Abstract
Everyone recognizes the current nursing scarcity, but not everyone recognizes the need for a diverse nursing workforce to adequately serve patients whose social determinants of health include racism, racial bias, and reduced access to care. This article explores how building innovative partnerships between health-care providers and nursing institutions to advance the incumbent workforce can increase capacity and reduce staff burnout. Such partnerships can drive a culture of employee engagement through the development of career pathways while reducing barriers for nontraditional nursing students in advancing their credentials. This article reports on a strategy to address the nursing shortage and to increase the diversity of the nursing workforce through a licensed vocational nurse-to-registered nurse partnership between a school of nursing and a Federally Qualified Health Center.
Implications for Practice and Research
Underrepresented, disadvantaged, and/or nontraditional nursing students who are currently frontline workers in healthcare settings are prospective nurses to fill the workforce skill gap; addressing barriers faced by these students requires strategic partnerships between healthcare organizations and training institutions; interdepartmental collaborations; and an array of financial, educational, and social support. Compared to the more proscribed registered nurse (RN) role in hospitals, the less structured environment at federally qualified health centers requires hiring nurses with prior experience, to ensure patient safety, quality care, and seamless transitions. To ensure equitable opportunity for all employees and to promote student success, the AltaMed Nursing Workforce Diversity program provides financial, academic, social, and clinic support, and coaching and mentoring, from pre-application to post-completion; in return, students commit to remain at AltaMed as registered nurses (RNs) for 2 years and to serve as mentors and preceptors.
Debatable Issue
How can we reduce barriers to entry for nontraditional nursing students and the incumbent workforce to encourage careers as RNs?
Authors’ Position
As a nation, we are beginning to acknowledge the importance of social determinants of health (SDOHs) and health-related social needs (HRSN). As defined by the World Health Organization (WHO), SDOHs are “the broader social and nonmedical factors that influence health outcomes. They are the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life. These forces and systems include economic policies and systems, social norms, and social policies” (“Social determinants of health are the conditions in which people are born, grow, live, work, and age” (World Health Organization [WHO], n.d., para 1). HRSN are an individual's unmet, adverse social conditions (e.g., nutrition insecurity, lack of steady job, housing instability) that contribute to poor health, and are the result of underlying SDOH (Kaiser Family Foundation, 2023).
Given the changing demographics of the nursing workforce, there is a tremendous need for more diversity and skills of nurses with cultural and linguistic competency and lived experience to serve patients with complex HRSNs. For health-care organizations, this need can be addressed by providing career pathway opportunities that address barriers to entry to members of the incumbent workforce who possess experience in providing culturally concordant patient care. AltaMed Health Services, a Federally Qualified Health Center in the Los Angeles, California area, sees their licensed vocational nurses, frontline workers who are predominantly Hispanic/Latino, as prospective RNs to fill their workforce skill and nursing diversity gap (L. Shouse, personal communication, January 11, 2021). Addressing the barriers of underrepresented, disadvantaged, and nontraditional nursing students requires a strategic partnership between health-care organizations and nursing training institutions; interdepartmental collaborations; and an array of financial, educational, and social support to help working nursing students succeed.
Background
According to a National Nursing Workforce Study by the National Council of State Boards of Nursing (NCSBN, 2023), 800,000 RNs and 184,000 Licensed Practical Nurses (LPNs)/Licensed Vocational Nurses (LVNs) in the United States are likely to leave nursing by 2027 (para. 3). This exodus will constitute an immeasurable loss of experienced nurses with decades of knowledge, skills, and patient care history. The U.S. Bureau of Labor Statistics, U.S. Department of Labor (2022) projected that by 2032, employment of registered nurses will increase by 6% from the current workforce of 3,349,900, a faster rate of increase than the average for all occupations (U.S. Bureau of Labor Statistics, 2022). As the U.S. population ages and becomes more racially and ethnically diverse (U.S. Census Bureau, 2021), the health-care sector will require a substantial increase in nursing professionals who understand and can adequately address SDOH (e.g., poverty; access to health care; and cultural, linguistic, and complex health-care needs) in medically underserved, low-income communities.
Systemic Issues in Nursing That Impede Growth in the Workforce
Despite the enormous need for nurses, nursing institutions are not equipped to meet the demand due to several underlying, interconnected issues that include shortages of faculty; lack of clinical placements, preceptors, and classroom space; and budget cuts (American Association of Colleges of Nursing [AACN], 2023). Hiring faculty talent is challenging because, compared to clinical jobs, education programs cannot offer competitive salaries to meet the high cost of living in states such as California, and this is particularly evident in securing faculty with medical specialty expertise (Munday, 2023). As a result, nursing programs turn away thousands of qualified applicants; in 2022, 66,261 qualified applicants were denied entry into baccalaureate programs and 1,239 into RN-to-BSN programs in the United States (American Association of Colleges of Nursing [AACN], 2023, para. 7). In California, 41% of associate degree in nursing (ADN) programs enrolled fewer students in 2019–2020, compared to 27% in the prior year (California Board of Registered Nursing, 2020, p. 8).
Barriers for Prospective Nontraditional Nursing Students
Unlike traditional nursing students who apply to and enroll in college or university nursing schools shortly after graduating from high school, nontraditional nursing students typically enroll after a hiatus from academic/classroom settings. They tend to be older, disadvantaged, and have other characteristics that impact their educational and career aspirations. According to the National Center for Educational Statistics (NCES), these characteristics include financial and family status (e.g., single parent, working full time while enrolled), high school graduation status (earned a GED/high school equivalent), race, and gender (NCES, n.d.).
Nontraditional nursing students face multiple barriers to entry, including costs of education and stiff competition for admission into a traditional daytime structure. Most academic nursing programs only provide daytime classes and clinical schedules, making it difficult for students to work sufficient hours to help address their family's expenses and to allay student loan debt. Prospective working students also struggle to complete the course prerequisites, which are often offered only on days during the week.
AltaMed: A Federally Qualified Health Center
AltaMed Health Services (https://www.altamed.org) is one of more than 1,375 Federally Qualified Health Centers (FQHCs) in the United States that provide affordable, accessible, high-quality primary health-care services to underresourced patients, regardless of ability to pay (Health Resources and Services Administration, 2022). Located in Southern California, AltaMed serves more than 300,000 patients in its Los Angeles and Orange County service areas; 80% of patients identify as Hispanic or Latino according to the organization's reported demographics (GuideStar USA Inc., 2022). AltaMed's service areas include Southeast Los Angeles and Central Orange County, which according to the Centers for Disease Control and Prevention are communities with high social vulnerability. AltaMed has been contending with a significant shortage of RNs, particularly those who are culturally and linguistically competent to serve its predominantly Hispanic/Latino patient population.
Challenges to Recruitment
Like many safety net providers, AltaMed nursing leadership and human resource teams have continued to find recruiting RNs challenging. The organization must compete with the higher compensation provided by hospitals and for the limited pool of nurses with ambulatory care experience serving safety net populations. Compared to the more proscribed RN role in hospitals, the less structured environment of treating patients at FQHCs requires AltaMed to hire nurses with prior experience, to ensure patient safety, quality care, and seamless transitions. Many newly licensed RNs are not equipped to handle the nuances of treating patients with complex health-care needs and low health literacy, particularly if they did not grow up in the same community as their patients and/or receive coaching, mentoring, or experiential training in FQHC settings (L. Shouse, personal communication, January 11, 2021).
An LVN-to-RN Program Tailored for the Incumbent Nursing Workforce
Program
In 2017, with the support of the AltaMed Institute for Health Equity (“the Institute”), AltaMed built the infrastructure and programs to recruit, train, and develop mission-fit health professionals and health equity leaders to serve medically underserved communities. The Institute's programs include the Family Medicine Residency Program, Physician and Nurse Practitioner Fellowships, and experiential training partnerships with public nursing institutions. Given the challenges of recruiting and retaining RNs, and interest from staff LVNs in pursuing an RN career, AltaMed aimed to grow the nursing workforce from within. In June 2021, funding from the Health Resources and Services Administration (HRSA) Bureau of Health Workforce's Division of Nursing and Public Health Nursing Workforce Diversity was received to develop the AltaMed Nursing Workforce Diversity Program (NWD), in partnership with American Career College (ACC), a private health-care education institution, for LVNs to become RNs. ACC's Associate Degree in Nursing is one of 12 health-care programs provided by the institution.
Program Summary
The AltaMed NWD Program is an LVN-to-RN pathway program in partnership with ACC to enroll and graduate 20 incumbent LVNs with ADNs, during the 4-year grant project period (July 1, 2021 to June 30, 2025). The partnership with ACC made it possible to develop a multiyear training program tailored to four cohorts of five LVN participants each, to pursue their ADN degrees while working part-time. The pathway training program offers financial, academic, and social support and mentoring services, and aims to enhance opportunities for LVNs to pursue an RN career at AltaMed. ACC's ADN program comprises eight 10-week quarters (equivalent to 20 months). Combined with preparation for the National Council Licensure Examination for Registered Nurses (NCLEX-RN), the program is approximately a 2-year journey for students to become RNs.
Program Participants
Our NWD LVN-to-RN pathway training program is designed for LVNs with more than 1 year of full-time experience of more than 30 hours per week at AltaMed. According to an interest survey, our LVNs are predominantly Hispanic/Latino (88%), multigenerational (ages 20s to 40s), female (81%), bilingual in English/Spanish (94%), first-generation to attend college (81%) and first in their family to pursue a health-care career (94%; L. Shouse, personal communication, March 15, 2021). To date, 20 students (in four cohorts) are participating in the program. The last five eligible grant recipients began their ADN program in October 2023. More than 100 AltaMed LVNs have expressed interest in applying for the program.
Program Model
Information about the program reaches all LVN employees through the nursing distribution email list and during annual nursing retreats. To ensure equitable opportunity for all employees and to promote student success, the program addresses barriers through financial, academic, social, and clinic support, and coaching and mentoring, from pre-application to post-completion. In return, students commit to continue employment at AltaMed as RNs for 2 years and to serve as mentors and preceptors for LVN and ADN students.
Post-admission, participants receive a laptop with the necessary hardware and software to meet the requirements of the blended learning program. Since a recognized digital disparity of SDOH is home internet access (Shaw, 2023) students are encouraged to access ACC's library, study spaces, and computer labs with campus-wide Wi-Fi service. Students are encouraged to reach out to their instructors or academic retention specialists if they have any concerns or questions. If they need more academic support, they can contact ACC's Director of Nursing, who will work with their team to meet with the students one-on-one and create an individualized academic success plan.
Program Timeline
After receiving notification of the HRSA Grant award, AltaMed and ACC began biweekly meetings to determine the process for identifying, informing, and qualifying potential grant recipients for the NWD Program. Each prospective student had up to 2 years from first demonstrating interest to meeting the program's eligibility requirements (including general education coursework, preentrance exams, and years of service at AltaMed). During this phase, AltaMed employees were encouraged to attend Zoom information sessions for prospective students. Eligible applicants must pass screenings with the AltaMed Student Success Committee as well as meet American Career Colleges' admission requirements; prospective students are evaluated through a holistic application process (DeWitty & Byrd, 2021) including interviews with ACC nursing leadership.
Accepted students receive notice of acceptance and an invitation to ACC orientation. Each cohort is invited to a celebration dinner sponsored by AltaMed with motivational keynote speakers to encourage and prepare enrolled students for the challenging journey ahead to accomplish their goals and create a sense of community. The ACC Executive Director of Career Services also attends this important milestone in the students’ journey.
Program Team
AltaMed NWD Program stakeholders are represented by a multidisciplinary collaborative team co-led by Medical Educational Workforce Development leadership and two Associate Vice Presidents of Nursing who provide oversight and management of nursing and clinical support services at all AltaMed primary care clinics. These leaders bring the vision to meet the organization's needs while supporting a successful and sustainable pathway model. The team includes the Project Director, Director of Medical Education, Program Manager, Academic Partnership Coordinator, and Grant Manager. Together they created the AltaMed Student Success Committee that manages the pathway program, applicant participation, tracking of progress on admission requirements, and coordination of human resources support and student engagement. The AltaMed team focuses on creating a pathway for additional prospective students while supporting already enrolled students through coordinated activities and biweekly meetings to monitor deliverables and outcome measures.
The Executive Director of Career Services shares AltaMed's vision and service as project manager and liaison on behalf of ACC throughout students’ life cycle, providing mentorship for students. The Admission Training Manager coordinates the front end to ensure potential applicants understand the admissions criteria and program expectations during the application process. The campus Nursing Director and Assistant Director oversee the ADN program, providing academic direction, oversight, and curriculum development to ensure students achieve learning outcomes; they also interview potential students. Program instructors, clinical coordinators, and academic retention staff are available to support students throughout their academic journey.
Together AltaMed and American Career College collaborate to achieve the goal of supporting nursing students to complete the program, pass the NCLEX-RN, and become RNs.
Lifelong Benefits of the Program
The AltaMed NWD Program has the potential to generate innumerable benefits for the participants and all those impacted by their development as RNs.
Impact on Students
Impact on Students’ Families
Families may realize the improvement in their quality of life by having more economic security. Priorities based on their circumstances may include increasing their budget for school supplies, being able to pay for school trips, paying off debt, paying for repairs, moving to a community with better education and a safer environment, addressing health needs, and developing savings. Such changes may encourage the participants’ family members to pursue higher education and/or the health professions.
Potential Impact on Health Care
Health-care providers may see benefits that include:
Improved employee engagement and nursing culture, manifested in employee satisfaction data and increased clinic capacity to serve patients, which may in turn increase team morale and reduce turnover. AltaMed NWD Program graduates could be valuable preceptors and mentors. More career pathways and partnership opportunities with nursing education institutions, by developing clinic RNs who can address the shortage of preceptors, mentors, and clinical sites that hinder student clinical experiences. Improved patient engagement, care, and health-care outcomes, including key performance indicators such as patient experience and medication adherence, from more culturally and linguistically competent nurses, as well as increased nurse retention in clinical areas. Enhanced culturally concordant care for patients in the communities served by the nursing and clinic team.
Impact on the Region
Increased purchasing power of participants and their families could help the communities they reside in, such as businesses, schools, and places of worship, through increased purchases of school supplies, household items, and groceries, as well as donations, dining out, and/or opening bank accounts.
Case Study
Maria (a pseudonym), a 45-year-old Hispanic/Latino immigrant, came to the United States at age nine. She read newspaper articles in front of the mirror to teach herself English. The first time she turned on the television and understood what was being said, she cried.
She is currently studying advanced medical/surgical nursing. She enjoys learning the strategies of putting everything together to improve her understanding of the full scope of nursing. Her one regret is that she didn’t begin nursing school sooner. At the age of 19, she was accepted into college but became pregnant with twins and realized she did not have enough funds to support college and her family. When making the choice, she bought a gallon of milk rather than a textbook.
She never married, instead focusing on being the best single mother she could be. She attended a cosmetology program; after working as a salon manager for 5 years, she asked herself, “Do I want to be cutting hair for the rest of my life?” She returned to college, following a friend who chose a vocational nursing program. She developed a newfound admiration for the nursing profession and its ability to handle emergencies when, as a new mother, one of her twins started choking, and she didn’t know what to do.
Returning to school entailed more than she anticipated; she was older than the other students and had difficulty understanding some of the concepts. She cried herself to sleep but kept studying until she became a vocational nurse.
In her first nursing position, she worked with special needs adults in a day program setting. During her next employment, she provided nursing care to residential teenagers recovering from substance abuse addictions, a job she loved. She had finally realized her passion for helping people. Searching for more stability, she began working at AltaMed. After working there for several years, she heard about the opportunity to apply for the AltaMed NWD Program. When she was accepted, she felt like she had won the lottery. After she graduates and becomes an RN, Maria plans to continue serving marginalized communities through her employment at AltaMed.
Maria faces ongoing challenges as she attends the nursing program. Some weeks working part-time hours, she barely makes ends meet, but always believes the goal is worth the hard work. She finds the courage to lead by example, making sure her children understand the message Maria lives by: “If you follow your heart, you can change the world.”
Conclusion
Workforce strategies for LVN/LPN-to-RN pathway training programs like the AltaMed Nursing Workforce Diversity Program can be developed with federal funding opportunities and engagement with internal and external stakeholders, including incumbent vocational nurses. However, schools of nursing need to make systemic changes, including more flexibility for working students, in order to promote vocational nurses’ interest in becoming RNs. In addition, barriers to entry, especially for nontraditional learners, need to be addressed through nursing pathways programs that offer hybrid/online and evening/weekend programming. As nontraditional LVN working students share the lived experience and struggles of patients with complex health-care needs, building an RN career pathway tailored to their needs can net lifelong positive outcomes for their economic prosperity and the well-being of the clinical workforce, patients, and the community.
Footnotes
Acknowledgments
We want to acknowledge the Human Resource Services Administration (HRSA) for making our partnership possible, and the support and commitment of the Nursing Workforce Diversity (NWD) program team in the HRSA Bureau of Health Professions. In addition, we want to acknowledge the support, guidance, and trust of AltaMed's visionary executive leadership, along with other stakeholders too numerous to mention, at both AltaMed and ACC.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Health Resources and Services Administration.
Author Biographies
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