Bill Klaproth (Host): On this podcast from AONL, we're going to talk about disparities in opportunities for nursing students who are not advantaged by race or socioeconomic status with regard to nursing education and employment; and how Beth Israel, Deaconess Medical Center recognized this and came up with an innovative solution to address the issue.

With me is Marsha Maurer, Senior Vice President for Patient Care Services and Chief Nursing Officer. Also, Rachel Bresilla, a Registered Nurse and recipient of the graduate program. And Jennifer Thomas, Nursing Director, all from Beth Israel Deaconess Medical Center.

 This is Today in Nursing Leadership, a podcast from the American Organization for Nursing Leadership. I'm Bill Klaproth. Marsha, Rachel and Jennifer, thank you so much for your time in talking with me on such an interesting and important topic. Marsha, let me start with you. So, can you first explain to us the situation with Associate Degree nurse graduates and how they were being locked out of employment, if you will, locked out of employment opportunities at Beth Israel Deaconess Medical Center, versus those receiving their Bachelor's Degree and graduating from a four year program. Can you explain this to us?

Marsha Maurer, DNP, RN, FAONL (Guest): I would be glad to, and very nice to be here. Actually if we back up even a little bit, one of the things that is true about Beth Israel Deaconess Medical Center is for years, we've been committed to hiring nurses at the Bachelor's preparation level. And that's aligned with the Institute of Medicine, Future of Nursing Goals to make sure all nurses are prepared at the Bachelor's level.

But one of the things that we learned, as we thought also diversifying our nursing workforce, which was a priority because our patients are very diverse and it's important for the care of our patients, that we also have a diverse nursing workforce, and we didn't have a very diverse nursing workforce.

But we held a series of focus groups with some of our black nurses, in particular. And one of the things we really heard was that the Associate Degree path to nursing, which is a two year program, not a four-year program is actually a more affordable path, if you pipeline in and tends to have a more diverse student body, particularly in the sort of urban ring in the Boston area.

So our policy of only hiring Bachelor's nurses, was really an impediment to us being able to recruit Associate Degree nurses. So, we were very committed to having nurses prepared at a very high level, particularly because we're an academic medical center, very sick patients, a lot of acute programs, but we didn't want to have a situation where we were blocking people out who might come in, who would have a different and more diverse background. And so that's how we went forward and said, how can we both preserve our commitment to a Bachelor's preparation, but also take advantage of this more diverse student population in the Associate Degree programs around the city and make sure they get to a Bachelor's level. So, we created this program, which is in partnership with an RN to BSN program and works with community colleges to select students for the program. So, that's how we got started a couple of years ago.

Host: That's really interesting. Well, great that you realized that and went, hey, wait a minute, here. There, there seems to be an issue here. So, I think it's great that you realized this and went, hey, we need to change something here. So I think that's great. And Jennifer, as the nursing director, how did you implement this or how did you address this or solve this issue that Marsha was just talking about?

Jennifer Thomas, DNP, RN (Guest): So to add on to what Marsha was saying a little bit, one of the things we would recommend that every organization do is take a step back and look at the organization themselves. As leaders in healthcare who are eager to employ minority and diverse nurses, we have to take an inventory of where our own house is, and this means like recognizing our own cultural and diverse biases. And considering what environment are we bringing these minority nurses into. Ensuring that we are welcoming, ensuring that we're having them feel as if they're part of the team. So one of the things we did in addition to not only speaking to our black nurses, is we paired up with some of our school of nursing in local areas to meet the minority nurses and meet the future nurses that we'll be onboarding, but also preparing our leaders in our organization about what it is to onboard minority and diverse nurses.

Host: Right. So, what were the results or what have been the results so far after implementing this program Jennifer?

Jennifer: I think we've had very positive outcomes, but we also had some learning in anticipated moments. I think one of our positive outcomes is that in the spring of 2021, we graduated successfully six, graduate nurses, for our nurse residency into our bachelor's degree program. We had an attrition of 50%. And with that attrition of 50%, we again had to take a pause, look at what we did well and what we could have done better, taking the time to talk to our nurse residents and learning what their experience was here. But I think one of the greatest things that we learned was that nurses who come into an acute care facility with an Associates Degree didn't have the same acute care experience.

And so they lack some of the experience they needed to be successful. So when we created our second cohort, we provided them with an eight week practicum, hands-on on one unit. So like, experience what it means to be a nurse in acute care facility. Also learning how to balance the work life and the commitment it takes to be an acute care nurse.

 With our second cohort, we are so far more than halfway through, have kept all 12 nurse residents on board. So, just providing that support, the clinical experience they needed and assisting them with recognizing the work-life balance.

Marsha: Can I just add a little something about the program itself, and this was out of the gate, which is that you really need to provide the supports people are going to need to be part of this program. So we hired the first, and this is the way the program works, is people get hired as a nurse in the organization and they're scheduled. They're in what they call three 12-hour shifts, but they're scheduled for 32 hours, not 36 hours.

They have four hours of protected time every week for studying that's thing one. Thing two, is that they were paying their tuition completely so full tuition. And then the third thing is we've provided mentors. So nurses who are senior nurses in the hospital, who are willing to work with and mentor our program participants.

So fundamentally having a program that really supports folks who are in it so that they have time to study, so that they're not overly stressed, so that they have resources, was a really important element of the program. And when I think about things like how other people have, you have to make a big, you have to make a financial commitment to doing this. You have to make a commitment to creating a certain environment that's supportive, but you, you literally need to make the investment that supports people to be successful.

Host: Yeah, that makes sense. Making sure that you have the environment where someone can learn and grow in it, I think is really important. And Rachel, you're a graduate of this program. You're like the star of the moment. So, this is great. I love this, that you're here to talk with us today, joining Jennifer and Marsha. So, since you are a graduate of the program, can you share your experience with us?

Rachel Bresilla, BSN, RN (Guest): Yes, I am definitely a proud graduate of the first cohort. And just being part of this nurse residency program has truly been one of the highlights of my life. I was able to successfully complete the nursing the program while benefiting from all of the built-in support that Jenny and Marsha touched upon and gaining truly the best nursing experience at our medical center. It's allowed me to grow in the clinical setting, but has also given me several opportunities to engage on the leadership front. I've been able to participate in unit and central council and just really be able to tap into some leadership skills and Marsha, Jenny, and just all the different folks we have involved in the program have all just led the way and set a tremendous example.

Host: You know, everybody's just looking for an opportunity to be a part of a organization and learn and grow. And this program, it sounds like it certainly has done that for you. So, correct me if I'm wrong, Marsha, before you started this program, someone like Rachel would have been shut out because she didn't have a four year Bachelor's degree? Is that right?

Marsha: Exactly. She would actually have not if she'd applied for a position, she wouldn't have been interviewed because she didn't have that BSN, yes.

Host: Wow. This is such a great program. So, I know there are people listening to this going, you know, this is really great, what Beth Israel Deaconess Medical Center did. How can I do that? So Marsha can, how would someone else duplicate or set up a program like this? Help us out with that.

Marsha: Well, I do think, you know, one of the early steps and Jenny can jump in, cause she was part of some of this too, but we had to find an academic partner who would be a good partner for us to work with. Now we happen to work in a very college and university rich area here in the Boston. So you literally can throw a stone to a couple of different schools.

And we were fortunate that Emmanuel College, which literally is down the street from the hospital, had such a program, but we were paying attention to what would be a geographically nearby organization so that it would be convenient for our participants to be able to go to class. Although, Rachel could talk a little bit about how COVID threw a wrench into her early experience, but, lots of things went virtual.

So that was important at the time. But all the things going on in Zoom might mean that you could be a little more broad in who you partner with. So, we had to find a partner and then we also had to go out to each of the local community colleges to do the recruiting for potential applicants. So, that was a partnership with our Workforce Development Department, going out meeting with different community hospitals.

So really laying that groundwork of both where are we going to get potential program participants from, the community colleges, who are we going to partner with, in this case, Emmanuel College. So we had to build all of that infrastructure. And then, like I said, making an organizational commitment to supporting people's tuition, buying people's books, having their protected time, you know, really sticking with that.

Having mentorship and leaders like Jenny who have time protected to build the program, you have to make those investments. Then I'd say even for myself to be continually paying attention. Rachel described that she's involved in our professional governance or unit-based council and our central councils, and she definitely took the initiative of that.

But for me as a CNO, paying attention to our graduates and thinking about future opportunities. So, Rachel's now sitting on a system-wide mission strategy work group, which I nominated her for because I'm always thinking, okay, now we have students who came from community college. Now they've gone through our program. They're showing leadership and skills. Where can I give them more opportunities? So it doesn't stop after someone graduates or it doesn't stop after someone just gets in the program.

Host: Right. That's a really good point. And Jenny, as Marsha said, you really helped to build this program. Was there anything that you learned that you didn't think that you would have learned or are there any lessons you can share with us that, you know, you came, that you discovered along the way that would be helpful for us?

Jennifer: Yes. As a nurse, one of the things we always do is we say we assess our patients. You always go back to assess your patients. But as a nurse leader, I think sometimes we forget to assess or reassess. And I think the biggest thing I learned from cohort one to cohort two was taking the time to reassess the program instead of feeling defeated by losing, you know, a good amount of students the first time around, but taking the time to assess what we did well and what we could, what we could have done better, but also taking the time to provide the first cohort an opportunity to talk and listen, reassessing and listening to how they can, they added to our program to make the cohort second, the second cohort, even better. So really just not knowing, not having the answers and being okay with that, but taking the time to work with a team and work with the primary team to see what is best for the students.

Host: Right. That's a really good point. And Rachel, I'm just curious from your point of view, being a graduate of the program and being on the floor every day with patients, how do you think this has affected patient care overall for the better? Give us your thoughts on that.

Rachel: It's definitely allowed us to just provide better culturally competent care. I have the amazing opportunity of just serving a variety of patients from all kinds of different cultures and backgrounds and one of the things that I experienced that just never gets old is the sigh of relief or just the feeling of ease that a patient of color experiences when they learn that I'll be their nurse.

It's a weight of trust that I feel like is instantly placed on me. But it's also an honor because I just am able to advocate for them a little bit differently by just being able to connect a little bit more on the cultural level. My family's from Haiti and I'm Haitian and Boston, we have a large Haitian population. So, often I'm caring for patients who look like my parents and speak our language. So that's also always an honor to just be able to connect with them and be able to just kind of add a little bit of special touches to the care that I provide. So I think, my other cohort members who are from different parts of the country also share that same sentiment. So, I think it all comes together and just really benefits the patient and the care that we provide when our nursing staff is diverse.

Host: Yeah, thanks for sharing that with us. That's a great thought. As you said, you know, patients are breathing kind of a sigh of relief when they know that you will be caring for them and how you carry that weight of trust. I think that's really cool. And I think that's probably what you were hoping to find right, when you started this program?

Marsha: That is definitely what we were looking to happen. I'm actually feeling a little choked up listening to Rachel, say that. That's such a great outcome. But you know, for me back to learning too, I think that I went into this understanding there were a lot of structural barriers to racial equity and to people's being able to be entering the profession, but I will say even through this, I came to understand, for example, this issue that Jenny's brought up where the Associate Degree program didn't always prepare people adequately to work in the acute care setting. Well, most of the acute care hospitals in the Boston area don't have associate degree nurses doing their clinical placements in like the tertiary medical center, we tend to reserve those and have for years reserved those clinical placements for the Bachelor's programs. And so it's a sort of a double do in terms of not getting the experience that one needs to be comfortable in the acute care environment. You know, Jenny described that we sort of, in the second cohort, we dealt with that by adding what really was kind of the equivalent of a senior practicum that you would get in a Bachelor's program. Adding that to the program, again, another investment, but it really opened my eyes as well to just the depth of the way different ways we've structured things, create barriers for people to access our hospital.

Host: So Marsha, when you're talking about racial equality and quite frankly, when you're talking about barriers, there's a barrier to some people getting in, if you will. When we talk about systemic racism in this country, that's kind of what it is. Nobody's really outwardly racist, but programs are built where it's tougher for people to breakthrough. And what you've done is you broken that wall down and you're making it easier for people to get in and participate in the workforce. Is that a fair statement?

Marsha: I think it is a fair statement. And I think too, that, you know, so we recognized that there was this barrier, that the Associate versus Bachelor's Degree, but I also want to emphasize that there is a real difference in preparation in a two year program or four year program. So, the line we were trying to stay on here was to both make sure people had the preparation they needed to be safe and successful in our environment, but also create a way in for folks from an Associate Degree program where you might be economically less advantaged, in terms of accessing an academic medical center. So, we tried to balance both those things. And I think we did. I think we've done that. And really a challenge now is to just keep expanding, to continue to run a program every year to expand the program in terms of the number of entrants, it's that support the whole way through.

It's not just a program that gives someone tuition reimbursemen. It's really designing a program that's going to maximally make successful the program participants.

Host: So, right. So, when we talk about being fair and just in achieving racial equality, it's looking at our programs like you have done and going, you know what, this isn't really structured right. We need to structure it a little bit differently.

Marsha: The thing too is that the climate we're in was favorable in the sense that when I raised the issue with the program and the institution has to make financial commitment to this program. And even at some other point in history, the institution being willing to make the full tuition, reimbursement payment, to have protected time for studying. I think the awareness everybody's having in the United States right now about social justice, about racial inequity, created more support so that when I went to people and said, I want to do this program and this is how I want to do it, the state of readiness was much better than it might've been even five years ago.

Host: So true. Well, I want to thank the three of you for this great discussion. And before we go, I would like to ask each of you the same question. Just kind of give you the floor and give you the opportunity to add anything you want to add that maybe we haven't talked about. Marsha, let's start with you. Any final thoughts?

Marsha: Well, I would really encourage folks to make this commitment. I would really encourage people to think about how people can access their enterprise and think about what investments one could make and what levels of support one could give to really have people be successful because there is a long history of people not having those supports.

Host: Absolutely. And Jennifer, how about you? Any final thoughts?

Jennifer: My final thought is is that as a minority nurse working in this organization, I often sat at the table and thought, why am I the only one who looks like me at this table? But this program has provided me the opportunity to bring a few of my peers and realizing that the influence I can have as a single minority to have other minorities join the team and be part of the team and feel part of the team and educate them through it all. I think that's also really important, sometimes even how lonely you may feel being at the table, the importance of staying at the table and that retention to retain more minority nurses.

Host: Yeah. You've got a purpose to serve. There's no question about that. So thank you for that. Rachel, let's wrap up with you as a graduate of this program. Any final thoughts? Anything you want to add right now?

Rachel: Just in nursing, one of the things we really pride ourselves in is providing holistic care to our patients. And an important part of that is the cultural component. And this program addresses it. And I think through a layered approach, it's possible for other organizations to model this program and create just different entryways for nurses of color to really just succeed and participate and contribute to cultural competence.

Host: Right. And I think the bottom line here is the overall message is, is you are delivering better patient care. And that's really what you're after, right? Is to take care of people better. So, that's certainly a, an, another benefit of this program is better patient care as well. So thank you again, the three of you for this great discussion, Marsha, Jennifer and Rachel. Thanks again. We appreciate it.

Marsha: Thank you for having us.

Jennifer: Thank you.

Rachel: Thank you.

Host: And once again, that's Marsha Maurer, Rachel Bresilla, and Jennifer Thomas. And for more information, please visit aonl.org. And if you found this podcast helpful, please share it on your social channels and check out the full podcast library for topics of interest to you. This is Today in Nursing Leadership. Thanks for listening.