Cultivating inclusive learning environments that foster nursing education program resiliency during the Covid-19 pandemic

Abstract

Nursing education programs faced multiple challenges to increase the size, diversity, and skill set of the nursing workforce while contending with shortage of clinical placement sites and retiring faculty. A program that is unable to be resilient in the face of crisis will fail in its mission to graduate resilient nurses. The purpose of this paper is to describe how nursing programs can respond to the challenge of creating a resilient program poised to graduate a diverse, inclusive, and resilient workforce. Utilizing resilience-oriented strategies to impact educational services solidified program relevancy, promoted student belonging, and enhanced student recruitment/retention. While programs have become accustomed to doing more with fewer resources, many of these programs may not survive these unprecedented times without incorporating a holistic approach for organizational well-being that promotes resilience through inclusivity.

Nursing education programs are tasked with increasing the size, diversity and skill set of the nursing workforce while contending with student retention, shortage of clinical placement sites and preceptors/formal mentors, and well-documented discontent, high stress, and burnout among nurses in many health care institutions. Additionally, nursing faculty shortages due to retirements, non-competitive salaries compared with nursing positions outside of academia, and increased teaching/service/scholarship workloads add additional strain to an already fragile paradigm.

Nursing education programs faced multiple challenges before the COVID-19 pandemic hit in the early months of 2020 such as increased costs, financial strain from budget cuts, and limited internal resources (AACN, 2016; Aiken et al., 2009). Prior to COVID-19, many schools of nursing, ours among them, were focused on attracting and retaining a diverse and talented student body as well as fostering a sense of belongingness among our faculty, staff, students, and clinical partners to promote resilience through inclusivity. COVID-19 has forced us to step back and consider not only the resilience of our students as they transition into practice, but also the very survival of our program. A program that is unable to be resilient in the face of crisis will fail in its mission to graduate resilient nurses. Responding to these unprecedented demands while ensuring our organization's ability to fulfill its mission is a huge challenge. The purpose of this paper, using our baccalaureate nursing programs as an exemplar, is to describe how nursing education programs can respond to the challenge of creating a nimble, resilient, nursing education program poised to graduate a diverse, inclusive, and resilient workforce.

The case for inclusivity in the classroom

Fostering inclusivity and producing nurses that reflect our national population will build our capacity to meet the health needs of all communities (National League for Nursing, 2016, p. 9). According to Metzger, Dowling, et al. (2020), inclusivity, defined as “the intentional incorporation of practices that foster a sense of belonging by promoting meaningful interactions among persons and groups representing different traits, perceptions, and experiences (p. 5),” is a prerequisite for excellence in nursing education. A sense of belonging develops when students feel accepted, valued, and understood as an important part of the group. Feeling that they “fit in” aids in academic motivation and learning (Freeman et al., 2007) as well as student engagement and retention (Masika & Jones, 2016). Creating an environment that promotes belonging has contributed to enhanced student well-being, cognitive development (Grobecker, 2016), increased engagement, motivation, satisfaction with learning and self-confidence (Grobecker, 2016; Metzger & Taggart, 2020; Rainey et al., 2019).

Cultivating inclusive learning environments requires purposeful intention (AACN, 2017; Breslin et al., 2018), honoring and affirming differences (AACN, 2017; Bleich et al., 2015; Breslin et al., 2018), and curtailing barriers that impede full engagement (Bleich et al., 2015). The outcome, however, is well worth the investment. The results of a recent mixed methods study conducted with majority and underrepresented minority 4th-year students in a traditional BSN program indicated that pedagogical strategies designed to promote inclusion and a sense of belongingness in the classroom were associated with positive outcomes, including satisfaction with and confidence in learning, clinical self-efficacy, and clinical belongingness in all students (Metzger & Taggart, 2020). Pedagogical strategies included sending a pre-class letter of introduction to the students; providing an inclusive student-centered syllabus; incorporating first day of class get- acquainted activities; establishing guidelines for respectful engagement; collaboration activities, within the classroom, among clinical group members; and learning student names.

The importance of organizational resilience

While nursing education programs have become accustomed to doing more with fewer resources, many of these programs may not survive these unprecedented times without incorporating measures that ensure organizational well-being and resilience. To move beyond a mode of survival to a state of thriving and resilience, a nursing education program must be able to anticipate change (Moran, 2016), have the capacity to adapt (Witmer & Mellinger, 2016), and integrate resources and best practices (Moran, 2016) all while maintaining its integrity and mission as an institution of higher learning.

van Breda (2016, p. 63) defines organizational resilience as the “process that organizations (including the individual members of the organization and the organization as a community or collective) engage in, in the face of significant adversity to maintain the well-being and functioning of the system and to recover efficiently from disruption”. Resilient organizations, characteristically, can deliver “excellent performance and effectively innovate and adapt to rapid, turbulent changes” (Westphal, 2005, p. 414). A holistic approach for organizational well-being is needed to align all facets of the nursing education program to promote resilience through inclusivity.

van Breda (2016) proposed a three-legged conceptual model for building resilient organizations that focus on the organizational system, the staff of the organization, and the services rendered by the organization. While these three components are necessary for organizational resiliency, this paper focuses on utilizing resilience-oriented strategies to impact educational services provided by nursing education programs. Focusing on educational services and how these services are delivered solidifies a program's purpose/relevancy, promotes student belonging/engagement, and enhances student recruitment/retention.

Resilience-oriented educational strategies

Being intentional in delivering inclusive educational services to prospective and current students positively impacts student recruitment and retention (Read et al., 2013). Instituting a resilience-oriented educational service model “connects systems, people, processes, and information in a way that allows the enterprise to become more connected and responsive to the dynamics of its environment and stakeholders” (Erol et al., 2009, p. 1). Masten and Powell (2003) constructed a resilience framework that used resilience-oriented methods of practice: risk-focused methods, asset-focused interventions, and process-oriented methods to contribute to organizational performance. Several strategies, displayed in Table 1, employed by our organization intertwined the framework's methods falling into all three categories. Employing strategies that incorporate these resilience-oriented methods will promote a sense of belonging and inclusivity which, in turn, leads to organizational resilience and sustainability.

Risk-focused strategies

Risk-focused strategies attempt to mitigate the risk of potential negative outcomes (van Breda, 2016) and begin when students enter a nursing education program. Preparing students for academic success upon entrance into the program increases student satisfaction and improve learning outcomes (Gilchrist & Rector, 2007). Risk-focused strategies that remove barriers to learning and minimize risk factors include holistic admission review, supportive student advisement, tutoring, early warning systems, academic support sessions, inclusive teaching practices, and equity and inclusion training. Holistic admission review considers the applicant's attributes that will contribute to the profession instead of solely focusing on how successful an applicant will be as a student (Scott & Zerwic, 2015).

Early warning systems identify at risk students and enable better monitoring of academic performance (Murray, 2015). It should be noted that this be done in a way to minimize labeling and potential stigma. The University of Virginia School of Nursing's (UVASON) early warning system is called an academic action plan. This plan is designed to facilitate communication between the course faculty, advisor, and student to devise an individualized plan that capitalizes on student strengths and available resources. The action plan includes follow-up and on-going support. It is not deficit-focused or part of the permanent student record, but rather success-oriented and focused on removing barriers to achievement.

UVASON's Inclusion, Diversity and Excellence Achievement (IDEA) initiative's strategic plan cultivates an environment that values difference and allows room for a rich variation of perspectives, beliefs, experiences, and people. The Director for BSN programs and Associate Dean for Diversity and Inclusion collaborated and instituted equity and inclusion training for BSN program faculty and students prior to the start of the fall semester. These training sessions were incorporated into faculty development sessions and student cohort orientations.

Equity and inclusion training for faculty (e.g., inclusive teaching toolkit: first days, lectures and small groups; facilitating respectful conversations following breaches of inclusivity; and designing an inclusive syllabus) and students (e.g., implicit bias training, improving awareness of microaggressions) develop better allies and leaders as well as leads to practice behaviors that strengthen belonging in today's workplace. These strategies coupled with a ‘success for all’ orientation allow for a reframing of what have been traditionally viewed as student deficits to opportunities for growth. Equity and inclusion training strategies led by the IDEA team are described in Table 1.

Asset-focused strategies

Asset-focused strategies amplify positive resources (van Breda, 2016). Students who feel connected to the program, peers, and faculty are more likely to succeed (Gilchrist & Rector, 2007). Asset-focused strategies aimed to increase assets in the social environment include peer tutoring, undergraduate student teaching assistants (TAs), interprofessional education (IPE) collaboration, involvement in nursing organizations/clubs, involvement in academic committees, and social engagement activities. Murray (2015, p. S79) states “social interactions with faculty and student peers foster engagement, learning, and add to students' confidence and sense of belonging in the academic milieu”.

Strategies, such as sharing a meal or socializing with students outside of class, learning students' names, role-modeling collaboration with clinical partners and peers, and incorporating personal experiences as classroom exemplars, were identified by undergraduate nursing students as strongly influencing their sense of belonging in the classroom (Metzger & Taggart, 2020; Metzger, Taggart, & Aviles, 2020). Undergraduate student TAs assist during anatomy and physiology (A&P), nursing assessment, and fundamentals of nursing class lab sessions as well as open lab practice sessions. Peer tutors provide flexible, student-peer partnerships that promote academic achievement, in various subject matters (A&P, Microbiology, Pathophysiology, and Pharmacology), and social engagement. Both undergraduate student TAs and peer tutors are paid positions funded by the UVASON.

Process-oriented strategies

Process-oriented strategies target natural aspects of systems that foster nurturing and supportive relationships (van Breda, 2016). Students' “confidence, motivation to learn, and future career decisions are influenced by the extent to which they experience belongingness” (Levett-Jones & Lathlean, 2008, p. 319). Process-oriented strategies fostering belongingness and relationships include mentoring, building a student cohort with orientation, expectation setting and check-ins, engagement activities with staff/faculty allies, parent/caregiver engagement activities, inclusive teaching practices, anti-racism/equity workgroups, student advisement, and peer tutoring. Targeted advising, mentoring, and tutoring lead to increased student retention and graduation rates (Gilchrist & Rector, 2007).

A RN-BSN student mentoring program was initiated, in fall 2020, to foster a support system for our 1st year RN-BSN students and enhance community engagement within the SON. The student mentor serves as a supporter, motivator, and resource while imparting insightful guidance and best practices to being successful. Five years ago, UVASON established a Faculty and Staff Ally Group who agreed to be readily available to our underrepresented students when they needed support or someone to help problem solve a situation. Twice a year, IDEA and the Faculty and Staff Allies host receptions for underrepresented undergraduate students to build community and to discuss things that are both going well and challenging for them in the SON (i.e., students from racial/ethnic populations, 1st generation students, those with religious underrepresentation, male students in nursing). While in-person receptions were suspended during the COVID pandemic, the IDEA team pivoted to include co-facilitated common read opportunities. These were attended by 67 students, staff and faculty and included White Fragility by Robin DiAngelo, How to Be an Antiracist by Ibram Kendi, and “So You Want to Talk About Race?” by Ijeoma Oluo.

The University of Virginia Model

UVASON BSN (prelicensure 4-year BSN and post-licensure RN-BSN) programs utilize a “high-touch”, asset-based approach to engage students and ensure student success. An asset-based approach focuses on “what a student does right” versus “what a student does wrong” as seen with a deficit-based approach. The focus is on building relationships and understanding the student holistically rather than focusing on their shortcomings.

Our BSN programs employed resources to promote inclusive teaching, student engagement in online learning environments, as well as redesigning courses from in-person to online course delivery modality. Inclusive teaching practices include course syllabi that set the tone for diversity and inclusion by incorporating inclusive language related to religious accommodations and usability/disability; setting expectations for valuing diverse viewpoints; sharing gender pronouns; learning and using students' preferred names; and ensuring that the course reflects our diverse societies. Offering inclusive office hours that meet at a variety of times, formats (e.g., video conference, phone call, text message, email), and structures (e.g., one-on-one and in small groups) have increased student engagement and a sense of belonging.

Motivation, persistence, and academic performance decrease significantly in an online learning environment where physical cues of acceptance are not readily noticeable. Therefore, it is imperative to cultivate a sense of belonging in the online learning environment by diversifying engagement strategies and mirroring the involvement expected of learners. Faculty, also, greet students as they enter the virtual classroom, participate in discussions along with students, ensure accurate and timely communication, emphasize professional behaviors in the virtual environment, and use virtual breakout rooms to foster student-student connection during synchronous online class sessions.

Faculty participated in several virtual professional development workshops focused on online teaching and incorporating technology into their learning environments. Additional methods were instituted to promote inclusivity to address issues of connectivity, technology, and access for students. Weekly infographics on principles of inclusion in the virtual environment were distributed to faculty. UVASON's instructional designer, also, created a webpage to share teaching continuity resources which included practices, strategies, learning technologies, and additional instructional resources.

While many of the strategies described have been in place for years, the national and global health crisis caused by the covid-19 virus forced the UVASON BSN programs to rapidly institute several resilience-oriented strategies targeted to maintain connectedness in a predominantly virtual environment while remaining safe and healthy. We instituted separate virtual orientations for 1st year students and their parents/caregivers. We believe in partnering with families to support their student's educational goals. Program expectations, pandemic safety measures, and tips for academic success were discussed during the parent/caregiver orientation. Orientations for the other student cohorts (2nd year, 3rd year, 4th year, and RN-BSN students) were established for community engagement, emotional support and encouragement, review of pandemic safety measures, equity and inclusion training (e.g., addressing racism and bias in the clinical setting and implicit bias) and clinical skills practice.

To reduce exposure to the covid-19 virus, most of the BSN courses were delivered synchronously and asynchronously online. Lab, clinical, and simulation experiences remained in-person to meet clinical hour requirements set by the state board of nursing requirements and promote collegiality among students, clinical faculty, and clinical partners. Shared learning spaces were provided to RN-BSN students for community engagement and to enable access to stable wireless internet service. RN-BSN students expressed gratitude for having a space that was conducive to learning as many of them have children learning remotely from home due to the pandemic.

Although we do not have scientific evidence to validate the impact of our resilience-oriented strategies, early anecdotal evidence (course evaluations, in addition to enrollment, admissions, and graduation trends) suggest that our resilience-oriented service model solidifies program relevancy, promotes student belonging, and enhances student recruitment and retention. By embodying this service model, we were able to maintain a sense of belongingness despite having to change from face-to-face to an online delivery format. While students have expressed feelings of loneliness because of social distancing and social isolation to reduce covid-19 exposure, they have commended the UVASON BSN program faculty and staff for their responsiveness in addressing their needs, fears, and concerns. On the occasion that a student was furloughed for exhibiting covid-19 symptoms, testing positive for covid-19, or being directly exposed to someone who has tested positive for the virus, faculty, staff, and students frequently called and/or lent a helping hand in securing basic needs such as food and medication. Our peer mentors have also played a tremendous part in helping students feel supported and connected.

We incorporated the following item into all our course faculty evaluations: “The instructor fostered an environment where I felt valued as an individual and that I belonged in the class.” In one 4th year class, the overall level of agreement (scale 1–5, with higher numbers indicating greater agreement) with that statement was 4.8/5. In addition, 58 out of 88 students entered free text responses to support their rating. A few examples include: 1) “[Professor] did an amazing job of making the virtual classroom respectful and engaging”; 2) “Professor did a great job of fostering a caring, compassionate environment geared to meeting learning needs and furthering learning. She fostered respect and inclusion in the classroom and as outlined in the syllabus and intro to the course as well. …This was seen in her case studies and discussions…”; and 3) “[Professor] created a space that felt safe and like everyone was respected.”

Despite the covid-19 pandemic, our BSN student enrollment and retention have remained steady. As a precautionary measure, we overenrolled as we expected student melt, when college-intending students fail to enroll despite admission, including deferment to the following year or program withdrawal, due to the global pandemic's effects on the economy and personal livelihood. A total of 140 BSN students (81-prelicensure and 59 post-licensure) matriculated for Fall 2020 with a melt of seven students (1-prelicensure and 6 post-licensure). A 45% increase in Fall 2021 Early Action and Early Decision applications for our pre-licensure baccalaureate nursing program was also reflected by 1220 applicants compared to 801 in Fall 2020.

The fall 2021 pre-licensure BSN class promised to be diverse. Among the early decision (binding) offers made, nearly half were to underrepresented minority (URM) students (46%). There was also a strong showing among early decision applicants who are first-generation college attendees who have accepted their offers, which exceeded our typical averages for early decision applicants. Of the 75 students admitted, 28% were first generation college attendees, 41% were non-white, 32% were from out of state, and four were men.

There are a few things that may have influenced the steady enrollment numbers, increase applications, and increased interest from URM applicants. Many became interested in the nursing profession, during the global pandemic, for job security and the desire to make a direct impact on the health of their communities. UVASON, also, dropped the requirement for standardized testing (ACT/SAT) for admission for the fall 2020–2021 and 2021–2022 academic years. While many of our resilience-oriented educational strategies were in place before the start of the pandemic, we believe that the increase in interest, applications, and enrollment attest to our resilience-oriented educational service model that champions belonging at the first point of engagement. Our inclusion efforts are action-oriented versus passive or reactive and we believe this has made a difference. Applicants and new students experience a sense of belonging through our recruitment efforts such as program information sessions where our dedication to diversity, equity and inclusion is highlighted, admission appointments, UVASON social media, and new, highly engaged student orientations to familiarize them with our school, programs, and people.

Although there is a vast amount of evidence that confirms the benefits of an inclusive learning environment (AACN, 2017; Breslin et al., 2018; Metzger, Dowling, et al., 2020), there are limited concrete examples that reflect what a learning environment that cultivates belonging and inclusion actually looks like. Cultivating a learning environment that supports belonging and inclusivity improves recruitment outcomes as well as student engagement, motivation, retention, and satisfaction. Having a resilience-oriented service model has proven to be beneficial as it reflects organizational resilience. Our program completion (graduation rates) and the pool of qualified registered nurses held steady since 2014 as demonstrated by the 4-year BSN program reflecting 96% or more graduate within four years and no more than 10% attrition within their first year. Also, NCLEX-RN pass rates reflect 95% or higher since 2017.

Resilient nursing education programs are in a better position to answer the call to prepare competent nurses to meet the challenging health care needs of diverse patient populations in the United States. Although there are no exact, one-size fits all, foolproof recipes for an inclusive resilient learning environment, there are some essential ingredients that move us in the right direction. Having these strategies underway allowed us to respond to unforeseen additional covid-19 related demands without losing our way.

Declaration of competing interest

None.

Appendix A

Table 1.

Educational services that align with resilience-oriented methods that cultivate an inclusive learning environment.

{*} Asset focused strategies: increase assets in social environment {^} Risk focused strategies: remove risk factors/barriers to learning {#} Process focused strategies: foster nurturing relationships Target groups: {S} student {F} faculty {M} staff
Strategies	Brief description	Anecdotal evidence
Early Warning Systems: Academic Action Plan ^ S	Potential problem areas are identified early and an individualized, success-oriented plan is co-created with the student.	Graduation rates remain steady at 96% or more within 4 years since 2014.
IDEA Initiative Activities: Equity and Inclusion Training *^#SFM	Holistic Admission Reviews: The Experience – Attributes – Academic Metrics (EAM) Model is used to give equitable weight to holistic admissions criteria.	Total number of enrolled undergraduate students went up 408 in 2016 to 437 in 2020 (6.6% increase). African American enrolled students increased from 32 (7.8%) in 2016 to 41 (9.4%) in 2020 (22% increase). Hispanic enrolled students increased from 9 (2.2%) in 2016 to 33 (7.6%) in 2020 (72.7% increase). Asian enrolled students increased from 35 (8.6%) in 2016 to 51 (12%) in 2020 (31.5% increase). White enrolled students went from 270 (66.2%) in 2016 to 250 (65.2%) in 2020.
	Inclusive Syllabus Workshop – Following lecture on principles of inclusion, faculty work in small groups to workshop course syllabi to incorporate DEI into readings, lectures, assignments, methods of evaluation, and principles of engagement.	Over the course of 4 years, at the beginning of each semester, 15–20 faculty attended each session and made changes to their course syllabi, including adding expectations for engagement and diversifying readings and assignments.
	Stepping In: Addressing Discrimination and Bias in Health Care – A model to identify and respond to bias is presented using videos, role playing and small group discussion.	In 2021, 61 BSN faculty, 92 3rd year, and 88 4th year students attended training.
	HEALS Training – A model for promoting respectful discussion on difference or breaches of inclusivity is presented and practiced using scenarios.	For the last 5 years, HEALS training was offered 5 times to faculty and graduate teaching assistants.
	UVA Acts Inclusive Teaching Toolkit – Applied theater is used to present a 3-part training on first days in class, lectures, and small groups.	18–24 faculty attended each session.
	Anti-Racism Workgroups – Following George Floyd's murder, we instituted workgroups co-led by faculty and students to plan actions in the following areas: implicit bias training, facilitating conversations with diverse perspectives, addressing racism in the hospital, and integrating LGBTQ+ content into courses. Groups met through the summer and fall to plan and implement strategies.	Over 40 students, staff and faculty were regular participants in Antiracism Workgroups.
	Faculty and Staff Ally Group – Allies are trained to support students who are underrepresented in nursing, including underrepresented minority, LGBTQ+, male, international students, and students with disabilities. Allies attend an annual “How to Be an Ally” workshop and attend events for underrepresented students.	An average of 34 faculty and staff commit to serve as Allies per year.
First Year Seminar: Pathway to Success Course *^SFM	This course is designed to assist first year nursing students in their transition to academic and college life. Explores academics, diversity, goal setting, lifestyle choices, healthy behaviors, responsibility and commitment in personal actions, community service, and leadership.	Quoted feedback from course evaluation: •“Allowed me to get to know fellow nursing students and also learn about different topics that I can carry with me throughout my four years of nursing school. The assignments were also very helpful in thinking about my future and goals”. •“Really helpful in getting used to college and learning about staying motivated, setting goals, managing stress, etc.” •“Puts things in perspective and gives an outlet to vent about struggles and explore ways to do better socially and academically.”
Nursing Organizations/Clubs at UVASON *#SFM	Advocates for Medical Equality (AME) is a student-run organization dedicated to increasing awareness and education of different cultural topics related to healthcare, along with encouraging exposure to marginalized groups often adversely impacted by the healthcare system.	Weekly Anti-Bigotry Info-letter sharing topics related to race and ethnicity issues, LGTBQ+ awareness, healthcare policy and accessibility, and mindfulness for nurses.
	Diversity in Nursing for a Better Community (DNBC)	Annual “If you can Dream it, you can Achieve it” Event Series aimed to give prospective nursing students the opportunity to discover more about the nursing profession and UVASON. Tour of UVASON, discussions with advisors, and open forum with current students.
	Nursing Students Without Borders	Partnered with Building Goodness Foundation to finish a Red Cross medical clinic in El Salvador.
	Men Advancing Nursing (MAN) Club Club founded by male nursing students to promote nursing as a profession.	Provide community outreach to local and surrounding areas.
	Student Nurses' Association of Virginia (SNAV) Pre-professional, student-run organization that prepares nursing students for success by fostering service, leadership, and professional nursing values.	Community outreach included canned food and toy drives, Ronald McDonald House, visiting elementary schools, and compiling care packages for soldiers.
NCLEX Review Sessions *^#SFM	Identify students who are at risk and create a plan for remediation	UVASON sponsored NCLEX Summer Prep Event held at end of spring semester. Topics included How to Review Your ATI Score Reports; NCLEX Test Overview; Building/Updating a Study Plan; NCLEX Test-Taking Strategies; Reducing NCLEX Anxiety; Content Review sessions; and Practice Question Sessions.