Supporting Health Equity Through APRN Workforce Development: Strategies for Nursing Graduate Programs to Increase Access to Care in Underserved Areas

Abstract

Graduate nursing programs have an opportunity to support health equity, especially for people who live in rural communities and other health care provider shortage areas. The Advanced Practice Registered Nurse (APRN) bridges access to care gaps across a variety of care settings and populations, but the employment of APRNs is generally skewed toward urban areas. Institutions of higher education are uniquely positioned to address this imbalance. This article outlines the strategies, success, implications for current practice, and recommendations of a federally funded project launched in 2023 aimed at improving the distribution of APRNs in Oklahoma. Utilizing the social determinants of health model, the project employed 3 strategies: recruit from diverse backgrounds, support students with financial assistance and extracurricular courses, and help students engage through mentorship, preceptorship, and dissemination activities. A diverse group of students (n = 55) were selected for the scholarship based on a weighted application and disadvantaged background score. All students completed the extracurricular training in preparation for clinical rotation, and 10% attended and/presented their work at professional conferences, and approximately 75% of graduates reported working in rural or underserved communities. Graduate nursing programs can influence health equity and healthcare access in their regions by enhancing clinical rotation experiences through mentorship, preceptorships, and extracurricular education. Graduate nursing program directors can implement these strategies independent of extramural funding. Integrating these approaches across all programs will better prepare APRNs to serve diverse populations and improve placement in underserved areas.

Keywords

advanced practice nursing health equity rural health social determinants of health nursing education underserved populations

Highlights

Extracurricular educational initiatives play a critical role in demystifying practice environments involving vulnerable and stigmatized populations.

Increased exposure to rural, vulnerable, and stigmatized populations during nursing education significantly enhances the likelihood that graduates will pursue employment in these underserved areas.

Required clinical rotations in rural and disadvantaged communities can expand access to healthcare and promote equitable workforce distribution.

Access to healthcare is a strong determinant of health, and inequities persist despite advances made through telehealth during the COVID-19 pandemic. The pandemic further exposed the national nursing shortage and disparities in social determinants of health (SDOH). Approximately 100 000 Registered Nurses left the profession during the pandemic and over 600 000 more are expected to leave by 2027.¹ According the Health Resources and Service Administration (HRSA), medically underserved areas (MUA) are geographic regions where populations face limited access to primary care services.² Advanced Practice Registered Nurses (APRNs) provide comprehensive health services across care settings and are often the sole providers of primary care in MUAs.³ As more nurses leave the workforce, disparities related to healthcare access in underserved areas are likely to increase. Addressing the maldistribution of APRNs supports health equity, especially for those living in rural areas.^4,5

Together, Bronfenbrenner’s socio-ecological model and the World Health Organization’s SDOH model illustrate how social inequities can exacerbate health disparities.^6,7 Higher rates of morbidity, mortality, and lower rates of patient compliance with care plans are common among marginalized groups with low socioeconomic status.⁸ These poor health outcomes are compounded by a lack of access to healthcare providers who reflect the unique characteristics of these communities and a nationwide shortage of healthcare providers.

Throughout the nation, the healthcare workforce faces both shortages and maldistribution, with the majority of providers residing and practicing in urban areas. According to the 2024 Health Rankings report, Oklahoma ranks 47th in the United States for access to healthcare.⁹ HRSA recognizes geographic maldistribution of healthcare providers as medically underserved areas and healthcare provider shortage areas (MUA/HSPA). This inequity is evident in Oklahoma, where 71 of 77 counties are designated as HPSAs for primary care, and every county is designated as a Mental Health Professional Shortage Area.¹⁰

In addition to geographic distribution, increasing the diversity of the nursing workforce is essential to decrease health disparities among populations with marginalized socioeconomic status.^11,12 Better patient outcomes are likely when providers have shared cultural experiences or are culturally competent.^12,13 Graduate nursing programs are uniquely positioned to address inequities exacerbated by geographic distribution and homogeneity of providers. This paper describes how a nursing program in a large, urban, public university implemented student recruitment, support, and engagement strategies to address healthcare inequities.

Attracting APRNs to rural, tribal, and other underserved areas and disadvantaged populations is not as simple as offering higher wages. Successfully recruiting APRNs to these practice settings often requires the APRN to be comfortable and familiar with the populations. Healthcare providers from rural or underserved communities, as well as those who complete a residency or clinical rotation experience in such areas, are more likely to seek employment within those populations.¹⁴ Students who undergo extended periods of rural training during undergraduate or postgraduate education are more likely to remain in rural practice.^7,9 Establishing relationships during clinical rotations is also key to employment and retention.¹⁵ Additionally, students’ social determinant factors affect academic performance and job placement outcomes, so it is important to evaluate and address financial support needs for students who understand and/or share a similar background as under-resourced or underserved patients. These considerations are critical to support workforce diversity and expansion goals.^11,13,16

Strategies to Support Health Equity

Providing support for current rural health professionals to enhance their skills or obtain higher qualifications also contributes to higher retention rates. Targeted recruitment initiatives within undergraduate nursing programs have shown promise in improving the placement of nursing graduates in rural and underserved communities.¹¹ Factors for employment in MUAs include the nurse’s familiarity and strong relational ties to the community, as well as financial incentives that extend beyond competitive pay packages such as loan forgiveness and academic scholarship awards.^14,17

The Future of Nursing 2020 to 2030: Charting a Path to Achieve Health Equity¹⁸ and Improving and Expanding Programs to Support a Diverse Health Care Workforce¹² provide clear guidance to improve and support health equity through the diversification of the nursing workforce. Findings and recommendations were combined with the socio-ecological and SDOH models then aligned to create the guiding framework of the project.^14,16,19 Patient compliance in disadvantaged populations involves creating a resonance with patients, which may be built in part on shared experiences.²⁰ It is important to note that the determinants of health affect every group, including healthcare providers and students. A student’s personal SDOH impact their personal health outcomes and influence where they are likely to practice.²¹ A nurse’s understanding of the SDOH and subsequent application thereof impacts care delivery and planning. There are even further implications for nurse-driven policies that could affect population health.²²

Supporting health equity, especially for people who live in rural communities and other health care provider shortage areas requires that providers are prepared to serve in these communities. Effectively equipping nursing students with the skills to recognize, respect, and integrate SDOH factors is key in preparing the nurse to work with underserved and marginalized populations. Providing the nursing student with psychologically safe network to explore these populations with experienced professionals dispels stigma and fear to the effect of increasing likelihood to practice therein. The framework developed incorporates student profile characteristics, socioecological factors, SDOH, professional integrations, and networking, and location of clinical rotations.

Project Description

An interprofessional team of faculty developed the Oklahoma Workforce Innovations in Nursing (OK-WINs) project (academic years 2023-2027) in response to the notice of funding opportunity posted by HRSA’s Advanced Nursing Education Workforce program. The program aims to increase the number of APRNs in underserved and rural communities. This funding mechanism allows for tuition and cost-of- living scholarships to qualified students and requires grant recipients to extend clinical rotation partnerships to underserved populations. HRSA has funded many successful projects. The OK-WINs project differentiates itself from others by the novel combination of academic-clinical partnerships and experiential learning opportunities with a wide range of underserved populations.

The intent of the project is to increase and retain APRNs in rural and underserved populations in Oklahoma. The project is based on 3 strategies: (1) Participant selection through recruitment of diverse and disadvantaged students; (2) Student support through financial assistance and extracurricular education; and (3) Student engagement through mentorship, preceptorship in underserved patient and population settings, and professional development through dissemination activities.

Methods

To advance the overarching objectives of the federal grant program, a structured, 3-part implementation strategy was employed from 2023 to 2025 and will continue through the length of the grant funding (2027). This quality improvement initiative, supported by federal funding, aimed to promote health equity in MUAs and HPSAs by enhancing access to care through targeted efforts to increase the placement of APRNs in these communities. Oklahoma served as the implementation site. The institution identified and selected eligible participants, provided academic and financial support, and actively engaged students in project activities. Formative and summative evaluations were conducted to assess program fidelity, participant outcomes, and overall impact on workforce distribution. The University of Oklahoma Health Sciences’ Internal Review Board determined that this project did not meet the criteria for human subjects research and was exempt from informed consent requirements (IRB# 18446).

Participant Selection

The premise of student selection was supported by the literature: healthcare students with experience in rural areas and underserved populations are more likely to seek employment and remain employed in those communities.^11,12,14,18 The project supports student enrollment, recruitment, and retention in the Family Nurse Practitioner (FNP), Psychiatric Mental Health Nurse Practitioner (PMHNP), and Adult Gerontology Clinical Nurse Specialist (AGCNS) programs. These specific programs of study were chosen to align with the aims described in the notice of funding opportunity. The overarching goal is to increase job placement in underserved care settings. Full and part-time enrolled students were recruited through direct emails to new students, and group emails and internal listserv reminders to students currently enrolled in Doctor of Nursing Practice (DNP) programs.

A weighted scoring system was used in the application process incorporating information such as disadvantage scores, high school location, and the applicants’ understanding of the SDOH. Financial need was not considered due to difficulties accessing Bursar records and inability to determine current employment or household status. The online application consisted of 2 short response essay questions and a video response to a third question. Apart from the video response, applications were de-identified at the time of scoring to reduce the risk of bias. Each of the 4 application components (application with disadvantage score, 2 short essays, and 1 video response) was scored using standardized rubrics then summed. For the review process, 2 faculty and a staff member were randomly assigned to a group of applications.

To mitigate affinity bias, a staff member unfamiliar with all applicants contributed to the assessment of the essay responses and calculated the disadvantaged score. Only the calculated disadvantage score was shown during the final selection phase. For the essay response portion, the score for each applicant was calculated by averaging the scores from the 3 reviewers. The sum of the disadvantage score (not specific responses) was then added to the essay response score for a total that ranked students for selection. Lastly, applicants were selected based on their program of study, with the intent to distribute funds across all 3 programs: Family Nurse Practitioner, Psychiatric Mental Health Nurse Practitioner, and Adult Gerontology Clinical Nurse Specialist. Researchers interested in the scoring sheet and associated rubrics are asked to contact the corresponding author directly.

Application Details

The National Institutes of Health diversity and disadvantage definitions were used to identify student characteristics.²³ Of note, the indicator, “Were or currently are homeless, as defined by the McKinney-Vento Homeless Assistance Act” was inadvertently omitted from the student scholarship application in years 1 and 2. Table 1 provides an example of a scoring sheet that can be customized to meet the needs of various target populations.

Table 1.

Sample Scoring Sheet Suggestions.

Criteria	Description	Points range
NIH Disadvantaged Score	Add one point for each item selected	0-7
1. Were or currently are homeless, as defined by the McKinney-Vento Homeless Assistance Act
2. Were or currently are in the foster care system, as defined by the Administration for Children and Families
3. Were eligible for the Federal Free and Reduced Lunch Program for two or more years
4. Have/had no parents or legal guardians who completed a bachelor’s degree
5. Were or currently are eligible for Federal Pell grants
6. Received support from the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) as a parent or child
7. Grew up in one of the following areas: (a) a U.S. rural area, as designated by the Health Resources and Services Administration (HRSA) Rural Health Grants Eligibility Analyzer, or (b) a Centers for Medicare and Medicaid Services-designated Low-Income and Health Professional Shortage Areas
Race/ethnicity (optional)	Add one point if applicant self describes as the race/ethnicity of the target population.	0-1
Multilingual	Add one point if is fluent in more than one language that is relevant to the target population	0-1
Essay 1	Excellent: The essay compellingly demonstrates a strong desire to work in a rural/underserved or HPSA. There is a strong connection between the applicant’s past experiences, current academic pursuits, and future career aspirations.	0-10
Describe the setting in which you want to work upon graduation. Discuss location of practice, type of practice, and patient population.		0-10
Essay 2	The essay provides a comprehensive and compelling explanation of the impacts of SDOH on patients’ physical and mental health.	0-15
Insert case study or pick a population of underserved patients and discuss how their physical and mental health are impacted by social determinants of health.		0-15
Video response	Score on desired criterion	0-15
How would this scholarship opportunity influence and advance your nursing career and aspirations? Do not address the obvious personal financial relief/benefit/need, but to your future practice.	Content
	Clarity
	Connection
	Future impact
	Overall Impression

The first essay question asked the applicant to describe the setting and population in which the applicant might want to work following graduation. The second question asked applicants to identify a population of underserved patients and discuss how the SDOH have influenced the population’s health. The video response was required in response to the prompt “describe how the scholarship will impact your learning and future career goals.” Responses to these questions allowed applicants to demonstrate their understanding of the SDOH, intent to work among disadvantaged patients, and how receipt of financial support would impact their studies and intent to practice.

Student Support

Financial support reduces stress and positively affects student retention and performance.^11,21 Recipients were supported with financial assistance and extracurricular online education. Financial support reduced economic barriers so that students could participate more fully in scholastic opportunities without as much distraction from employment obligations and other economic factors. Additionally, online education was provided to address stigma and align student expectations.

Financial Assistance

Students who were accepted into the project qualified for funding. Scholarships were provided for tuition, cost of living, and professional development and dissemination travel. Averaging 75% of tuition expenses, a stipend was also given to offset additional expenses of fees, books, transportation, and cost of living. Additionally, funds were allocated to support student presentations (registration and travel) at local, state, and national conferences. The financial assistance provided to students was supported exclusively through grant funding, without the inclusion of state, local, or institutional funds, and without any in-kind contributions.

Extracurricular Online Education

New nurses are more likely to leave employment when they feel unprepared and lack confidence, encounter disheartening situations, and unwelcoming environments.²⁴ Providing insight to and experience with marginalized populations and practice settings outside of the mainstream urban environment can mitigate attrition. Online modules were developed to demystify and destigmatize nursing care among disadvantaged populations and underserved settings. Students are required to complete 3 modules per academic year. The SDOH module includes a pre and post evaluation, and the SDOH learning module is required of all award recipients.

Students select at least 2 topics per year that align with their clinical rotations. Subjects covered include but are not limited to older adults, Lesbian, Gay, Bisexual, Transgender, Queer, Intersex, Asexual, Two-Spirit (LGBTQIA+), Native Americans, and Veterans in underserved settings such as skilled and long-term care nursing facilities, correctional facilities, federally qualified health centers, and rural areas. By incorporating SDOH education, students are empowered to address patients’ social-determinant needs and better coordinate care for disadvantaged patients. Coupled with a social justice lens, including the SDOH in didactic work sparks awareness and interest in affecting issues at a population level and promoting health equity.²² Table 2 provides a comparison of standard degree program requirements and the expectations of scholarship recipients.

Table 2.

Comparison of Standard Program Requirements to Scholarship Recipient Expectations.

Doctor of nursing practice degree example	Standard student	Scholarship recipient
Course credits	35-45 SCH (Dependent on program track)	Same
Extracurricular learning modules	Not required	Three modules (~0.5 SCH each) per academic year of award.
		• Social Determinants of health overview and application to nursing practice
		• +2 Modules specific to underserved/disadvantaged populations/settings
Clinical hours	1000 Contact hours	1000 Contact hours
Clinical hours	All sites with a business agreement accepted	50% or more of hours must be completed in a HRSA designated medically underserved area or health professional shortage area

Student Engagement

Student engagement is an important factor for degree completion, scholastic success, and positive academic behaviors.²⁵ Two methods were used to promote student engagement. Faculty mentorship and clinical preceptorship are critical relationships for nursing students. Students’ preconceptions about advanced practice nursing were challenged by requiring recipients to complete clinical rotations in underserved communities. These opportunities lie beyond convenient sites of large family practice clinics and acute care settings in metropolitan areas.

Orientation

Scholarship recipients first become familiar with the requirements and expectations of the project during a daylong orientation. The orientation provides information about available support, dissemination initiatives, and the settings/populations for clinical rotation expectations. Preceptors and stakeholders present information about their respective populations and clinical rotation opportunities.

Faculty Mentorship and Clinical Preceptorship

Students are required to meet at least once each semester with faculty mentors who review their progress in the program and discuss any challenges the student is encountering. This mentorship provides individual attention and often results in a symbiotic placement for the student in clinical rotations as well as encouragement and relationship building between faculty and students. These student development sessions are an opportunity to discuss clinical experiences related to the federal grant, dissemination of clinical experiences with rural and underserved populations, and completion of the online learning modules.

Faculty perform site visits in the community with students who are in a clinical rotation. During the site visit, faculty can meet with students and their preceptors to gauge student progress. These site visits also provide an opportunity to network with the preceptor and thank them for their dedication to the program. Relationships with preceptors provide psychological safety and a network of job placement opportunities.²⁶ Site visits also offer the opportunity to recruit future preceptors and students.

Clinical partners are crucial to the success of the graduate nursing program. Without them, students would be unable to practice their skills and perform clinical hour requirements. In addition to being preceptors, several of the clinical partners serve on the advisory board for the grant. Meetings are held with the advisory board to gain insight from practice partners and to collaborate on projects. Preceptors are invited to serve as guest speakers at the scholarship recipient orientation and attend a virtual preceptor appreciation event annually.

Dissemination

As part of the Doctor of Nursing Practice (DNP) degree, all students are required to develop, implement, and analyze a quality improvement project, and many scholarship recipients chose to focus on rural and underserved populations. All students are encouraged to document their progress and cumulative assessment from their project and disseminate their outcomes at a local, state, and/or national conference. Grant funds are available to support related travel and registration expenses. Faculty mentorship is the primary catalyst for dissemination. When able, faculty accompany the students to conferences as mentors.

During the annual scholarship recipient orientation sessions, only 20% of students reported having ever traveled by plane outside of the state, and only 10% shared that they had previously attended a state or national nursing conference. Understandably, students are reluctant to ask questions, likely due to reluctance to acknowledge ignorance or inexperience. To dispel fear of travel, faculty lead an interactive session to help students feel more comfortable with airline travel and the conference experience. Faculty present Generative AI (GenAI) platforms and related digital tools. Specifically, goblin.tools (online at https://goblin.tools/) is introduced during the required orientation event. This tool helps users break down complex tasks into manageable steps. During the session, faculty briefly demonstrate how to create effective prompts such as “How do I prepare for my first out-of-state national professional nursing conference? How do I prepare for my first time traveling by airplane in the United States?” Faculty then share their own conference experiences to help students conceptualize the experience. Together, faculty and students explore the response from goblin.tools. The tool offers step-by-step planning support to help students prepare for travel, conference session attendance, and maximize networking and professional development opportunities. Additionally, students are required to meet with the program coordinator and a faculty member prior to the conference to review the itinerary, craft a meaningful experience, and mitigate potential travel mishaps.

Results

Anonymized Quotes related to the results are given in Supplementary material.

Diversity of Recipients

Scholarship recipients are a very diverse group as evidenced by race and ethnicity of the scholarship cohort in comparison to the Fran & Earl Ziegler College of Nursing, the University of Oklahoma, the State of Oklahoma, and national data as shown in Figure 1. Aligning with the literature, the application scoring was weighted and included a disadvantaged background score, fluency in more than 1 language, and graduation from a rural high school. The average cumulative disadvantaged score is 3.47 and over 14% self-reported fluency in more than 1 language. Forty-two percent graduated from a rural high school and 44% indicated intent to work in rural communities upon graduation.

Figure 1.

Recipient race and ethnicity comparison.

Over 30% of recipients are first-generation college graduates (Figure 2). One student stated that she is both a first-generation college student and a first-generation American citizen. Her parents immigrated when she was a young child and always emphasized education, even though they did not graduate from high school themselves. She was able to earn her DNP degree as a result of the scholarship and is now practicing in an underserved mental health clinic.

Figure 2.

Recipient demographics.

Student Support Outcomes

A total of 55 scholarships have been awarded to date. Among them, 39 were full-time and 16 were part-time students. The scholarships were distributed across different tracks, with 23 awards going to FNP students, 15 to PMHNP students, and 7 to AGCNS students. All recipients have completed the SDOH online module and at least 2 modules related to their clinical rotation placements.

Student Engagement

Orientation

In addition to meeting the requirements and expectations of scholarship recipients, the orientation session is scheduled based on the availability of advisory board members. These members, who represent clinical rotation sites and often serve as preceptors, attend the orientation to meet the students. They also participate in a panel discussion about their respective facilities. Students have consistently provided positive feedback about this panel discussion. All students attending the year 2 orientation completed an evaluation of the event. Of particular interest, all students agreed or strongly agreed with the following statements (5-point Likert scale strongly disagree – strongly agree).

The orientation as a whole (the feeling throughout the day) created positive feelings related to access, opportunity, belonging, and wellness.

I found this activity worthwhile.

I intend to practice in underserved communities and/or with disadvantaged populations.

Faculty Mentorship

Faculty mentorship not only provides the students with expert advice from a trusted source, but it also cultivates a lasting relationship with a colleague that can last well past graduation. Program satisfaction also directly ties back to student and faculty engagement.

Clinical Preceptorship & Rotations

Grant recipients in a clinical rotation completed at least 1 rotation with a preceptor either located in an underserved area or who serves patients from underserved or disadvantaged backgrounds. Scholarship recipients complete 50% or more of their program’s required clinical experiences in underserved patient populations. Grant year 1 preceptors (n = 135) are diverse in their patient populations, locations, and practice specialties. Clinical partners found the project a valuable opportunity to recruit students. During the second grant year, the number of preceptors rose to 157. This represents a 30% increase in the number of academic clinical site partnerships with the College of Nursing. The support of our clinical partners and preceptors emphasizes the value of clinical experience. For instance, rotations in the prison system provide exposure to diverse backgrounds and a range of mental health services. Similarly, understanding the underlying anxiety, depression, or PTSD (often due to past discrimination) in the LGBQTIA+ patient population helps students become more affirming in their care. Partners also mention that students precepting with them often join their team as employees.

Dissemination Efforts

Support and encouragement from faculty resulted in the dissemination of scholarly activity and professional development at national conferences. In the first 2 years of the program, 12 students traveled to conferences and 5 students disseminated their work across 7 professional conferences. Two students in the FNP program presented posters at the National Organization of Nurse Practitioner Faculties Conference. Three AGCNS students presented nationally and internationally. Notably, 1 student had 2 abstracts accepted to present virtually at international conferences.

Overarching Results

At the conclusion of year 1 of the grant, 8 scholarship recipients graduated, and follow-up data indicates that all 8 are employed as APRNs. Of the 8 graduates, 2 are working in FQHCs, and 6 are working in HPSAs. Therefore, 75% of the 2024 (grant year 1) graduates are working in an underserved area and providing care to diverse and vulnerable populations. Results for year two are similar for the 7 students graduating: confirmed working in MUAs, and 2 indicating intended employment with the targeted populations following board certification. Students expressed that their experiences have heightened their awareness of patients’ struggles beyond medical conditions. They emphasized the importance of recognizing and addressing underlying challenges that impact health. These personal experiences have significantly influenced their approach to nursing, motivating them to ensure that discharge plans are feasible for each patient. It is unclear if there is a direct correlation between having the scholarship program and the number of applications and subsequent admission to the APRN programs. However, enrollment continues to rise. During the Fall 2023 admission cycle, 55 APRN students were admitted to 1 of the 3 specialty tracks offered: Family Nurse Practitioner, Psychiatric Mental Health Nurse Practitioner, and Adult Gerontology Clinical Nurse Specialist. In the Fall 2024 admission cycle, 69 students were admitted to the APRN tracks, and over 80 students are expected to enroll in the Fall 2025 semester. This represents a 25% increase in admissions.

Student Feedback

Feedback from student scholarship recipients has been overwhelmingly positive. They have expressed great appreciation for the life-changing financial assistance that has allowed them to focus on their education. One student who attended a national nurse practitioner conference mentioned she has been a nurse practitioner for over 10 years but had never been able to attend a conference due to cost. However, with the travel stipend she was able to attend and learn from her colleagues and networked with other providers. She stated this was the greatest benefit of the grant to her career. Another student stated that she was able to finish her FNP degree all while her husband is active-duty military. Without the scholarship she would not have been able to do this due to financial strain. Beyond the financial impact, students state they have enjoyed working in the underserved areas. One student who did clinical hours in the Department of Corrections stated they were nervous to go to the prison system prior to the rotation but ended up really enjoying the rotation and learning a great deal about this population of patients.

Discussion

Supporting health equity is a lofty goal and a commendable aim. Theoretical synthesis of the socio-ecological model and SDOH model indicate that multi-level interventions are necessary to improve health equity in rural areas and other underserved populations. While the results of the project do indeed support the literature related to increasing job placement of nurses in these communities, project results also highlight many areas for improvement. First and foremost, there is an opportunity to hardwire many of the project’s activities and student requirements into the whole of the graduate program.

The holistic approach to APRN education for project participants was made possible by the grant, which directed 70% of the grant award toward student activities. To be sure, the financial scholarship awards to students were beneficial to the project’s and students’ success. However, all other elements of the 3 strategies could be melded into the curricula and graduate program design to support workforce growth and diversity.

Activities that bear integration included the strength of the strategy to engage students through program orientation and relationships with faculty and preceptors. Specifically, presentations from clinical partners during the student orientation are critical since this may be the first time students have heard stories from the human and clinical perspective of serving marginalized patients such as LGBTQIA+ and incarcerated individuals. These informal presentations remove the fear of the unknown by conveying a humanized experience of patient need and provider resiliency. Requiring all nursing graduate students to attend a similar 1-day intensive could have a ripple effect on the student body. This could be further magnified if all nurse faculty were also required to attend as faculty influence the students in their classrooms and programs. These students, in turn, will extend the reach of faculty across numerous settings. Ideally, faculty would incorporate health equity and SDOH components throughout curricula, having an impact that extends beyond the classroom to inform and reshape the mindsets of countless others.

Quality assurance and process improvement are vital to the evolution of successful programs. Many opportunities exist to increase diversity, engage students, foster preceptor relationships, and celebrate success. Roughly half of the population identifies as male, yet in 2025, just over 11% of Oklahoma nursing providers with a National Provider Identifier and only 5% of grants scholarship recipients identified as male.^27,28 The diversity of the student pipeline, including gender, race, ethnicity, and multilingual abilities, should be explored and integrated into recruitment and enrollment efforts to better match the nursing workforce with the community it serves.

Although both track coordinators and scholarship recipients value their relationships and required meetings, establishing a structured schedule with a semi-structured guide and clear objectives for each session could enhance the mentorship experience, making it more meaningful and purposeful. Similarly, the preceptorship experience could be enhanced by having students provide formal, written prompts to preceptors. These prompts should outline the skills development needed, the student’s career aspirations, the extracurricular learning gained (current student understanding of the practice setting), and questions about the patient population in the clinical rotation.

Engaging preceptors beyond the time spent with students clinically is another improvement opportunity. So far, preceptors have been reluctant to join events outside of their clinical setting. Traveling to the college for an event, whether celebrating student success or continuing education activities with a preceptor appreciation element, seems to be the main barrier. Investigation into preceptor attitudes, wants, needs, preferred methods of appreciation, and the like is needed.

Limitations

This study has several strengths and limitations. Federal funding was leveraged to dedicate faculty time to the development, implementation, and improvement of the project. Similarly, federal funds were used to provide financial support directly to the scholarship recipients. The funding source is also a limitation because the institution does not currently have an alternate funding source for student scholarships. However, by proposing policy and curricula change the tested strategies can be interwoven into nursing education programs. This would eliminate the need for financial incentive to participate in clinical rotations in MUA/HSPAs and to complete modules addressing characteristics as well as stigmas associated with disadvantaged patient populations.

At the time of publication, confirmation of employment by year 2 graduates was pending. With graduation held in May, graduates were focusing on board certification exams. Of the 6 graduates, 4 confirmed employment with targeted populations and 2 responded intent to accept positions in underserved populations.

Although the educational programs offered at the institution are hybrid, most of the student body reside within the state for the clinical rotations. This caveat comes for the state board of nursing as assigned faculty must be licensed in the state/territory of the program as well as the location of the clinical rotation. This limitation makes the study less generalizable, although the literature supports such strategies globally as described in this article previously.

The HRSA funded project is a 4-year grant, and this study encompasses results from the first 2 years. Adjustments to the application and scoring process have been made to include the missing NIH disadvantage item referencing homelessness and to decrease the weight given to video responses. The inclusion of all NIH disadvantaged scoring items may prove beneficial to some applicants relative to score. The reduced weight of the video response should serve to mitigate affinity bias during assessment and more appropriately weigh scholarly writing in the essay responses. These quality improvement measures are needed yet introduce additional limitations to assess the entire length of the project.

Conclusion

This project has been a valuable learning experience for the faculty, students, and preceptors. Beyond the obvious financial benefits of providing scholarship money for students, it has increased awareness of the SDOH and helped students become familiar with unique challenges these communities face. Being familiar with a population of patients or a community increases the likelihood of employment in these areas. Having a sense of belonging is a valuable predictor of happiness in the workplace and happiness in the workplace correlates with retention and longevity. The implications and recommendations for practice include:

(1) Expand clinical rotation opportunities by recruiting more preceptors from diverse backgrounds and clinical settings,

(2) Incorporate student generated clinical rotation information exchange sheets,

(3) Provide extracurricular education to address stigma and prepare students for rotation in rural areas and among vulnerable populations,

(4) Institute a requirement for a portion of clinical rotations to be completed in rural areas or with vulnerable populations, and

(5) Prepare and encourage students to attend professional conferences with coaching to facilitate networking and dissemination.

The goal of this project is to is to increase job placement in underserved care settings. The strategies help nursing students understand how the SDOH manifest as barriers in patient care and compliance. APRNs are thus empowered to practice effectively, compassionately, and confidently across care settings. Holistically integrating non-financial project strategies into the graduate program would improve access to care and support health equity in rural and underserved.

Supplemental Material

sj-docx-1-inq-10.1177_00469580251366933 – Supplemental material for Supporting Health Equity Through APRN Workforce Development: Strategies for Nursing Graduate Programs to Increase Access to Care in Underserved Areas

Supplemental material, sj-docx-1-inq-10.1177_00469580251366933 for Supporting Health Equity Through APRN Workforce Development: Strategies for Nursing Graduate Programs to Increase Access to Care in Underserved Areas by Julie A. Gordon, Amy Costner-Lark, Kimberly A. Allen, Susan Dresser, Karina M. Shreffler and Melissa Craft in INQUIRY: The Journal of Health Care Organization, Provision, and Financing

Footnotes

Acknowledgements

Not applicable.

ORCID iDs

Julie A. Gordon

Amy Costner-Lark

Kimberly A. Allen

Susan Dresser

Karina M. Shreffler

Melissa Craft

Ethical Considerations

The University of Oklahoma Health Sciences Center Internal Review Board (IRB), determined that this was not human subjects research and was deemed exempt by the IRB (IRB # 18446).

Consent to Participate

The University of Oklahoma Health Sciences Center Internal Review Board, determined that this was not human subjects research so consent was waived (IRB # 18446).

Consent for Publication

Not applicable.

Author Contributions

Julie A. Gordon: led concept and design of the manuscript and the interpretation of the data, drafted the manuscript, integrated feedback and revisions from all authors, approved final version, and agreed to be held accountable for all aspects of the work. Kimberly A. Allen: provided the initial conception of the impact of social determinants, provided interpretation of results, collected student employment data, approved final version, and agreed to be held accountable for all aspects of the work. Amy Costner-Lark: Aligned background of the project to the federal program, collected quotes from participants, drafted discussion and points of conclusion, acquired data, approved final version, and agreed to be held accountable for all aspects of the work. Susan Dresser: informed quality improvement strategies and lessons learned, edited, provided references for key points, collected quotes from participants, approved final version, and agreed to be held accountable for all aspects of the work. Karina M. Shreffler: interpreted population data, reviewed methods, and identified intellectual gaps in the manuscript, approved final version, and agreed to be held accountable for all aspects of the work. Melissa Craft: Conceptualized and aligned role of the institution to the project in the manuscript, reviewed the manuscript critically for intellectual content gaps, approved final version, and agreed to be held accountable for all aspects of the work.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This program is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of an award totaling $1 294 371 with 0% financed with non-governmental sources. The contents are those of the authors and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS, or the U.S. Government. For more information, please visit HRSA.gov.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

Due to the size of the student cohort and FERPA regulations, the raw data will not be available to the public. NPI and Census datasets are publicly available.

Supplemental Material

Supplemental material for this article is available online.

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