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Nursing as an Additional Language and Culture (NALC): supporting student success in a second-degree nursing program.


The nursing workforce does not represent the diversity of the United States population and while recruitment of diverse nursing students is high, so are their rates of attrition. The Nursing as an Additional Language and Culture Program (NALC) was implemented in an accelerated, second-degree baccalaureate nursing program to enhance retention by minimizing barriers and supporting activities to enhance student success. Results suggest that the NALC program was successful in decreasing the attrition rate of nursing students, including minority students.


Nursing Student Attrition--Nursing Student Retention--Minority Nursing Students--Second-Degree Nursing Programs


The Nursing as an Additional Language and Culture (NALC) Program for Student Success was implemented in April 2010 as a pilot study to increase retention and academic success for minority students in an accelerated, second-degree baccalaureate nursing (ABSN) program. Early data demonstrate that this program has improved the odds of success for program completion for minority nursing students.

Support for minority nursing students is important. The United States is facing a severe nursing shortage, with an even greater shortage of minority nurses. Minorities represent only 19 percent of US nurses; 6 percent of nurses are black/African American and only 3 percent are Hispanic/Latino (American Association of Colleges of Nursing, 2014). To better care for the diverse patient population in the United States, an increase in the number of ethnically and racially diverse minority health care providers is crucial. In its 2011 Future of Nursing report, the Institute of Medicine called for a diverse workforce capable of delivering high quality, culturally competent care.

Although recruitment efforts by schools of nursing have increased the population of minority students in nursing programs, retention and graduation rates continue to be disappointing. An extensive review of the literature identified that as far back as the 1990s, minority nursing students have struggled. Barriers cited in the literature include language difficulties, cultural differences, financial problems, and insufficient family support (Amaro, Abriam-Yago, & Yoder, 2006; Napierkowski & Pacquiao, 2010; Starr, 2009).

Nursing students who are linguistically diverse often do not contribute to class discussion because they are afraid of embarrassment (Fuller, 2013; Napierkowski & Pacquiao, 2010). Academic language in health care is discipline-specific and more difficult than conversational English (Fuller). However, certain strategies and interventions have been described as supportive of minority student success. These include faculty-student advisement, caring and supportive faculty, a supportive environment, tutoring, extra seminars, academic support, comprehensive education needs assessment, and study groups (Degazon & Mancha, 2012; Evans & Greenberg, 2006; Jeffreys, 2007).

This article reports on findings from the NALC program in an ABSN program. Attrition rates are compared for participants and non-participants in the program and examined by racial/ethnic groups. In addition, participants' perceptions about the helpfulness of the program are discussed.


When measured from May 2006 through May 2009 (five graduating cohorts), the ABSN program had an academic attrition rate (failure to graduate from program) of 14.4 percent for all students. Of these graduating cohorts, ethnically and culturally diverse students experienced an academic attrition rate of 22.4 percent in contrast to 2.2 percent for Caucasian students.

The NALC program was implemented to address the attrition rate for minority nursing students; however, the program was offered to all students who were offered admission to the ABSN program. NALC content was based on student needs assessment surveys, faculty and student focus groups, and literature review. The NALC program was provided over nine days, starting six weeks prior to the first day of the actual ABSN program. It focused on three broad domains: a) the languages of nursing, such as medical terminology, anatomy and physiology reviews, and medication math; b) activities designed to enhance student learning, including the development of effective reading and note-taking and test-taking skills; and c) an introduction to the unique culture of the profession of nursing and nursing education. Social activities (e.g., lunches with faculty, alumni, and peers) and smallgroup discussions intended to help develop professional relationships between students and faculty were part of the third domain.

Kolcaba's (2010) holistic comfort theory was applied to the nursing education environment and utilized during the development and implementation of the NALC program. A comfortable and supportive educational environment decreases fear and anxiety and enables the beginning of socialization into the nursing profession. By becoming comfortable with the classroom environment, the technology, and the new language and curriculum, students are further supported toward program success. Veal, Bull, and Miller (2012), in a study with ethnically diverse graduate students, found that the academic environment is important to students' feelings of acceptance and that interpersonal interactions decreased anxiety.


Data Sources/Measurement

Approval was obtained from the university's institutional review board prior to data collection. Administrative data from the university's central enrollment office were obtained for all students who enrolled in the ABSN program during the period April 2010 through September 2011. The data contained self-identified race/ethnicity, semester in which the student enrolled, and retention/withdrawal information.

Scores on the Test of Essential Academic Skills (TEAS) were merged with the enrollment data. The TEAS test, developed by Assessment Technologies Institute (ATI), was administered to all students offered admission to the ABSN program. It includes a total of 170 multiple-choice questions and is proctored and timed; according to ATI, it is a statistically proven predictor of nursing school success. Composite scores are computed in four areas: math, science, English, and reading. This study used overall TEAS scores in the analysis to control for academic skill across all dimensions evaluated by the TEAS.

At the completion of each offering of the NALC program, a survey was administered to participating students. The survey, developed by the investigators, measures students' satisfaction with the NALC program, program content, quality, and ability to ask questions; items are ranked on a four-point Likert scale, with scores ranging from excellent to poor. The survey also asks students to rate their levels of comfort with the ABSN program on a Likert scale; scores range from not comfortable to highly comfortable.

NALC program participation and race/ethnicity were the two focal independent variables. NALC participation was a dichotomous indicator of whether or not the student participated in the NALC program (1 = yes, 0 = no). Race/ethnicity was a categorical variable of whether or not the respondent reported non-Hispanic white, nonwhite, or unknown race.

Setting and Participants

The setting was a large state university with sampling from the ABSN program. Participants were 380 nursing students enrolled in the ABSN program for the study period. Of the 380 students, 98 participated in the NALC program on a voluntary basis.

Statistical Methods

Risk ratios (RR) for attrition by NALC participation were calculated separately by race/ethnicity. The Mantel-Haenszel test of homogeneity of risk ratios was used to assess whether the RR differed by race/ ethnicity. A log-binomial regression was then used to adjust the preprogram overall TEAS scores to control for academic skills in the four components of the test: reading, math, science, and English. A squared term for TEAS was included in the regression model to account for the quadratic relationship of TEAS to program withdrawal.

Relative frequencies were calculated to summarize NALC participants' responses to the postprogram survey. All analyses were conducted using Stata 12 (StataCorp, 2011); p < .05 indicated statistical significance.



Where the race of the sample was known, there was little difference between NALC participants (white, 33.7 percent; nonwhite, 35.7 percent) and nonparticipants (white, 35.1 percent; nonwhite, 31.9 percent). The mean TEAS score was 75.4 (SD = 9.2) among NALC participants and 77.8 (SD = 8.7) among non-NALC participants."

NALC participants ranged in age from 18 to 65 years, with the majority 26 to 35 years of age. Of NALC students, 15 percent indicated they spoke a language other than English at home; 28 percent were not born in the United States; and 22 percent were married. Just about all participants (99 percent) reported having "other" responsibilities at home; students stated they worked 16 to 40 hours per week. The surveys indicated that 76 percent of NALC participants had families that were supportive; 22 percent had slightly supportive families; and 2 percent had families that were not supportive.

Withdrawal Analysis

Prior to adjusting for TEAS scores, RR for attrition comparing NALC participants to nonparticipants was 0.59 for white, non-Hispanics; 0.96 for non-whites; and 1.03 for those with unknown race/ethnicity. The Mantel-Haenszel test of homogeneity indicated the difference in RR by race/ethnicity was not statistically significant (x2(2)= 0.17, p = 0.92). After controlling for preprogram TEAS scores and race/ethnicity, it was found that the overall risk of withdrawal from the program did not differ by NALC participation (RR = 0.73, p = 0.52). Among those who withdrew, there was no difference by NALC participation in whether withdrawal occurred by level 1 or a later semester (46.2 percent vs 42.9 percent, x2(1)= -02, p = 0.88).

NALC Survey

Postprogram survey results were very positive. One hundred percent of NALC students rated the quality of the content as excellent or good; 99 percent rated the delivery of content as excellent or good; and 98.1 percent rated the clarity and use of visual aids as excellent or good. Eighty-eight percent rated the faculty as excellent; 81.8 percent indicated they were "very" or "extremely comfortable" with the faculty; 100 percent indicated they were "very" or "extremely comfortable" with fellow students. Lastly, 91.2 percent reported that the NALC program met their expectations, and 99 percent reported the environment as conducive to learning.


It is important to note that this was purposeful sample. All the participants volunteered to actively engage in the pilot program study. Also, the study included only ABSN students.


Decreasing obstacles and barriers for students by providing a supportive learning environment is one way to help ethnically diverse students achieve success in nursing education programs.

In an analysis of five cohorts of students who completed the ABSN program, it was found that after adjusting for academic skill, attrition was equal between participants and nonparticipants in the NALC program; academic skill was lower among participants. This finding may indicate that the program was successful in its goal of reducing attrition as students with lower academic skill are more likely to withdraw from nursing programs (Jeffreys, 2007). Attrition rates were not significantly different by NALC participation among racial and ethnic groups, including minority students.

NALC participants also reported a high level of comfort with the faculty and fellow students and a moderate level of comfort with the nursing program, satisfying a primary objective of the program, to decrease anxiety so that learning can take place (Kolkaba, 2010). The NALC program supports previous research that concludes that culturally diverse and minority students benefit from a supportive academic and social atmosphere (Jeffries, 2007; Napierkowski & Pacquiao, 2010; Veal et al., 2012).

Additional research is needed to identify the specific needs of minority students. Expansion and continuation of this project, using a larger, more representative and comparative sample with a longitudinal study of outcomes would add validity to the findings. Data from this pilot program will continue to be evaluated. The findings of this project support the need for nursing schools to evaluate how well their programs support the retention, progression, and cultural adaption of minority nursing students.

doi: 10.5480/12-1007.1


Amaro, D., Abriam-Yago, K., & Yoder, M. (2006). Perceived barriers for ethnically diverse students in nursing programs. Journal of Nursing Education, 45(1), 247-254.

American Association of Colleges of Nursing. (2014). Enhancing diversity in the nursing workforce [Fact Sheet]. Retrieved from www.

Degazon, C., & Mancha, C. (2012). Changing the face of nursing: Reducing ethnic and racial disparities in health. Family and Community Health, 34(1), 5-14.

Evans, B. C., & Greenberg, E. (2006). Atmosphere, tolerance, and cultural competence in a baccalaureate nursing program: Outcomes of a nursing workforce diversity grant. Journal of Transcultural Nursing, 17, 298-305.

Fuller, B. (2013). Evidence-based instructional strategies: Facilitating linguistically diverse nursing student learning. Nurse Educator, 38(3), 118-121.

Jeffreys, M. R. (2007). Nontraditional students' perceptions of variables influencing retention. Nurse Educator, 32(4), 161-167.

Kolcaba K. (2010). Taxonomic structure of comfort. Retrieved from

Institute of Medicine. (2011). The future of nursing: Leading change, advancing health. Washington, DC: National Academies Press.

Napierkowski, D., & Pacquiao, D. (2010). Academic challenges for culturally diverse students. UPNAAI Nursing Journal, 6(1), 9-18.

Starr, K. (2009). Nursing education challenges: Students with English as an additional language. Journal of Nursing Education, 48(9), 478-487. doi:10.3928/0148434-20090610-01

Veal, J., Bull, M., & Miller, J. (2012). A framework of academic persistence and success for ethnically diverse graduate nursing students. Nursing Education Perspectives, 33(5), 322-327. doi:10.5480/1536-5026-33.5.322

E. Renee Cantwell, DNP, RN, CNE, CPHQ, is assistant professor and director, Accelerated BS in Nursing Program, Rutgers, The State University of New Jersey, School of Nursing-Camden. Daria Napierkowski, DNP, ANP-BC, CNE, is assistant professor, William Paterson University of New Jersey Department of Nursing, Wayne. Daniel A. Gundersen, PhD, is assistant professor, Family Medicine and Community Health, Rutgers, Robert Wood Johnson Medical School, Somerset. Zoon Naqvi, MB, BS is assistant professor, Albert Einstein College of Medicine, Bronx, New York. Contact Dr. Cantwell at for more information.
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Article Details
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Title Annotation:Research Briefs
Author:Cantwell, E. Renee; Napierkowski, Daria; Gundersen, Daniel A.; Naqvi, Zoon
Publication:Nursing Education Perspectives
Article Type:Report
Geographic Code:1USA
Date:Mar 1, 2015
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