Majoring in Minority Health

A decade ago, a smattering of nursing schools first began offering degree and certificate programs that focus specifically on minority health, eliminating health disparities and serving the needs of vulnerable patient populations. More recently, however, both the number and quality of these programs has begun to increase significantly.

“In the last five years, there has been a more serious attempt at understanding what we should be doing in these types of programs,” says Shirley Moore, PhD, RN, FAAN, director of a new pre- and post-doctoral training program at Case Western Reserve University’s Frances Payne Bolton School of Nursing in Cleveland that prepares nurses for research careers focused on vulnerable populations with multiple morbidities. “These programs are moving to more substantive issues in minority health and a greater understanding of culture as a context for care.”

A primary reason for this shift is the increased national awareness of the crisis of minority health disparities. Studies such as Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, the landmark report issued by the Institute of Medicine (IOM) in 2003, have documented extensively that Americans of color do not receive the same quality of care as the white majority. The IOM report also suggested that bias, prejudice and stereotyping on the part of health care providers may contribute to these differences in care.

The underlying principle of social responsibility runs deep in the nursing profession. As nurses become increasingly concerned about health care inequities in communities of color, they are spurred to gain a better understanding of these issues and to build the skills needed to address them. “Nurses have always had the underlying value of tailoring care and incorporating patient preferences,” says Moore. “But how do we tailor care for patients when we don’t know much about their [cultural] background?”

Another reason for the proliferation of these programs is that federal agencies, such as the Health Resources and Services Administration (HRSA), have earmarked millions of dollars in funding specifically for nursing schools. In fiscal year 2006, the agency awarded 151 Advanced Education Nursing grants, 53 Nursing Workforce Diversity grants and 138 Nurse Education Practice and Retention grants, says Annette Debisette, PhD, ANP, RN, director of HRSA’s Division of Nursing. Last year, HRSA appropriated almost $150 million to nursing schools that offer programs focusing on underserved populations.

“The availability of [federal] dollars has permitted us to act on our good will to create these centers and programs that train people with new views on how to approach [cultural issues in nursing care],” Moore says.

Changing the Student Profile

Many of these minority-health-focused nursing programs are attracting a highly diverse mix of students from a wide spectrum of racial and ethnic backgrounds. While they are not targeted specifically to students of color, there’s no denying that these types of programs have helped boost minority enrollments in nursing schools across the board.

“Every training program we’ve had that was working toward understanding diversity, access to care and other minority health issues has been a big attraction for minority students,” says Moore. She adds that the new pre- and post-doctoral training program “is changing the profile of the doctoral student here at Case.”

The Catholic University of America (CUA) School of Nursing in Washington, D.C., offers three HRSA-funded master’s degree tracks in community/public health that focus on decreasing health disparities and increasing the number of nurses from minority populations. Of this year’s graduates, 58% are students of color, says Eileen Sarsfield, PhD(c), MSN, APRN, BC, project manager of the Immigrant, Refugee and Global Health Clinical Nurses Specialist (CNS) Program track.

Three quarters of the students enrolled in this track for the fall semester are racial and ethnic minorities. “This program appeals to nurses who are immigrants themselves or minorities interested in giving back to their community,” Sarsfield notes.

Most of these types of programs are offered at the graduate level, and the nurses who are enrolling in them are as diversified in their career tracks as they are in their ethnic and cultural backgrounds.

Of the 33 students currently enrolled in the University of Texas at Arlington School of Nursing’s PhD program, which focuses on preparing nurse scientists to meet the health needs of diverse and vulnerable populations, some are nurses who work in an administrative capacity at large health care organizations, says Jennifer Gray, PhD, RN, associate dean of the program. Others are nurses with years of clinical experience at the bedside or advanced practice nurses who want to move into a leadership or management role. Some are faculty members at other educational institutions. Some of the full-time students work as graduate research assistants.

Similarly, the 60 students enrolled in the University of Illinois at Chicago (UIC) College of Nursing’s Adult/Geriatric Nurse Practitioner programs, which focus on caring for diverse patient populations, range from master’s-entry students making a career change into nursing to RNs with a few years of experience, says Jean Berry, PhD, RN, CNP, director of the nearly three-year-old programs.

There are even some students coming directly from the undergraduate nursing program, Berry reports. However, they are encouraged to work part time to gain clinical experience, because that will help when they start their clinical courses.

Common Goals, Different Options

While these types of programs all share a common focus on improving the health of underserved populations, each one has its own unique twist. Some are research-oriented, others have a clinical focus and still others address the need for more nursing educators who are specialists in minority health issues.

The goal of Case Western Reserve’s program is to prepare a cadre of nurse researchers committed to the elimination of health disparities. The nursing school received a grant from the National Institute of Nursing Research (NINR) to create the program, which was launched in Fall 2006.

“We’re looking for nurses who understand that [these] patients come with multiple morbidities,” says Moore. “They have diabetes, hypertension, cardiovascular disease and arthritis. Studying only one of these conditions in isolation doesn’t provide a good picture of how to manage the patient’s health.”

Students learn new study design methods and statistics based on complexity science that take into account that it’s difficult to disentangle the factors associated with health disparities in vulnerable populations, she adds.

Moore is hoping to collaborate more closely with other academic departments, such as sociology and anthropology, as well as the Case School of Medicine’s Center for Reducing Health Disparities and Center for Health Promotion. “Working with the different disciplines and centers will help our students get a bigger picture,” she explains.

The new pre-/post-doctoral training program’s minority health focus is also helping the school’s entire nursing faculty expand its parameters. “It has galvanized us around understanding the complexity of health care issues [affecting] people who are economically disadvantaged, and what that means in terms of the impact on the mental, physical and psychosocial health of this population,” says Moore. “The program is challenging us about the methods we’re using, the knowledge we’re producing and how we’re moving into social policy and practice.”

The University of Texas at Arlington’s PhD program offers two areas of study: clinical research and academic role development. The clinical research track is designed to prepare nurse scientists for original research and theory development that will improve health care for diverse and/or vulnerable populations. The academic role development track focuses on developing nursing faculty who will create learning environments that attract students from culturally diverse backgrounds and prepare them to provide care to diverse populations.

Students in the Catholic University of America’s community/public health MSN program who are interested in working with underserved populations can choose from three different options. In addition to the Immigrant, Refugee and Global Health Clinical Nurse Specialist track, there is also a Promoting Healthy Families in Vulnerable Communities track and a Community/Public Health Nurse Specialist Educator track.

The Promoting Healthy Families program prepares students for the blended role of family nurse practitioner and community/public health CNS. The Nurse Specialist Educator program is designed to prepare community/public health nurses to teach in associate and baccalaureate degree programs, staff development programs and patient/family education programs. This track addresses the critical shortage of nursing faculty and strives to improve community-based care for vulnerable populations.

Serving the Global Community

Last July, CUA’s School of Nursing was awarded a three-year, $778,077 HRSA grant to create the Immigrant, Refugee and Global Health CNS program, the newest of the three tracks. As the name implies, the program’s goal is to prepare community and public health nurses to improve access to health care and reduce health disparities in medically underserved immigrant and refugee populations. The program also seeks to attract immigrant and international students as a means of diversifying the nursing workforce and giving immigrant and refugee patients access to caregivers who share a similar cultural and linguistic background.

Students gain exposure to theoretical content and clinical experiences that focus on health policy, global health issues, finance and information systems, and emergency preparedness.

“Nurses involved in immigrant and public health need to know about policy structures, such as Medicare, Medicaid and the State Children’s Health Insurance Program,” says Sister Rosemary Donley, PhD, APRN, BC, ANP, FAAN, project director for both the Immigrant, Refugee and Global Health CNS program and the Community/Public Health Nurse Specialist Educator program. “They also need to know about immigration issues and about diseases that are endemic to different parts of the world, such as tuberculosis and malaria.”

Despite their differences in focus, the three tracks have one thing in common: Most of the students in the programs have a strong sense of social responsibility and many are mission focused. “We don’t get a call from someone asking, ‘How much money will I get when I graduate?’” says Sarsfield. “That’s not usually the kind of students we attract.”

Adds Donley, “They come here because they want to work with underserved populations with health disparities. When they graduate, most do just that.” In fact, 62% of the programs’ graduates work in underserved areas. Many work for public health departments and community clinics, and some have long-term goals of opening clinics in developing countries. CUA has agreements with several entities, such as the U.S. Congress and the World Bank, to provide students with health policy practicum opportunities.

Increasing Students’ Access

Social responsibility is also at the core of the Fuld Fellowship program at Emory University’s Nell Hodgson Woodruff School of Nursing in Atlanta. The program, made possible through a grant from the Helene Fuld Health Trust, targets career-changing students with degrees in fields other than nursing who are strongly committed to improving care for vulnerable populations.

The full-tuition fellowship provides much-needed assistance for these students, who typically don’t have as much access to financial aid resources as first-degree nursing students, says Ann Connor, MSN, RN-C, FNP, assistant professor of nursing. Since 2001, eight students have graduated from the program, and there are 14 Fuld Fellows currently enrolled.

Fuld Fellows attend core courses leading to a BSN degree, followed by a master’s degree in specializations such as nurse-midwifery, public health and family nurse practitioner. They also participate in the school’s social responsibility programs, such as the Farm Worker Family Health Program (http://www.whsc.emory.edu/_pubs/en/2003spring/feature_lessons.html), Alternative Spring Break Trips (http://www.whsc.emory.edu/_pubs/en/2005winter/newsbriefs.html) to work with HIV/AIDS patients in Jamaica and the Bahamas, and the Korean Exchange Program (http://whsc.emory.edu/_pubs/en/2003spring/feature_root.html).

These second-degree nursing students enrich the pool of nurses because of their diverse professional and educational backgrounds, says Connor. They have the advantage of maturity and a variety of life experiences and skills that allow them to assess issues from a different perspective than traditional nursing students. “They help change health care delivery models because they come with fresh ideas,” she explains.

Some nursing schools are using distance learning to make their minority-health-focused programs more accessible to students. The Oregon Health & Science University (OHSU) School of Nursing in Portland has an online Master of Public Health (MPH) degree program focusing on primary health care and health disparities. It is offered in conjunction with the Oregon Master of Public Health (OMPH) program (http://www.oregonmph.org/), a collaborative statewide degree program offered through OHSU, Oregon State University and Portland State University.

Launched in 2005, the Primary Health Care & Health Disparities MPH program emphasizes improvement in primary health care accessibility and quality for underserved populations. The curriculum evolved over a year of increasing collaboration between the MPH program and OHSU’s Center for Health Disparities Research, explains associate professor of nursing Deborah Messecar, PhD, RN, MPH, CNS.

The program currently has approximately 40 students, roughly half of whom are nurses. The Center for Health Disparities Research has relationships with community-based agencies, creating opportunities for student field experiences. The program is also linked to the international initiatives of the OHSU School of Nursing’s External Programs, giving students opportunities to work with vulnerable populations in Thailand and Ecuador.

Students with a Mission

Why are students responding so enthusiastically to these new nursing programs that focus on minority health and cultural diversity issues? It’s because many of the students pursuing these degrees have a deep commitment to serving vulnerable populations and eliminating health disparities—a commitment that has been fueled by work-related experience, personal experience or both.

Carmen Alvarez, who graduated in May from the Fuld Fellowship program at Emory University’s Nell Hodgson Woodruff School of Nursing, believes that nurses are obligated to help the underserved and that they become empowered when they learn how to address the issues that affect these patients. “When we don’t address their health care issues as early as possible, [those problems] are going to become more challenging, and then we’re going to see the effects in the hospital or at the tertiary level, which is more costly and taxing for us as health care providers,” she says.

For Alvarez, who is of Belizean descent, the motivating factor that led her to return to school and pursue a nursing degree after four years of conducting research in nutritional science was her exposure to marginalized groups in the developing countries in which she lived up until the age of 13. Her father was a plant geneticist who traveled to countries such as Nigeria and Rwanda to help farmers improve their crops.

Tarsha Jones, a full-time student in the Catholic University of America’s community/public health MSN program, points out that the growth of immigrant and refugee population in America means that even more people from disenfranchised groups will require health care in the future. “We need to reach out to them to provide knowledge and resources to improve their health outcomes,” she emphasizes. “If we can focus more on health promotion and disease prevention within specific minority populations, eventually we will improve the overall health of our country.”

Jones, a former pediatric nurse, was born in Jamaica and emigrated to the U.S. when she was 10 years old, so she knows firsthand what it’s like to be a part of a disenfranchised group. “I have a working understanding of being an immigrant and of not having one’s health care needs represented,” she says.

At least once every two years Jones returns to Jamaica, where some impoverished areas don’t even have running water. “Being in a Third World country has opened my eyes to realize what a great opportunity I have living in America and being able to attend a graduate school like CUA where they encourage us to be aware of what’s going on nationally and also internationally,” she says. “[This program] is empowering us to help people here in the United States and also giving us a better understanding of global health nursing.”

When she graduates in 2008, Jones plans to obtain a leadership position in program development where she can work on health promotion and disease prevention to benefit vulnerable minority populations.

Similarly, Alvarez would eventually like to work for an entity such as the World Health Organization (WHO) that uses clinical research to affect public policy. It may take her a little longer to get there, though. This summer, she began pursuing her PhD in nursing with a focus on health promotion and risk reduction at the University of Michigan in Ann Arbor.

Karen Johnson-Guy returned to school after five years of working as a nurse in high-risk obstetrics. With a master’s in nursing and certification as a nurse-midwife and childbirth educator, she plans to start pursuing a PhD in nursing with a focus on vulnerable populations from Case Western Reserve University’s Frances Payne Bolton School of Nursing this fall. After conducting research in Uganda on midwives’ attitudes toward patients with HIV, she knew that she wanted to prepare herself for a career as a nurse scientist. Her research interests include breastfeeding and preventable pathologies of newborns related to the intrauterine environment in mothers who are addicted to crack cocaine and/or methamphetamines.

Johnson-Guy feels that her personal experience of having grown up in public housing projects in inner-city Minneapolis enables her to relate to medically underserved people with health disparities. And where does she see herself five years from now? “I see myself with a PhD—teaching, practicing and researching.”