George_536 Online Journal of Rural Nursing and Health Care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.536 209 Predictors of Success in a Graduate Nurse Practitioner Program Tracy P. George, DNP, APRN-BC, CNE 1 Allison C. Munn, RN, PhD 2 Sarah H. Kershner, PhD, MPH, CHES 3 Tiffany A. Phillips, DNP, NP-C 4 1 Assistant Professor, School of Health Sciences, Francis Marion University, tgeorge@fmarion.edu 2 Assistant Professor, School of Health Sciences, Francis Marion University, amunn@fmarion.edu 3 Assistant Professor, School of Health Sciences, Francis Marion University, skershner@fmarion.edu 4 Assistant Professor, School of Health Sciences, Francis Marion University, tphillips@fmarion.edu Abstract Background: Prior research studies on the predictors of success in nurse practitioner programs have not focused on students in rural areas. Purpose: The purpose of this study was to examine factors that influence student success in a rural nurse practitioner program in the Southeastern United States. Methods: Admission data from family nurse practitioner students at a rural university were obtained from a secured drive and transcribed into an Excel spreadsheet. Bivariate analysis using independent t-tests for continuous variables and chi-square tests for categorical variables was Online Journal of Rural Nursing and Health Care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.536 210 conducted to determine group differences between successful and unsuccessful students by demographic and education factors. Results: A total of 84 students were enrolled in the family nurse practitioner program, including 70 (83.3%) females and 14 (16.7%) males. Student demographics included 15 (17.9%) African American, 67 (79.8%) Caucasian, one (1.2%) American Indian or Alaska Native, and one (1.2%) Asian, with 67 (80%) residing in the local rural Pee Dee Region. Of the 84 students, 49 (58.3%) successfully completed the program and 35 (41.6%) were unsuccessful and either withdrew or were dismissed. African American students had decreased rates of program enrollment and completion compared to Caucasian students, with only 3 (20%) of the 15 enrolled students successfully completing the program. Conclusions: Identification and examination of sociodemographic and education factors influencing student success in southeastern rural nurse practitioner programs may improve overall program completion rates, facilitate program success for minority students, and increase the diversity of the nurse practitioner workforce. Keywords: academic success, nursing students, school admission criteria, nurse practitioner Predictors of Success in a Graduate Nurse Practitioner Program Nurse practitioners (NPs) have been vital in providing healthcare in rural and underserved areas where primary care provider physician shortages are most prevalent (Streeter, Zangaro, & Chattopadhyay, 2017). The United States (U.S.) Health Resources and Service Administration (HRSA) recently released primary care physician workforce data for 2013 and projected models for workforce supply for the year 2025. Prediction models forecast significant shortages in U.S. Midwest and southern regions with an expected deficit of over 700 primary care physicians in the Online Journal of Rural Nursing and Health Care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.536 211 state of South Carolina (Streeter et al., 2017). According to the American Association of Nurse Practitioners (AANP) (n.d.), 86.6% of NPs are certified in a primary care area with 77.8% providing primary care. In order to continue to meet the nation’s healthcare needs, nurse practitioner students must successfully complete a graduate nursing program and subsequently pass a certification examination. Graduate nurse practitioner students who are from rural areas and attend a local rural-based graduate nurse practitioner program are likely to both reside and practice in the region after completing their program of study (Skillman, Kaplan, Andrilla, Ostergard, & Patterson, 2014). In order to retain local rural-dwelling students, it is important to understand the factors most important to student success in rural graduate family nurse practitioner programs. The U.S. Census Bureau (2010) defines rural as the population, housing, and territory not included in an area with at least 50,000 residents. Although the county in which the university is located has more than 50,000 residents, the city comprises the majority of the population with approximately 37,778 residents in 2017 (U.S. Census Bureau, 2017). The remaining residents are spread throughout nearly 800 square miles of small towns and rural farmlands. The graduate program is comprised of both online and on-campus curriculum components, and many commuter students live in surrounding counties that are designated as rural by the Federal Office of Rural Health Policy (Health Resources and Services Administration [HRSA], n.d.a.). The Pee Dee region that surrounds the University is a largely rural area comprised of 12 counties (HRSA, n.d.b). Eight of the 12 counties are designated as rural, with three counties having portions of the counties defined as rural. Only one county in the region is not designated as being rural (HRSA, n.d.b). The South Carolina Department of Health and Environmental Control, Bureau of Community Health and Chronic Disease Prevention ([SC,DHEC,BCHCDP], 2016) provided statistical information on the population and health rankings for this region. The region Online Journal of Rural Nursing and Health Care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.536 212 is 59% Caucasian, 35% Black, 4% Hispanic, and 2%. Seven of the 12 counties in this region of the state rank in the bottom third of county health rankings. Three counties in the region are designated health provider shortage areas with between 16% and 25% of county residents reporting inability to access a health care provider due to cost. The above data indicates there is a need for more nurse practitioners to meet the healthcare needs of this rural, underserved region. Three factors found to predict student success in graduate nursing programs were the admission grade point average (GPA), nursing GPA, and undergraduate science GPA (Ortega Burns, Hussey, Schmidt, & Austin, 2013; Patzer et al., 2017). Similarly, undergraduate GPA has been found to be indicative of graduate GPA (El-Banna et al., 2015). At a large, public, Midwestern urban university, a formula for graduate doctor of nursing practice admissions was developed, which included a weighting of 70% for GPA, 15% for the professional statement, and 15% for the three recommendation letters (Creech & Aplin-Kalisz, 2011). A national investigation of rural nursing programs found barriers to student recruitment included program expense, distance of commute to campus, and work schedule considerations (Skillman et al., 2014). However, there is limited data on barriers to program completion or factors contributing to student success in those rural nurse practitioner programs. There is a need for more research on the predictive factors for graduate nursing success. Prior research studies on the predictors of success in nurse practitioner programs have not focused on students in rural areas. The purpose of this study was to examine data on the factors that influence student success in a rural nurse practitioner program in the southeastern US. Theoretical Framework Tinto’s Model of Student Departure provides a framework for considering the predictors of student attainment and persistence (Tinto, 1993). According to Tinto, a student’s decision to Online Journal of Rural Nursing and Health Care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.536 213 withdraw from a university occurs due to both student characteristics, including pre-entry attributes and goal commitments, and his or her academic, environmental and social integration in an institution. Pre-entry attributes include factors such as family background, abilities, skills, and prior schooling. Goal commitments refers to the intentions of the student when entering the program and external commitments by the student to family, friends, work obligations, and others. Tinto (1993) identified that African American students, students from low-income families, and adult students required individualized interventions to decrease attrition. Although Tinto’s model was originally designed for undergraduate students, it may be applicable to graduate nursing students. Methods Data collection. The study was conducted through academic admission record review of family nurse practitioner students at a rural, public university in the southeastern US with expected graduation dates of December 2016 and December 2017. Approval for the study was received from the University’s Institutional Review Board. The protocol approval number is 09-26-2017-008. Data were extracted from a secured drive and transcribed into an Excel spreadsheet, with the collected data providing program information for the phase I analysis of a multi-phase study. A small sample size was expected due to few cohorts with both program admission and completion information. Phase I included extraction of pre-entry attributes data from both successful (program graduate) and unsuccessful (non-program graduate) students and included demographic and education variables (Table 1). Table 1 Study Variables Online Journal of Rural Nursing and Health Care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.536 214 Variable Name Classification / Categories Determination Variable Level Dependent Outcome Variable Success Success = graduated Program completion and exit data Nominal Non –success = Withdrew or dismissed Demographic Outcome Variables Gender Male Self-identified in admission record Nominal Female Race White or Caucasian Self-identified in admission record Nominal Black or African American American India or Alaska Native Asian Ethnicity Hispanic / Latino Self-identified in admission record Nominal Non-Hispanic Latino Age N/A represented as Mean (SD) Birth Year in record Ratio Education Independent Variables College/University where obtained BSN Study Site Official Transcripts Nominal Other SC College/University i Non-SC Based College/University ii RN to BSN Status Previously completed a RN to BSN program (Yes/No) Official Transcripts Nominal BSN GPA N/A represented as Mean (SD) Official Transcripts Ratio Miles from campus N/A represented as Mean (SD) Permanent address in admission record Ratio Rurality iii Pee Dee Residents HRSA Grant Eligibility Nominal Non-Pee Dee Residents Undergraduate Course Grade Point Average (GPA) Microbiology N/A represented as Mean (SD) Official Transcripts Ratio Anatomy N/A represented as Mean (SD) Official Transcripts Ratio Physiology N/A represented as Mean (SD) Official Transcripts Ratio Science iv N/A represented as Mean (SD) Official Transcripts Ratio Masters of Science of Nursing (MSN) MSN GPA N/A represented as Mean (SD) Official Transcripts Ratio i Includes 7 South Carolina based colleges or universities. ii Includes 9 non-South Carolina based colleges or universities. iii Rurality defined as HRSA Grant Eligibility (HRSA, n.d.b). ivAverage GPA for undergraduate science courses: Anatomy, Physiology, & Microbiology. Online Journal of Rural Nursing and Health Care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.536 215 Data analysis. Data were de-identified in the Excel spreadsheet and imported into SPSS Statistics for Mac (Version 24.0). Data were screened for missing values, outliers, potential transcription errors, and normality. Descriptive statistics were computed for student demographic variables and education characteristics. Independent t-tests and chi-square tests were used to determine differences between successful and unsuccessful students. For the variables of race and location of undergraduate BSN institution (study site or within/outside of the state of South Carolina), those categories with very few students were collapsed to strengthen the chi-square analysis. Undergraduate Anatomy, Microbiology, and Physiology GPA were combined into an Undergraduate Science GPA variable. Group differences were reported using 95% confidence intervals and alpha was set at 0.05. Results During the study time period, 84 students were enrolled in the family nurse practitioner program, including 70 (83.3%) females and 14 (16.7%) males. Of these students, 15 (17.9%) were African American, 67 (79.8%) were Caucasian, one (1.2%) was American Indian or Alaska Native, and one (1.2%) was Asian. Eighty percent of these students provided permanent addresses in the admission record that corresponded to a location in the rural Pee Dee Region. Bivariate analyses (Table 2) revealed that 49 (58.3%) of the enrolled students successfully completed the program, with 35 (41.7%) exiting the program unsuccessfully. Of the 15 enrolled African American students, 12 (80%) were unsuccessful in completing the program compared to 23 (34.3%) Caucasian students (p = 0.003). Additionally, students who were unsuccessful in program completion were older and had a mean age of 38.7 (10.9) years compared to 35.6 (8.7) Online Journal of Rural Nursing and Health Care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.536 216 years for successful students (p = 0.2). Undergraduate BSN institution was a non-significant factor, as was the mean number of miles students lived away from campus. Mean undergraduate BSN GPA was higher for successful students 3.5 (SD = 0.36) when compared to unsuccessful students 3.36 (SD = 0.39) (p = 0.1). Although age and BSN GPA were non-significant factors, there are apparent differences between the groups that may be significant in a larger sample size of the population. Table 2 Student Characteristics Overall and by Level of Success (graduated vs. did not graduate) Variable n (%) Overall (n=84) Level of Success p-value Did Not Graduate (n=35) Graduated (n=49) Gender 0.6 Male 14 (16.7) 5 (35.7) 9 (64.3) Female 70 (83.3) 30 (42.9) 40 (81.6) Race 0.003i White or Caucasian 67 (79.8) 23 (34.3) 44 (65.7) Black or African American 15 (17.9) 12 (80) 3 (20) American Indian or Alaska Native 1 (1.2) 0 (0.0) 1 (100) Asian 1 (1.2) 0 (0.0) 1 (100) Ethnicity NA Hispanic/Latino 1 (1.2) 1 (100) 0 (0.0) Age, mean (SD) 36.9 (1.1) 38.7 (10.9) 35.6 (8.7) 0.2 Rurality 0.3 Pee Dee Resident ii 67 (80) 26 (38.8) 41 (61.2) Non-Pee Dee Resident ii 17 (20) 9 (52.9) 8 (47.1) BSN College/University 0.3 Study Site 43 (51.2) 18 (41.9) 25 (58.1) Other SC College/University iii 27 (32.1) 9 (33.3) 18 (66.7) Non-SC College/University iv 14 (16.7) 8 (22.9) 6 (42.9) RN to BSN 38 (45.2) 16 (45.7) 22 (57.9) 0.9 BSN GPA, M (SD) 3.45 (0.38) 3.36 (0.39) 3.5 (0.36) Miles from campus, M (SD) 41.1 (3.2) 42.8 (27.6) 39.9 (30.7) 0.7 Undergraduate Course / Science GPA Microbiology 3.0 (0.1) 3.0 (0.8) 3.1 (0.8) 0.6 Anatomy 3.1 (0.1) 3.0 (0.9) 3.2 (0.8) 0.2 Physiology 3.1 (0.1) 3.1 (0.7) 3.1 (0.7) 0.8 Science v 3.1 (0.1) 3.0 (0.7) 3.2 (0.6) 0.4 Masters of Science Degree (MSN) GPA Online Journal of Rural Nursing and Health Care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.536 217 Variable n (%) Overall (n=84) Level of Success p-value Did Not Graduate (n=35) Graduated (n=49) MSN 3.3 (0.1) 2.2 (0.7) 3.7 (0.2) <0.001 i P-value obtained for 3 categories: White, Black, & Other (American Indian or Alaskan Native, Asian). iiDetermined by reviewing student home zip codes and counties listed in “Pee Dee Region” as defined by South Carolina Department of Health and Environmental Control (n.d.) Regional Health Care Coalitions. iii Includes 7 South Carolina based colleges or universities. iv Includes 9 non-South Carolina based colleges or universities. v Average GPA for undergraduate science courses: Anatomy, Physiology, & Microbiology. Discussion Analysis of program admission data revealed suboptimal program completion rates for local Pee Dee residents and African American students. Additionally, students with mean undergraduate GPAs below 3.5 were less successful in program completion. There were no conclusive demographic or education factors for program success among the students. African American nurse practitioners are underrepresented in the workforce and in graduate nurse practitioner programs despite the need for a more diverse nursing workforce to meet the nation’s healthcare needs (National League for Nursing, 2016). Membership demographics for the AANP (2010) revealed that 90.3% of members are Caucasian. In a 2016-2017 national survey, 13.9% of students who graduated from master’s in nursing NP and post-master’s NP programs were African American, while 66.0% of students were Caucasian (American Association of Colleges of Nursing, 2018). The program completion rates do not correspond with the nearly 40% of ethnic minorities representing the U.S. population and local community (SC, DHEC, BCHCDP, 2016; U.S. Census Bureau Quick Facts, 2017). Supporting minority students to successfully graduate nursing programs is of great importance in order to develop nurse practitioners that represents the demographics of the surrounding population and meet the healthcare needs of rural diverse communities. Understanding factors that positively and negatively influence minority student success can aid graduate nursing programs to support and respond to the unique needs of rural minority students. Online Journal of Rural Nursing and Health Care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.536 218 For this Phase I analysis, barriers for rural and African American students for successful program completion were not clear given the information available in the academic admission records. Thus, a Phase II qualitative study is planned to investigate barriers and facilitators to successful program completion for African American students who have previously been enrolled in the program. Phase II will include focus group sessions led by African American nurse practitioners to interview former African American students to discuss both program and socio-demographic factors that influenced their success in the program. Several themes have been cited in the literature as barriers to minority student success. Isolation and loneliness, discrimination and a lack of cultural competence by faculty, peers, patients, and staff, and lack of emotional and advisory support have been frequently identified in the literature (Loftin, Newman, Dumas, Gilden, & Bond, 2012; Murray, 2015; Veal, Bull, & Miller, 2012; Gardner, 2005). These themes, highlighting a lack of social integration, are consistent with factors identified in Tinto’s Model of Student Departure as influencing a student’s decision to depart from an institution (Tinto, 1993). Factors associated with minority student success includes program and personal factors. The presence of academic support, mentoring, and a minority student association are positive program factors (Loftin et al., 2012; Murray, 2015; Veal et al., 2012). Integration and inclusivity within the program and among peers is also very important (Murray, 2015; Veal et al., 2012). Academic progression, defined as successfully obtaining knowledge and proceeding to the next course, helps instill confidence (Veal et al., 2012). Personal characteristics associated with success include determination, overcoming obstacles, and a resolve to succeed (Loftin et al., 2012; Gardner, 2005). These factors showing positive social, academic, and environmental integration and positive intentions by students are consistent with the elements of Tinto’s Model of Student Departure Online Journal of Rural Nursing and Health Care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.536 219 found to support student retention (Tinto, 1993). Phase II findings will be analyzed and interventions will be tailored to meet the specific needs of rural and African American students in the program in an effort to increase student success. Limitations Although the generalizability of the phase I results is limited due to sampling from one rural nurse practitioner program and a small sample size, findings revealed important group differences and warrant further investigation. The limited nature of the information available in the admission record hindered understanding of the influence of programmatic and socio-demographic factors on both overall and African American successful program completion. In response to these limitations, a Phase II qualitative exploration is planned to gain understanding of barriers and facilitators to successful program completion. Although location of the institution and distance of student residence from campus were non-significant in this analysis, focus group sessions may reveal additional barriers unique to rural-dwelling students and their access to program support services. Additionally, future study phases will include replication of the quantitative analysis and a logistic regression analysis using a larger number of student cohorts to increase power and generalizability of findings. Conclusion Decreased successful program completion rates overall and for both rural and African American students in a southeastern US rural graduate nurse practitioner program are not well understood by examination of admission factors and criteria. However, understanding barriers and facilitators to successful program completion for African Americans is vital to providing tailored support for these minority graduate students. There is a need for more research to better understand the perceived beliefs and barriers experienced by rural minority students and how those beliefs are Online Journal of Rural Nursing and Health Care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.536 220 related to successfully completing a family nurse practitioner program. Focus groups with successful and unsuccessful nurse practitioner students may provide qualitative data on this population and pathways to support minority student success. By identifying and ameliorating the factors associated with minority student success, it may be possible to increase minority students’ graduation rates and to ultimately see the number of minority advance practice registered nurses increase to be more representative of the population being served. References American Association of Colleges of Nursing. (2018). 2017 - 2018 enrollments and graduations in baccalaureate and graduate programs in nursing. Washington, DC: American Association of Colleges of Nursing. American Association of Nurse Practitioners. (n.d.). NP fact sheet. Retrieved from https://www.aanp.org/all-about-nps/np-fact-sheet American Association of Nurse Practitioners. (2010, May). 2010 membership demographics. Retrieved from https://www.aanp.org/research/10-research/146-member-demographics Creech, C. 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