Building the Nursing Pipeline by Addressing Social Determinants of Learning

Building the Nursing Pipeline by Addressing Social Determinants of Learning

The U.S. nursing shortage is projected to hit the hundreds of thousands, and the ability to educate and train nurses is more vital than ever. Yet, prospective caregivers still encounter barriers within nursing education that can limit their degree completion. And this disproportionately includes college applicants from diverse communities.

The nursing leadership team at Adtalem Global Education  helps nursing schools better meet the needs of their students through the Social Determinants of Learning (SDOL). Principles that emphasize access over exclusivity and put students at the center, and ultimately, help decrease the nursing shortage. If adopted more widely, the framework can help nursing schools better meet the needs of their students and, ultimately, help reduce the nursing shortage.

Among the core principles are:

  • Student Admissions: The process evaluates factors beyond standardized test scores and GPA.
  • Student Success: Personalized learning approaches encourage strong student outcomes.
  • Mindfulness: An 8-week program integrated into a pre-licensure BSN program helps manage the stress that can hinder student progress.

Daily Nurse spoke with Karen Cox, PhD, RN, FACHE, FAAN, president of Chamberlain University and member of the leadership team at Adtalem Global Education, who helped create and implement a learning framework to adjust for those factors. She’s committed to assisting students to overcome all barriers, including past academic performance. As a healthcare executive and a former clinical nurse specializing in pediatric intensive care, burn care, and infectious diseases, she leads the largest school of nursing in the U.S. with nearly 38,000 students across 23 campuses and online programs. As a result, Chamberlain University is the leading grantor of bachelor of science in nursing degrees to underrepresented minority students in the U.S.


Karen Cox, president of Chamberlain University, talks about how the Social Determinants of Learning can help schools build a nursing pipeline

Prospective nursing students encounter barriers within nursing education that limit their degree completion, and this disproportionately includes college applicants from diverse communities. What can nursing schools do to adjust those factors?

First, nursing programs don’t tend to look at students as a whole. Their gold standard is the GPA. And that gets them the students with the most privilege and advantage. Those will be students that are usually independent or dependent, do not have to work full time, are very likely to be highly successful and pass the boards at a high rate.

As long as the profession generally does that, diversity in general, and I’m talking about ethnic and socio-economic diversity, diversity won’t be accomplished because people are more than their GPA. And so our approach is what nursing and other parts of higher ed talk about holistic admissions. And that’s where you look at the person, their life experiences, and their GPA, but you also try to understand what was behind that GPA if it was lower. And figure out if they will likely succeed, knowing they need more support.

And that’s where the Social Determinants of Learning framework comes in. We did a study at Chamberlain that shows only 30% of success or progress is related to people’s academic abilities. Seventy percent is related to psychosocial factors. So we have students that are independent, work full time, and if they lose a job, or if their car breaks down on the way to one of their clinicals, they can’t figure out what to do to get there. Those are nuisances to many people, but it could be the difference between success and failure to our students. So you have to look at supporting people. I will tell you I saw a school admitting students before they accepted your application. You have to take a test that you have reliable transportation, which is code for lots of things. But number one, if you say yes, and then you don’t, they won’t have to work with you on it. And what I find so interesting is that nursing is the most caring profession. And we’re not caring for students, and then we wonder why they’re not as caring for patients and families as we’d like them to be.

So we role model that level of care. And nurses have to accept people in all situations, all walks of life. And if nursing faculty can’t accommodate that, it doesn’t send the right message. Some schools say, “We want more diverse students, but we can’t get them.” And it’s not just that some diverse individuals haven’t had privileges. So you’re setting up another factor that could cause structural racism. You build the procedures that are the advantage—the majority group.

As a leadership team member at Adtalem Global Education, what are you doing to create and implement a learning framework to adjust for those factors?

A couple of different things. As mentioned in the admissions piece, we look at the faculty role differently. Faculty teach a class for three hours once a week or twice a week. And go home. Faculty are coaches and mentors, and guides and help us identify resources that students need. And then, we ensure we have the requisite resources that we need on-site or connections. We recently identified an organization that can help people who find themselves without a home and how to navigate that system and find them housing. We can’t provide all these things for people, but we can help them identify what that looks like in a crisis.

Food insecurity is an issue for many of our students, and we’re working to make sure we have either food available, or a pantry available on campus, but also, if we can’t, for whatever reason, have a connection and a seamless way to work with community services. So it’s paying attention not just to their learning but the things that get in the way of their learning. The other piece we’re doing at Chamberlain is that our students have to work full-time. But we don’t want them to work in retail, not because it is bad, but because it’s a couple of things. Retail work isn’t as flexible in considering the schedule of nursing clinicals and courses. But the bigger issue is if they can work in a hospital or healthcare setting, that’s one more experiential option where they see healthcare in action. And they get some hands-on experience. And they get to know an employer. It’s called “Earn to Learn” because the next step is that so many state boards now allow students to do some of their clinical work in an organization while getting paid not all but some hours for each specialty. And again, they’re not with faculty in the same way as they are typically, so they get yet another look at the day in the life of nurses. The nurse has extra pair of hands. And so we feel like it’s important. And if we had had something like this setup before COVID started, we’d have over 13,000 pre-licensure students nationwide. We could have been a force to support the workforce in a very seamless, organized ready-to-go way.

How has Chamberlain University become the leading grantor of bachelor of science in nursing degrees to underrepresented minority students in the U.S.? 

So right now, getting into nursing school takes work. And I’m not saying it should be easy. But a 3.8 or 3.9 gets you looked at for nursing admission. What we do is look, again, we have students with a 3.2, who turn out to be extraordinary nurses with a high level of resilience and a high level of passion and excitement about being in the nursing profession. And so it’s about feeling that belonging. And if you walk onto one of our campuses, you will immediately see the diversity. It’s not in pockets. It’s prominent. And we’re so proud of it because of our scale. We can have an outsized impact on sending diverse nurses into the workplace. And the bigger we get, the more outsized that impact is.

So nursing graduates match what it’s like out there in the real world?

Exactly. Health equity has a chance. And we feel very strongly about that. I can’t tell you the disappointment when you read about well-educated Black women who died in childbirth. I tell people we see that disparity because it’s not normal, and you shouldn’t ever die at birth. But if two people get colon cancer, colon cancer is bad no matter what. So it’s hard to measure when you look at outcomes, but it’s harder and takes longer. But when you’re talking about something that’s supposed to be a normal part of life, yeah. It’s just stark.

Some of it comes down to not listening to or believing people. And if somebody says, I don’t feel right, and this is going on, I always tell students and new nurses, if a patient says or a parent says, this is not right, then something’s wrong. You stop in your tracks. And you investigate, and you get a colleague to look at it. The worst that can happen is everything’s okay. But often, patients know their kids, especially when you work with children and their families. And so what I think the piece about structural racism, there are lots of factors in healthcare. But the fundamental thing of listening and trusting someone and not just making assumptions or the notion of biases that have no basis effect.

How can the framework – the Social Determinants of Learning help other nursing schools better meet the needs of their students and, ultimately, help decrease the nursing shortage?

Education overall is about elitism, it’s about the best of the best going to the best schools. And the best, you know, promulgating that notion that it’s for the people with the highest abilities, the money to go to school. And so, we published that framework in 2021. And we’ve had a lot of interest. I would say the interest has been more at the faculty level than the leadership level. We plan to speak about it at a few conferences, but it’s a fairly new kind of name that we put on and developed this framework. I think that if people are honest, they know that your chances of diversifying go down dramatically if you don’t have a holistic admissions process. Still, we’re going to struggle with this because this was developed and discussed ten years ago at a national level how important the holistic admissions process is, and it’s just simply not there to the degree it needs to be.

When you sat down and created the SDOL framework, what did you envision as the desired outcome for nursing schools and the nursing profession?

It was to scale it, share it, and disseminate and hopefully get the attention of people who go to it who say to themselves, “Oh, yeah, I can now see that I know the social determinants of health because I teach that.” Now I can see how you brought that out to somebody in education. And, of course, this has applicability past nursing for any education situation looking at people’s barriers. And what can you do about those barriers? If you want to do something, there are a lot of people who still like the survival of the fittest. You met ten people, and two aren’t making it, and that’s okay. That’s not Chamberlain. We take it personally when we lose a student we went with and invested in. And that could be a real asset to the profession.

When creating this framework, you anticipated there would be pushback. What are your thoughts about selling the idea and having it makes sense?

The narrative is that everybody should have a level playing field and be at a certain place. And we’re not talking about not having the same outcomes. We’re talking about coming into a program. The other pieces, it takes more people, more work, different structures, different ways of organizing classes. Some schools will say they don’t have the dollars to do it. Or they don’t see the need. And that’s why I think that, at some point, the accrediting bodies will have to talk about being more holistic. But they don’t. They’re going about their business. They’ve got a busy school. They got plenty of applicants. They have twice as many applicant slots. In their mind it doesn’t make a difference, but it sure does nationally.

Chamberlain can influence, and as we grow with purpose and quality in mind, the more that we have, the more have to listen to us. We aren’t just going to sit over here. We’re in a category of one in terms of our mission, scale, and national presence. And so we’ve been more about just making sure that we have that impact and that people know about it and see it and the people who see it or the health system leaders locally hiring our graduates

Anything else to add?

There is a study that came out recently that talked about how many lost years and lost dollars occur in this country because of health inequities. And when we say the cost of healthcare in the U.S. is unsustainable, and I believe it is, one big component is addressing health disparities. And if we got busy and worked on that, we could work together across sectors. We could make an impact.