork, & Chaves, 2005; Winograd & Tryon, 2009), and a feeling of social isolation when attending a predominately Caucasian college or university (Winograd & Tryon, 2009).
Stereotypes can have powerful negative factors. Depending on socialization many Hispanic women are aware of racial discrimination and stereotypes that can become barriers. The number of Hispanic women entering the labor force is rapidly growing resulting in issues and concerns. For example, regardless of race or ethnic background, there are a higher number of single mothers solely responsible for their family’s income. Hispanic women have been viewed as uncommitted employees because of the additional responsibility. Another problematic stereotype is Hispanics females are to motherly or too emotional and cannot be objective in business dealings. Aggressiveness and confidence are qualities for a number of leadership positions but these qualities are frowned upon in women (Cocchiara et al., 2006). To ensure Hispanic women are fairly treated, financially compensated for their education and employment and have opportunities for advancement society must search for solutions. By devaluing a growing segment of potential employees, organizations may be missing out on a significant group of workers (Cocchiara et al., 2006).
Vygotsky believed learning appears twice: first between people on a social level, and secondly inside the child at the individual level (Wang, 2007). Vygotsky’s sociocultural approach considers the relationship and the dynamic interdependence between individual mental processes taking place in the individual and the social processes taking place in society as they related to the construction of knowledge and the selection of ideas obtained from daily experiences. Knowledge comes in different forms and is active at different levels. Prior knowledge exists on learned concepts, various levels of perception, an individual focus of attention, procedural skills, modes of reasoning, and individual beliefs about knowledge. To make the most of new learning experiences, a better understanding of how prior knowledge and perceptions can affect learning is needed (Roschelle, 1995).
Educators strive to improve their understanding of how students learn using Vygotsky’s theory of social cognitive development. Vygotsky believed cognitive development has three elements: culture, language, and social interaction. Language and social interaction are viewed as the means by which culture drives cognitive development (Louis, 2009). By gaining an understanding of the learning process educators can refine prior knowledge, anticipate a long-term process, and shape the content of concepts based social interaction (Roschelle, 1995). Roschelle (1995) stated, “Vygotsky sees spontaneous concepts growing upwards in generality, preparing the ground for more systemic reasoning. Simultaneous scientific concepts, which are introduced by instruction, grow downwards to organize and utilize the spontaneous concepts” (para. 73). The intertwining of concepts, reasoning, and instruction enables the learner to gain both the power of the abstract and the concrete.
A resource for reconstructing prior knowledge comes from culture and external social interaction. Children share their interpretation of social experiences and adults form those meanings by bringing them into the cultural traditions. The pervasive influence of established knowledge will result in the need to foster sensitivity to the different points of view, making listening to expressed thoughts and learning from the thoughts important. In Vygotsky’s theory situated learning and social discourse is the means for conceptual change.
Learning is a shared process in response to social context. A child is more competent when he or she has the proper assistance from an adult. Vygotsky believed that educational development in children is the result of social learning through cultural and social relationships and human development is a series of qualitative, dialectic transformations. Each stage of development is characterized by a psychological activity. Two classes of psychological functions include natural and cultural. Natural function consists of rudimentary perception, memory, attention, and the characteristics of the nervous system. These are the functions that create a biological predisposition. Cultural function includes abstract reasoning, logical memory, language, planning, and decision making. These especially human factors “appear gradually through a transformation of the lower functions which are structured and transformed according to specific human social goals and behavior (“Psychology Applied to Education,” 1997, para 3).” A child’s higher mental function is formed by psychological tools used in mediated activities and led by an adult or competent peer. With the proper assistance by an adult a child is much more capable of learning than on his or her own. Vygotsky believed that cognitive and social theories were connected and human cognition is embedded in culture (Psychology Applied to Education, 1997). His educational theory is based on a philosophy that supports and reinforces the importance of an individual’s social origins. A child seeking knowledge and skills has distinct, varied, individual learning needs. Education should generate growth and development with the result being social learning through the adaptation of cultural beliefs, values, and attitudes (Dahms et al., 2007).
A student’s experiences and prior knowledge help the student to make sense of new situations with new knowledge and skills being greatly influenced by one’s family and culture. Vygotsky’s sociocultural theory can provide a model for the relationship perceptions of career options and cultural forces. Specific functions and intellectual abilities are provided as cultural and social patterns. Based on individual interpretations and perceptions an individual will adapt to his or her environment and gain additional knowledge through social interaction with peers, adults and beliefs that have been instilled by his or her cultural and parental upbringing. Society permits learning to take place and cultural heritage helps the individual to develop cognitively though social interactions (Dahms et al., 2007).
Vygotsky’s theory of learning was based on his concept of the Zone of Proximal Development (ZPD; Au, 2007). ZPD is “the distance between the actual development level as determined by independent problem solving and the level of potential development as determined through problem solving under adult guidance or in collaboration with more capable peers” (Dahms et al., 2007, p. 2). The ZPD works in conjunction with a six step approach Vygotsky referred to as scaffolding. An individual’s general knowledge is based on past knowledge, experiences, and skills. To complete a task successfully, students will interact with other students, peers, or adults. For scaffolding to be a successful learning tool experiences must be shared (Dahms et al., 2007). For education and learning to take place there must be some form of transmission. Vygotsky referred to these individuals as the more knowledgeable other (MKO). The 52 MKO is anyone who has a greater knowledge or understanding of particular tasks, concepts, or process understanding than those of the learner. Traditionally, the MKO has been the parent, another adult, or an educator. In some cases the MKO could be an older sibling, a peer with a greater sense of understanding or even a computer (Dahms et al., 2007).
Further review of literature identifies parents, family members, teachers, and guidance counselors as individuals who strongly influence a student’s perception of nursing as a career choice. Cohen, Elrich-Jones, Burns, and Stromber (2004) described how children perceived nursing as a career, how nursing was portrayed, and how the child’s perceptions affect his or her attitude toward nursing. The study found that one source of influence is high school guidance counselors as school guidance counselors can have a strong influence on career perception. The next section includes an understanding of career planning and development.
The healthcare system is experiencing a nursing shortage. A lack of understanding about the nursing profession contributes to disinterest. Because nursing is perceived to be caring, busy, and a hardworking profession many young students do not consider nursing careers (Beacham et al., 2009). For high school students to make an informed career decision information needs to be made readily available and high school guidance counselors need to offer sufficient direction. High school guidance counselor can be a very influential part of a student’s career choice decision. Ensuring that counselors have realistic perceptions of nursing as a profession is important. A nursing education curriculum should attract and retain students who have the potential to be competent caring healthcare providers. Bolan and Grainger (2005) conducted a qualitative study examining high school guidance counselors and their perceptions of nursing as a career choice. Questionnaires were mailed to junior and senior high guidance counselors. The results revealed that guidance counselors did have realistic expectations and identified cognitive and personal attributes of students they believed would be successful in a nursing program.
The roles and responsibilities of a nurse are not limited to bedside patient care. Roles include administrator, coordinators, advisors, counselors and educators. Nurses are responsible for health education, wellness promotion, and illness prevention and counseling. Attributes identified by the guidance counselors were a caring manner, a desire to help others, strong work ethics, personable, good interpersonal skills, and academically strength. The study found that guidance counselors may understand the roles and responsibilities of a nurse but have a limited knowledge of the practice, setting and opportunities that would assist with continued growth and development of the student. Counselors should be encouraged to provide direction and use their abstract thinking skills to encourage and promote nursing as a career choice (Bolan & Grainger, 2005). For students to make informed-career decisions information should be made readily available by guidance counselors. Factors such as lack of study time due to other family obligations, difficulty in obtaining admission into a nursing school, lack of financial support and lack of academic preparation are some of the identified barriers as they relate to the underrepresentation of Hispanic nurses. Continued measures and innovative ideas must be explored to increase the supply of culturally competent Hispanic nurses
The Bureau of Labor Statistics reports that by 2016 the United States will need an additional 1 million Registered Nurses (U.S. Bureau of Labor Statistics, 2006). The nation has experienced intermitted nursing shortages since WW II. Recurring key factors include job dissatisfaction related to heavy workloads, inadequate staffing, and low wages. Additional concerns include the shortage of nurse educators and role models (Doheny, 2006; U.S. General Accounting Office, 2001). A review of sources reinforced the fact that a shortage of qualified nurses has an impact on healthcare services and organizations often resulting in poor-patient outcomes and increased cost of care (Aiken et al., 2007; Buerhaus et al., 2007; CMS, 2010; Evans, 2007; Garret, 2008; Rothberg et al., 2005; Vogt & Taningco, 2008).
The theoretical construct of the study took into consideration Ajzen’s theory of planned behavior and Vygotsky’s sociocultural approach. National studies show an aging workforce and reduced college graduation rates as fewer young people are entering nursing. Many students make initial career decisions at an early age but often their decisions are based on stereotyped images and with partial knowledge of potential opportunities (Gordon & Steele, 2003; Hoke, 2006; Lepre, 2007; Whitmarsh et al., 2007). Vygotsky’s sociocultural approach gave further understanding to the role played by an individual’s culture and looked at a possible correlation between culture and career choice (Cohen et al., 2005; Cocchiara et al., 2006; Phinney et al., 2006; Winograd & Tyron, 2009). The literature review further provided an increased understanding of the impact of cultural influences on the nurse to patient relationship and its importance in the provision of quality patient care (Beacham et al., 2009; Lowe & Archibald, 2009; Marguand, 2008). It is important to seek ways to better understand how young adult Hispanic women make career choices. It is also important to further examine what types of opportunities need to be put into place to motivate and draw Hispanic women to the nursing profession.
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Chapter 2 presented a review of the research literature with the focus being on the ongoing nursing shortage, perceptions of nursing as a profession, and the under representation of Hispanic women in nursing. Additional review of the literature described career theory, cultural influences on career choice, and the career decisionmaking process. The Hispanic population has been identified as one of the nation’s largest and fastest growing minority groups. In 2006, the U.S. Census Bureau reported the Hispanic population to be 14.8% of the U.S. population. Of the RN population only 3.6% are of Hispanic origin (which is only a 1.3% increase over a 4-year period) resulting in a large disparity between the Hispanic representation in the U.S. population and in the RN population. The question remains, what unidentified factors may still exist that could influence a Hispanic female undergraduate’s perception of nursing as a career choice. Further research is needed to specifically investigate factors that influence career choices and Hispanic female undergraduates’ decisions to rule out nursing as a career option. An increased understanding of factors affecting a Hispanic student’s perception of nursing from the viewpoint and lived experiences of a Hispanic college student could help healthcare providers, nurse educators, and nursing professionals more effectively meet the needs of Hispanic students and aid in shaping the future of a culturally diverse nursing workforce.
Chapter 3 includes on the methodology that was employed for the study. The chapter will also contain a discussion of the research design and appropriateness of the design to the current study. In addition, the research questions, study population, sampling frame, and data collection also is discussed as will instrumentation and the validity, and reliability of the research questions. Chapter 3 concludes with the methods employed for data analysis and provides a rationalization for the use of a qualitative phenomenological study method.
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