Health Careers Exploration Club: Improving the Healthcare Workforce Kara Perry Parker College of Nursing, East Carolina University Doctor of Nursing Practice Program Dr. Krystle Vinson April 14, 2023 Notes from the Author I want to extend my gratitude to my project site champion for her expertise and support during the entire process of this project to make it a success. Also, thank you to the project site staff for their help and knowledge in assisting with the health careers exploration program. Lastly, thank you to the youth for their dedication and efforts during the program and for feedback refining the continuation of the project. To my faculty member, thank you for your continued guidance throughout the project planning, implementation, and evaluation. Thank you to my family for supporting me during this project's planning, implementation, and evaluation. This project is dedicated to my three children as a constant reminder that every child should have equal opportunities in life. Abstract Career exploration programs introduce fundamentals of career pathways to youth and help them explore career interests, employment, and academic advancement. Youth from lower socioeconomic status (SES) have fewer opportunities to gain exposure and achieve employment, which largely impacts health outcomes through lower education achievements, employment opportunities, financial security, and access to health care. It directly impacts the healthcare workforce's diversity, negatively affecting minority healthcare outcomes. This project was reimplemented using an evidence-based curriculum and feedback from the initial project to conduct a health careers exploration club for middle/high school minority youth from lower SES. The program consisted of ten sessions focused on healthcare occupations by exploring interest profiles, financial knowledge, college/career readiness, and community/academic resources. The outcomes data reinforced the project's objectives to increase the youth’s preparedness to succeed in academics and careers to improve overall health and well-being. By the end of the program, 100% of the participants self-reported increased knowledge and interest in healthcare careers, and 80% reported improved college/career self-efficacy. Future project implementations should include exposure to various healthcare career employees and mentorships. This can be achieved through expanding partnerships within the community through the project site, local community college/university, and the major healthcare system. As the project grows and partnerships strengthen, more youth will be influenced by the program's positive outcomes, improving individual health and well-being and the communities they serve. Keywords: middle school student(s), high-school-student(s), after school, out of school, career development, career planning, health pipeline, health pathway Table of Contents Notes from the Author 2 Abstract 3 Section I: Introduction 6 Background 6 Organizational Needs Statement 6 Problem Statement 9 Purpose Statement 9 Section II: Evidence 10 Literature Review 10 Evidence-Based Practice Framework 19 Ethical Consideration and Protection of Human Subjects 21 Section III: Project Design 23 Project Site and Population 23 Project Team 25 Project Goals and Outcomes Measures 26 Implementation Plan 34 Timeline 34 Section IV: Results and Findings 36 Results 36 Discussion of Major Findings 40 Section V: Interpretation and Implications 43 Costs and Resource Management 43 Implications of the Findings 45 Sustainability 47 Dissemination Plan 47 Section VI: Conclusion 48 Limitations 48 Facilitators 50 Recommendations for Others 50 Recommendations for Further Study 53 Final Thoughts 54 References 55 Appendices 63 Appendix A: Health Careers Exploration Club Flyer 63 Appendix C: Health Careers Exploration Club Questionnaire 64 Appendix D: Health Career Exploration Club Participant Application and Consent 65 Appendix E: Health Career Exploration Club: Pre-survey for Participants 67 Appendix F: Health Career Exploration Club: Program Evaluation for Participants 69 Appendix G: Session Evaluation Tool 72 Appendix H: Team Member Post-Implementation Evaluation Tool 73 Appendix I: Project Timeline 74 Appendix J: Outcomes Measures: Knowledge and Interest 75 Appendix K: Outcomes Measures: Self-Efficacy 76 Appendix L: Project Budget 77 Appendix M: Doctorate of Nursing Practice Essentials 78 Section I. Introduction Background The afterschool program (Boys and Girls Clubs of the Coastal Plains [BGCCP], n.d.-c.) is a non-profit organization that serves at-risk youth ages 6-18 by providing afterschool and summer programs to help them develop skills to succeed throughout their life. Moreover, the afterschool program (BGCCP, n.d.-a.) serves seven counties in Eastern North Carolina, with five locations across Pitt County. The program offers services to help the youth learn essential skills to succeed academically and in everyday situations. Goode & Landefeld (2018) identify a need for more diversity in healthcare. According to the U.S. Bureau of Labor Statistics (2021, September 8), healthcare employment opportunities will increase by 16 percent from 2020 to 2030. However, youth may be unfamiliar with the different disciplines that encompass healthcare. As the country's demographics shift, more underserved populations need representation in the healthcare workforce to care for disadvantaged communities properly (Goode & Landefeld, 2018). Thus, a program that targets at-risk minority youth in seventh through ninth grade by exploring healthcare careers through a curriculum-based course will inspire and direct the population to seek employment in healthcare. Targeting this population will improve the healthcare workforce, diversify healthcare, and improve the health of underserved communities. Organizational Needs Statement The organization strives to provide youth with opportunities and education that they would not necessarily have the chance to participate in if it was not for this organization (Director of Strategic Partnerships, personal communication, February 24, 2022). Recent studies demonstrate that middle school is a vital time for youth to explore careers and prepare for college enrollment; however, few interventions target career exploration in middle school students (Glessner et al., 2017). Research also shows that youth from a lower socioeconomic status (SES) have higher dropout rates and fewer educational opportunities, which negatively impacts their communities by further enhancing the SES gap (American Psychological Association [APA], 2017). The combination of low SES youth having fewer opportunities to obtain information about college, higher student loan debt, fewer career aspirations, and lack of adequate preparation for employment negatively impacts this student population compared to higher SES youth (APA, 2017). North Carolina developed an initiative to have two million North Carolinians ages 25-44 obtain a postsecondary degree or credential by 2030 to help close the education gap (MyFutureNC, n.d.-a.). MyFutureNC (n.d.-a.) projects that over half of the jobs in North Carolina will require education beyond a high school diploma over the next few years and forecast healthcare and social assistance careers to grow by 135,000 jobs. Postsecondary enrollment in North Carolina in 2019 was 41%; however, among multiracial, blacks, Hispanics, and American Indians, the enrollment was below the average (MyFutureNC, n.d.-b.). Furthermore, first-year persistent rates, a continuation in postsecondary education after the first year, were lower among individuals from lower SES (MyFutureNC, n.d.-b.). Pitt County's postsecondary enrollment was above the average at 66% compared to 62% of the neighboring counties, but the persistence rate was slightly lower at 77% versus 78% for neighboring counties (MyFutureNC, n.d.-c.). However, of those enrolled in postsecondary education, only 50% graduated within six years, which is below the average for suburban counties (MyFutureNC, n.d.-c.). MyFutureNC (n.d.-c.) identifies goals specifically for Pitt County, including improving high school graduation rates within four years, increasing postsecondary completion rates, and improving college-and-career reading performance in third through eighth-grade students. One way to achieve the goals set by MyFutureNC (n.d.-a.) is to strengthen the preparedness for postsecondary enrollment of middle school students by targeting scholastic and social-emotional readiness. The Institute for Healthcare and Improvement (IHI, n.d.-b.) Triple Aim's objectives are to enhance patient care, enhance population health, and decrease the cost of health care. Lower levels of education have been shown to correlate directly to adverse health outcomes. Gefter et al. (2018) found there is a disparity in minority healthcare professionals, and findings have shown that patients are more prone to select healthcare providers from similar backgrounds. Increasing healthcare workers from lower SES backgrounds will help to positively influence this patient population and healthcare outcomes. Many students that utilize the organization are from lower SES and minorities, including black and Hispanics (Director of Strategic Partnerships, personal communication, February 24, 2022). Appealing to this demographic addresses The Institute for Healthcare Improvements Triple Aim by bringing diversity to healthcare fields, allowing patients to relate to their providers better, and providing more access to care. The project also correlates with various objectives defined by Healthy People 2030. Healthy People 2030 seeks to increase the graduation rate of high school students in four years, increase enrollment rates of students in college right after high school graduation, and improve proficiency in math and reading of eighth-grade students (Office of Disease and Prevention and Health Promotion [ODPHP], n.d.-a.). Furthermore, ODPHP (n.d.-b.) looks to increase public health pipeline courses, which are programs designed to support minorities in their education endeavors (Gefter et al., 2018). Pipeline courses enhance interest in healthcare among low SES racial/ethnic minority youth, increasing healthcare diversity and improving the community's health (Gefter et al., 2018). Problem Statement Lower SES youth are disadvantaged in educational, social, and financial situations, resulting in poorer health outcomes beginning in early childhood. A significant proportion of this is not having the same opportunities as those of higher SES. As a result, this demographic has lower reading/math proficiency, accrues more debt with college enrollment, are less aware of college resources, have fewer postsecondary enrollments and attainment, higher stress levels, and lower self-efficacy (APA, 2017). Without interventions to improve these areas in childhood/adolescence, the SES gap will continue negatively impacting the community's health. Purpose Statement This Doctorate of Nursing Practice (DNP) project aims to provide early intervention in promoting self-efficacy toward career development through healthcare exploration courses in at-risk seven to ninth-grade youth. These courses will aid in improving the growing healthcare workforce and enhance the health of the individual and community they serve upon employment. Section II. Evidence Literature Review A thorough literature search evaluated the best practices for career education in middle and high school youth. Nine databases, which include East Carolina University (ECU) One Search, The Cumulative Index of Nursing and Allied Health Literature (CINAHL), The Education Resources Information Center (ERIC), Sociological Abstracts, SocINDEX, PsychINFO, Education Research Complete, PubMed, and Scopus were searched using analogous methods. The searches were then recorded into a literature search log to detail the searches performed, the number of articles found in each search, how many articles were kept, and how many articles were redundant. The articles supporting the DNP project were then recorded in a literature matrix to concisely describe the necessary information from the articles. Various combinations of the following medical subject headings (MeSH) terms were used to conduct the literature search: middle school student(s), high-school-student(s), after school, out of school, career development, career planning, health pipeline, and health pathway. The first four and the last four terms were combined with the operator or. The operator and connected the phrases. Other search terms included career exploration, career interest, extracurricular, club, and career choice. All searches were narrowed to English-written articles, peer-reviewed/scholarly articles, and published within the last five years. Various combinations of MeSH terms were applied to each database except for ECU One Search and Scopus. Forward searching was performed in Scopus, identifying articles by the author whose program this DNP project uses. Global searches were performed in ECU One Search using similar MeSH terms. The searches yielded 1,167 articles for review. The following inclusion criteria were applied to the searches: studies that performed an intervention that reported outcomes on career exploration, career development, or career planning; participants were middle school or high school youth; and Level I to Level VI evidence. Mazurek et al. (2019) Level of Evidence model was utilized to evaluate the articles. Articles were excluded based on the following criteria: not within the targeted age range; studies conducted outside the United States, England, or Canada; intervention did not evaluate and measure the youth’s preparedness for college or careers. Seventy-seven articles were reviewed further after the inclusion criteria were applied. Furthermore, pertinent articles were hand-searched and assessed for inclusion in this review. Two Level VII sources were found through grey literature searches and were included due to their relevance of support. The total amount of articles considered relevant for inclusion in this literature review was 27. Current State of Knowledge The United States is experiencing a skills gap, which is a difference in a worker's skills compared to the skills required to perform a job (Career & Technical Education Caucus [CTEC], n.d.). According to the CTEC (n.d), 53% of jobs in the United States need more than a high school diploma but less than a bachelor’s degree. Moreover, 43% have specific skill requirements to perform the job (CTEC, n.d.). A vital avenue to help close the skills gap is exposing middle school students to career and technical education (CTE). Exposure to college and career planning in middle school is imperative because the youth are starting to prepare to make decisions that have a long-lasting impact on their futures (Associations for Career and Technical Education [ACTE], 2017; Middle Grades CTE Shared Solutions Workgroup [CTESS], 2020). Research has demonstrated that career exploration programs can increase career readiness and interest, improving the workforce (Bates et al., 2019; Chester et al., 2020; Daniels-Osaze et al., 2021; Garrison et al., 2021; Gibbons et al., 2020; Glessner et al., 2017). According to ACTE (2017) and CTESS (2020), middle school students start to cultivate occupational identities and lay the proficiencies needed to help them succeed in college and career development, demonstrating the importance of career investigation during this time. After middle school, students must decide on high school curriculum pathways, which will prepare them for college and career choices in the future (CTESS, 2020). Therefore, one of the main objectives of CTE in middle school is to increase exposure and knowledge of the various career pathways, which is critical for youth from lower socioeconomic status, minorities, and rural communities due to the lack of access outside of school (ACTE, 2017; Ali et al., 2017, 2019, 2021; Boekeloo et al., 2017; Bidwell et al., 2019; CTESS, 2020; Daniels-Osaze et al., 2021; Dunn & Saks, 2020; Garrison et al., 2021; Gefter et al., 2018; Gibbons et al., 2020; Glessner et al., 2017; Harris et al., 2020; McLean et al., 2018; Robinson et al., 2017). There is a lack of best practices supported by literature for implementing career development programs in youth, especially in rural, low SES, minority, and middle school programs. Youth from underserved communities obtain most of the exposure to career development opportunities through out-of-school or after-school-programs (Cohen et al., 2019). Both in-school and out-of-school programs vary based on state and county levels, funding sources, requirements for graduation, and traditions (Cohen et al., 2019; CTESS, 2020). Furthermore, programs vary in length of intervention from one day/session to numerous sessions over more than one year. Current literature on best practices for CTE comprises pilot studies; thus, the validity of the interventions is less substantial than in longitudinal studies. Burrus et al. (2017) performed a systematic review of adolescents’ preparation for adulthood, which found no studies that would serve to change evidence-based practices in career development for adolescents. The focus of the studies was to define interventions that would aid in creating specific components of a CTE-based program (Burrus et al., 2017). Without best practices, programs are not fully serving their intended populations (CTESS, 2020). Regulation of programs and standard measurements will optimize protocols and methods to build best practices in the career development of adolescents (Burrus et al., 2017). Despite limited research and best practices for CTE-based programs, many national organizations agree on providing career development to middle school and underserved youth (ACTE, 2017; Burrus et al., 2017; Cohen et al., 2019; CTESS, 2020). The organizations agree that programs should include key components in academics, practical skills, essential career skills, and especially employability (ACTE 2020, Cohen et al., 2019; CTESS, 2020). Employability is a vital aspect of career readiness and focuses on skills in applied knowledge, building effective relationships, and workplace skills (Cohen et al., 2019). While the literature expresses the importance of implementing CTE-based courses in middle school, there is a gap in research supporting the effectiveness of the programs within this population. Only nine articles were found from the literature search that focused on middle school career development, increasing career interest, and career education (Ali et al., 2017, 2019, 2021; Blotnicky et al., 2018; Glessner et al., 2017; Garrison et al., 2021; Jiang et al., 2021; Makransky et al., 2020; Williams, 2019). Most current literature supporting career development takes place in high school youth. Career development programs targeting middle school youth have been shown to increase career self-efficacy, strengthening one’s abilities to obtain goals (Ali et al., 2017; Garrison et al., 2021; Gefter et al., 2018; Glessner et al., 2017). Similar results were demonstrated in high school youth. Also, studies with high school youth research found youth to have increased career interest, improved academic outcomes, more developed professional skills, and better knowledge about the professions (Bates et al., 2019; Boekeloo et al., 2017; Dunn & Saks, 2020; McLean et al., 2018). According to ACTE (2017) and Cohen et al. (2019), middle school youth should start developing similar proficiencies in high school youth studies. Despite the positive outcomes in career development, many articles lack longitudinal data, have small sample sizes, utilize self-reported data, and lack generalizability across race, ethnicity, and social status. These factors can hinder funding and the creation of standard practices for implementing career development programs. The literature search produced 16 articles addressing healthcare career development or healthcare career interest. Various approaches were utilized to address healthcare career exploration and positively influenced career development for the targeted populations. This DNP project focuses on expanding the healthcare sector due to the increased need for healthcare professionals and more representation of diverse cultures within the healthcare sector. According to MyFutureNC (n.d.-c., n.d.-d.), health care is the largest industry in North Carolina and Pitt County. In addition, healthcare occupations are one of the fastest-growing occupations, with a 16.1% increase (North Carolina Department of Commerce, 2018). However, healthcare demographics need to reflect the diverse demographics of the state and the nation (Daniels-Osaze et al., 2021; Goode & Landefeld, 2018). Therefore, correcting the diversity of the healthcare workforce improves access to healthcare for rural, underserved, and minority patients (Daniels-Osaze et al., 2021; Goode & Landefeld, 2018). Recent studies by Ali et al. (2021) add that sociopolitical development positively affects underrepresented youth and their decisions to pursue healthcare while striving to correct those inequalities more passionately. Bidwell et al. (2019), Gibbons et al. (2020), and Robinson et al. (2017) highlight barriers that underserved youth face when obtaining education past high school, which include cost, inadequate school preparation, less self-efficacy towards postsecondary education, more self-doubt towards post-secondary education, higher verbalization of direct entry to the workforce after high school, length of post-secondary education, apprehension towards healthcare, and a lack of appeal in healthcare careers. Identifying barriers and solutions to improve the obstacles is a key aspect of this DNP project. Current Approaches to Solving Population Problem(s) This paper evaluates methods to increase career development/planning and career interest targeting two career pathways highlighted by CTE, which include Science, Technology, Engineering, and Mathematics (STEM) and healthcare careers. STEM is included in this paper as most jobs within the healthcare field, including microbiologists, computer programmers for electronic health records, biomedical engineers, and accountants, use this skill set. The various methods used to engage youth in career development were online career exploration, college tours, mentorships, virtual reality simulations, guest speakers for fields of interest, career education programs in and out of school, and internships. The programs also ranged from one-day to four-year programs. One of the most prominent themes across the literature search is how programs increase the youth’s career self-efficacy. The most significant evidence support comes from Project HOPE (Healthcare Occupations Preparations and Exploration) interventions, a career development program for middle school youth. The program has been conducted and revised multiple times to see the best methods to help increase self-efficacy and healthcare career interest/knowledge. Since the first study, sociopolitical development (SPD) and a multimodal creative activity have been added to the primary Project HOPE program to test the cognitive career outcomes. A key finding made by Ali et al. (2017, 2021) was that healthcare career self-efficacy did not increase in the minority group with participation in the Project HOPE program with or without the sociopolitical development (SPD) aspect. However, among rural white youth, self-efficacy was impacted with and without SPD. Conversely, Garrison et al. (2021) found that the implementation of a multimodal literacy method, where the youth had to identify their career selves through the reflection of the interventions using writing and collages, had positive outcomes on healthcare self-efficacy, an opposite finding from Ali et al. (2017, 2021). Garrison et al. (2021) postulated that adding the creative multimodal method may have allowed minority students to better express and explore their thoughts, thus feeling more supported by their colleagues and facilitators. Furthermore, Project HOPE was conducted in a rural community. Ali et al. (2017, 2021) and Garrison et al. (2021) found some significance in increasing healthcare self-efficacy and interest across minority and white youth. While urban community interventions can be utilized to formulate a program, considerations about the demographics, access to resources, and exposures that rural communities have, need to be accounted for when tailoring these programs to specific populations. While most studies were pilot studies to test various methods to introduce career development in underserved youth, Harris et al. (2020) provide longitudinal data supporting the importance of a hands-on STEM education program for minority youth. The 20-year study has found that the Science, Language Arts, and Mathematics program has reached 987 individuals, and 44% of participants pursued careers in medicine, 17% in science, and 39% in public health. Another longitudinal study of 26 years of rural youth reported that 57% of youth participating in health science and technology academy pursued a career in healthcare or STEM (Chester et al., 2020). Another critical aspect that Ali et al. (2017) and Garrison et al. (2021) contribute to improving the success of career development programs in rural, minority, and unserved communities is the role of mentorship and similar background role models. Culturally similar mentors can relate to the population's experiences and help them succeed more efficiently at overcoming these barriers (Garrison et al., 2021). Boekeloo et al. (2017) found that youth from underserved communities that participated in the Climbing Up and Reaching Back program, an in-person mentoring program in health science careers, reported that forms of traditional education about health sciences were less impactful than personal interactions and encouragement. Robinson et al. (2017) study had 64% of the program attendees sign up with mentors in medical school to help them guide them in college preparedness. Many youths from minority, rural, and underserved communities are first-generation college/career seekers and are not knowledgeable about career development; thus, having role models of similar backgrounds can help this population overcome this knowledge barrier and help them properly prepare for entry into college or careers. Lastly, in the age of technology, virtual reality and simulations have been shown to positively affect career interests in STEM and healthcare. Rosser et al. (2018) found high satisfaction in a simulation of surgical skills and improved their interest in pursuing a medical career. Similarly, Bidwell et al. (2019) saw a significant increase in interest, knowledge, career-seeking, and self-efficacy with a summer surgical skills program. Makransky et al. (2020) found a significant increase in interest and self-efficacy in youth that participated in immersive virtual reality simulation versus video groups in scientific career education, demonstrating that switching to more realistic education opportunities are significant when providing instruction and engaging the interest of youth. Technology has also allowed those with limited access to in-person career development resources to obtain education through Internet access to online programs (Heinert et al., 2020). Based on the literature review, collaboration with the organization, and review of suggestions from the initial Health Careers Exploration Club (HCEC) project, this DNP project utilized Project HOPE lesson plans and tailored them to fit the targeted population. Furthermore, based on recommendations from previous participants, guest speakers from various healthcare careers presented to serve as role models for the youth to relate to. As the initial program evaluation suggests, the youth also took a campus tour at the local community college. Lastly, another healthcare education program came to the site, allowing the youth to have hands-on simulations and see health and disease cadaver organs. Evidence to Support the Intervention While various methods have been found through literature searches, this paper discusses strategies that best serve the population at the afterschool program. The organization (Boys and Girls Clubs of America [BGCA], 2019) focuses on preparing youth for future workforce projections and targeting STEM-based and healthcare careers, starting in middle school. The curriculum outlined by Project HOPE served as a guideline, and adjustments will be made to meet the population's needs and the local workforce's current trends. In addition to the primary Project HOPE curriculum, SPD will be incorporated to highlight the inequalities in healthcare and the workforce sector. It is supported by Ali et al. (2017, 2021), which found that SPD and SCCT contributed to increasing healthcare interests in rural middle school youth compared to only SCCT-based programs. Another aspect incorporated in the primary SCCT-based Project HOPE is utilizing creative multimodal activities that allow the youth to envision how they would see themselves as a healthcare professional (Garrison et al., 2021). This study found that adding multimodal activities increased healthcare interest and self-efficacy in rural middle school youth (Garrison et al., 2021). While the Project HOPE interventions mentioned above did appeal to the use of role models/adult encouragement from an instructor aspect, they did not bring in healthcare professionals to support the youth (Ali et al., 2017, 2021; Garrison et al., 2021). Boekeloo et al. (2017) reported more impact from nontraditional education methods in the career development of underserved youth through personal interactions than those with traditional academic means of career development. One method not incorporated into Project HOPE is the aid of technology/simulations in increasing career development. Bidwell et al. (2019), Makransky et al. (2020), and Rosser et al. (2018) studies convey the success of healthcare simulations on youths’ interest, knowledge, and self-efficacy. Evidence-Based Practice Framework This DNP project utilized multiple theories and frameworks to guide creation and implementation. The literature search revealed SCCT as the most prominent theory supporting career development and planning (Ali et al., 2017, 2019, 2021; Blotnicky et al., 2018; Garrison et al., 2021; Gibbons et al., 2020; Jiang et al., 2021; Makransky et al., 2020). SCCT supports career development through three main structures: developing career interests, making choices relevant to academics and careers, and accomplishing educational and career interests (Lent et al., 1994). SCCT addresses the effects of one’s thoughts and external factors (i.e., socioeconomic status, environmental factors, social support, and cultural experiences) on advancing or hindering the career development process (Lent et al., 1994). Specifically, SCCT concentrates on self-efficacy, probable outcomes, and the methods of goal obtainment about self (one’s gender, ethnicity, or race), situation factors (one’s socioeconomic status), and environmental conditions (support systems) (Lent et al., 1994). SCCT-based intervention can be a vital influence for programs serving rural, minority, or underserved areas because it considers how personal, environmental, and overt behaviors influence career development and choices (Ali et al., 2017). Due to the multifactorial approach to career development and recognition of supports and barriers in cultivating career development, SCCT is an integral theory for creating career development programs for underrepresented communities. Furthermore, the organization's (BGCA, 2019) framework for career development encompasses three key elements: exploring careers, developing essential and technical skills, and applying learned experiences to real-life career opportunities. The program that most closely incorporates the framework and meets the objectives for career development set by the organization is Project HOPE (Ali et al., 2017), which utilizes a social cognitive career theory (SCCT) based program. The RE-AIM Framework served as the operational framework for this DNP project. RE-AIM Framework was developed to evaluate health promotion and how outcomes are affected by internal and external variables (Glasgow et al., 2019). The results of this project can be affected by many outside variables (social, environmental, emotional), which cannot be controlled in this project. The framework incorporates how the individual, organization, and individual plus the organization impact the effect/outcomes of the program, representing the multifaceted nature of life (Glasgow et al., 2019). Each element of RE-AIM was utilized in this DNP project as follows: Reach: recruitment of participants through pre-implementation flyers, in-person information sessions, and support of the Boys and Girls Club Unit Director. Effectiveness: pre-program, intra-program, and post-program surveys to evaluate the program's impact. Adoption: collaborating with the project site champion and Boys and Girls Club Unit Director. Implementation: utilizing research-based approaches to improve the quality of the intervention throughout implementation. Maintenance: creating a maintainable strategy for the program founded on the responses project team and participants. The Plan, Do, Study, Act (PDSA) model will be utilized weekly during the implementation phase to serve as a quality improvement measure (IHI, n.d.-a.): Plan: what is going to be tested, and how is the data going to be collected. Do: implement the test and collect the data. Study: analyze the data obtained and compare it to initial and previous results. Act: Revise and adjust for the subsequent implementation from the data collected. The PDSA model allowed for continuous improvement throughout the implementation phase. Ethical Consideration & Protection of Human Subjects This DNP project's development and implementation applied autonomy, nonmaleficence, beneficence, and justice. Autonomy was honored by obtaining parental informed consent for minors before participating in the project (Rich, 2020). Nonmaleficence, providing interventions without causing harm, was upheld due to the project's design (Rich, 2020). This project was not research-based and was a quality improvement initiative; thus, no testing was involved. An off-site college visit could impose risk to the participants but was minimal due to the site's travel arrangements and parental consent before visitation. Beneficence, providing interventions to benefit others, was upheld by providing interventions that would aid the participants in increasing interest and knowledge in healthcare and prepare them for career and college readiness (Rich, 2020). Lastly, justice, defined as fairness, was sustained by allowing all youth within the age range in the site to participate in the program once the application and parental consent were obtained (Rich, 2020). Collaborative Institute Training Initiative (CITI) modules were completed by this project leader as required by the university’s official approval process. Upon completing the modules, the researcher should clearly understand ethical principles when working with human subjects. The project site does not require Institutional Review Board (IRB) approval. An online Quality Improvement (QI)/Program Evaluation Self-Certification tool determined whether IRB approval was required or if the project was a QI/program evaluation initiative. The tool was completed, and the project was deemed a QI/program evaluation initiative by ECU, and IRB review was not required. Section III. Project Design Project Site and Population The afterschool program (BGCCP, n.d.-c.) is a non-profit organization that serves at-risk youth ages 6-18 by providing afterschool and summer programs to help them develop skills to succeed throughout their life. The organization covers seven counties across eastern North Carolina and has 17 clubs. This project was conducted at a site in Pitt County, North Carolina, predominantly comprised of low-income minority youth. The project serves to help close the socioeconomic gap by reducing disparity, improving the community's health, and creating a more diverse healthcare system for this population. Facilitators for the project included an evidence-based curriculum, stakeholder support, and initial project implementation at the site. A significant aspect of this DNP project was providing a career development program, which is a requirement for the organization and affects funding for the following year. Also, the organization strives to help the youth become their best selves through opportunities they would not get if they did not participate. There is a strong support system for the implementation of this project. Possible barriers to the project's success included a lack of participants, participants not attending consistently, a short implementation timeframe, limited time for each session, and parental support issues. These barriers were addressed by seeking help from the project champion, unit director, project leader’s faculty, and consistent project improvement approaches throughout the implementation. Description of the Setting Two sites within the organization were interested in re-implementing the program based on feedback from the Unit Directors. Site 1, the first Health Career Exploration Club site, is in a smaller rural area in Pitt County that served 153 members in 2021 (BGCCP, 2022-a.). Site 1 serves surrounding local schools with transportation to the site (BGCCP, n.d.-a.). Site 2, the largest site in the organization, served 248 members in 2021 (BGCCP, 2022-b). The site serves 12 schools, with transportation provided from 11 of them (BGCCP, n.d.-b.). Site 1 was selected to serve as the base for this program. During the school year, the site operates Monday through Friday from 2:30 pm to 7:00 pm (BGCCP, n.d.-a.). The site had modified hours during the school year for holidays and teacher workdays and served the youth from 9:00 am to 6:00 pm (BGCCP, n.d.-a.). However, the organization changed operation hours after implementation and closed for teacher workdays and holidays. The club is open on early release days from 12:00 pm to 6:00 pm (BGCCP, n.d.-a.). Summer hours follow holidays and non-school hours and have “early bird” hours from 7:00 am to 9:00 am (BGCCP, n.d.-a.). Membership fees are $50 per academic year (BGCCP, n.d.-a.). The site has designated areas for elementary, middle, and high school youth, a kitchen, a gymnasium, an outdoor playground, and multiple classrooms (Unit Director, personal communication, April 27, 2022). The site also has computers and tablets for youth use (Unit Director, personal communication, April 27, 2022). The youth can partake in various activities and programs during the afterschool program. Paid staff and volunteers assist and guide the youth through various afterschool activities and programs. Programs target academic growth, physical health, and social/emotional skills. Street Smart and Start Moves programs provide skills to improve the youth's ability to handle self-esteem, peer pressure, drug and alcohol issues, and abstinence (BGCCP, n.d.-a). Furthermore, youth also take field trips throughout the school year locally and out of town. Meals and snacks are provided for the youth daily. Description of the Population According to the Office of the Assistant Secretary for Planning and Evaluation (n.d.), poverty was considered at $26,500 for a four-person family in 2021. This program targeted underserved middle-grade youth in seventh, eighth, and ninth grade who regularly attend the afterschool program. There was 32.68% of youth aged 12 to 14 in the after-school program membership for 2021 (BGCCP, 2022-a.). 47.71% were female, and 52.29% were male (BGCCP, 2022-a.). The racial profiles during the 2021 year were: African Americans 65.36%, Hispanics 2.61%, multi-racial 9.15%, and white 22.88% (BGCCP, 2022-a.). 88.89% qualified for free or reduced lunch, a marker of low SES (BGCCP, 2022-a.). The majority, 59.60%, of youth were from single-parent households (BGCCP, 2022-a.). In addition, 52.52% of members had an income of $24,999 or less (BGCCP, 2022-a.). Project Team The project team included three members: the DNP student, the DNP faculty member, and the project site champion. This DNP student functioned as the project leader. This position's role was to modify the program for re-implementation based on results from the initial implementation and correspond with the team throughout the entire planning and implementation phase. The DNP student also reviewed the initial project paper, performed a literature review to find evidence-based strategies for implementing the intervention, facilitated the implementation, gathered/evaluated the data, and distributed the project results through a formal paper and presentation. The DNP faculty member is a doctorally prepared nurse who directed the DNP student throughout the project process and acted as a scholarly advisor. The faculty member assessed the methods and progression of the project in addition to the assessment of all written work and confirmed that the progression and completion of the project were done on time (Wilson et al., 2020). The project site champion, director of strategic partnerships, was the organization's mentor and expert about the organization/population where the project was implemented. The project site champion served as an interprofessional colleague and provided the DNP student with resources and feedback throughout the project. An interprofessional team has the benefits of influencing healthcare in alternative sectors and helps the student improve leadership competencies as defined in the DNP essentials (Wilson et al., 2020). The site champion helped identify improvements in the previous HCEC to better serve the organizational need, facilitated communication with other stakeholders within and outside the organization, and provided insightful information on the appropriate material for the population served. Another key team member was the Unit Director, a vital informant on the youth she worked with, and helped identify the population's needs and interests. She helped identify key times for recruitment, project timeline, and day/time of the week. Project Goals and Outcome Measures There are short-term and long-term goals associated with this project (Figure 1). The short-term goals of the project included increasing the youth’s interest in healthcare careers, strengthening the connection between academics and career achievement, fostering knowledge about healthcare careers, and improving college and career self-efficacy by 75% of participants. The long-term goals are divided into two categories, individual and community levels. These goals were not measured in this project because of the short time and limited capacity of the project. Still, they lay a foundation for future projects if the partnership continues with the organization. The individual outcomes are tied to improving the individual's health by helping the youth recognize and reduce socioeconomic barriers to academic and career achievement, graduate high school, and enroll in certificate, associate, or bachelor's level education to be financially sound. At the community level, the goals were to improve access to healthcare for underserved communities, decrease poverty and unemployment rates, and diversify healthcare careers. Figure 1 Health Careers Exploration Club Goals The goals of this project were addressed by developing and implementing HCEC for seventh to ninth-grade students in an afterschool program. The program comprised 10 sessions geared toward improving youth's interest, knowledge, and self-efficacy regarding healthcare careers. The measured outcomes included student pre- and post-implementation surveys on knowledge, interest, and college/career self-efficacy. Also, weekly self-evaluations on interest and knowledge about healthcare careers were utilized to evaluate the program throughout the implementation. Lastly, program evaluations were performed by team members. Description of the Methods and Measurement The QI/Program Evaluation Self-Certification paper copy was submitted to the ECU faculty prior to the implementation of the project. The approval was submitted to the university via an online QI/Program Evaluation Self-Certification tool. The online tool deemed that IRB approval was not required before implementation. The RE-AIM framework and PDSA model were utilized in the planning phase and the project's implementation phase. The frameworks helped ensure the project was planned and implemented efficiently and provided methods to evaluate continuous improvement. During the planning phase, the project leader met virtually with a DNP faculty member eight times and discussed the need for intervention for the population, project planning, outcome measures, data collection tools, IRB approval, and evidence obtained from the literature search. Also, during the planning phase, the project leader met virtually and in person with the project site champion five times to develop an intervention best for the target population. In addition, the project leader attended the organization's leader meeting, where the previous DNP student presented her findings from the initial project. This project leader also presented the intention for future project implementation. Interest in project implementation were voiced by Site 1 and Site 2. After discussing with the project site champion, Site 1 was selected to host the project implementation. Before implementation, healthcare careers questionnaires and flyers were distributed to the Unit Director at Site 1 to start tracking interest and gain insight into healthcare careers the youth might be interested in hearing from during a career panel (see Appendix A and B). Also, the project leader held an information session the summer before implementation to present the project. The seventh through ninth-grade youth were given a flyer and the healthcare careers questionnaire to start recruiting participants for the project. Before implementation, youth interested in participating in the club were asked to fill out an application with parental consent before starting the club (see Appendix C). The project content was based on Project HOPE and the initial HCEC (Ali et al., 2017; Cook, 2022). Furthermore, a healthcare career panel was added to one of the sessions based on literature supporting mentorship (Ali et al., 2017; Boekeloo et al., 2017; Garrison et al., 2021; Robinson et al., 2017). Lastly, the literature supports using hands-on simulation programs to increase interest in healthcare careers (Bidwell et al., 2019; Makransky et al., 2020; Rosser et al., 2018). The HCEC partnered with another healthcare education program, which ECU medical students lead. The healthcare education program exposes youth to health sciences by using anatomical models and medical equipment to foster new opportunities for learning other than content-based information (PhysioCamp, 2022). All 10 sessions have some form of hands-on participation to help engage and keep the interest of the youth. Eight sessions were planned for 60 minutes at the project site. The other two sessions were scheduled on days the youth are released from school early or on teacher workdays, with one held at the local community college and the other on-site. A student workbook outlining the lessons' goals, specific instructions, and evaluations was developed for this DNP project. The workbook was printed by the project leader and placed in a three-ring folder; each participant received one. PowerPoint presentations were made for six sessions discussing objectives and providing further instructions for the participants. Table 1 presents the lessons, activities, and objectives. Table 1 Health Careers Exploration Club, Weekly Curriculum Lesson Title Activities Purpose Session 1: Discovering Your Place in the World of Work Introduction, Ice Breaker Reality Check, Interest Finder, Health Careers Jeopardy Game Introduce the program to students and the different occupations that encompass the healthcare field. Introduce financial literacy. Session 2: Linking Your Strengths and Interest to Possible Careers Holland Code Ratings, Holland Code Game Students will evaluate their own strengths and interest. Help the students identify with occupations of interest within healthcare using the Holland Code. Session 3: Getting to Know My Barriers and Supports to My Career Path Opportunities and Roadblocks Game Students will learn about community resources and recognize support for career achievement. Help the students identify barriers and think about solutions. Session 4: Health Science Fieldtrip Campus Tour Apply your knowledge to real-life scenarios. Session 5: Healthcare Career Panel Guest Speakers Interact with role models and learn more in-depth about healthcare careers. Session 6: Getting a job! Job Research, Guest Speaker Select one healthcare career and research job requirements, salary, and education requirements. Interact with role model. Session 7: Career Poster Poster Creation Set personal goals. With the knowledge obtained throughout the program share your career story. Session 8: Career Story Sharing/ Skills Building Tell us your story Practice oral presentation skills. Session 9: Healthcare Education Program Visit Simulations Apply your knowledge to real-life scenarios. Session 10: Content Wrap-Up Group discussion Summarize the club and how key elements that will help you succeed in your career development plan. Note: The sessions are based on Project HOPE (Ali et al., 2017). This is the pre-implementation outline. Session one utilized an online self-assessment tool introducing financial literacy and career interest. Also, a health career jeopardy game was developed using an online jeopardy game creator covering educational requirements, healthcare careers, healthcare tools, and finances. The themes covered in the game served as introductions to topics that will be discussed throughout the program. Session two discussed the Holland Code, which helped the participants connect their strengths and interests to selecting healthcare careers. The participants participated in games including Shark Tank, Building Clocks, Categories, 20 Questions, Reverse Pictionary, and Pictionary. The games helped the students learn about activities that correspond to future career options. In session three, the participants played the Opportunities and Roadblocks game, which introduced the topic of barriers and ways to overcome obstacles. The participants were handed scorecards and asked to cycle through the various stations that would symbolize their path to a career in healthcare. The game's stations include Volunteering, Extracurricular Activities, Financial Aid, Family and Friends, Work Experiences, Two-Year College, Four-Year College, Healthcare School, and Finding a Job. At every station, the participants had to earn two points by answering questions regarding local resources connected to the subject of the station. In addition, the participants must overcome a roadblock at each station that symbolized barriers to success. The participants could only progress to the next station once they developed a way to overcome the barrier. Only some stations had to be visited, but some were required to participate in other stations before completion. A campus visit to the local community college health sciences division was planned for session four. Participants had a scavenger hunt to complete as they progressed through the tour. Session five was a healthcare career panel that was to include the top four or five careers selected from the questionnaire provided before implementation. The participants had questions to answer as the speakers presented and developed at least two questions to ask the speakers during the open floor. Session six required the participants to research a healthcare career of interest using an online tool, NC Health Careers. The participants had to obtain information, including brief job descriptions, education level, practical high school classes, salary, required skills, and tasks they would perform in their careers. The participants were asked to reflect on their chosen careers and identify what they liked, disliked, and were surprised about the job. Also, a guest speaker from the Health Science Academy, a high school health careers program, was planned to present. In session seven, the youth would use the career they researched to create Google slides on Chromebooks describing the job. The participants will be provided with relevant points to include in the slideshows. Session eight allows the participants to practice skills for public speaking by presenting the slides on the healthcare career they made in the previous session. The partnering healthcare education program was the focus of session nine and would provide hands-on participation to help the participants connect with healthcare careers. Session ten would summarize the information learned, and all the participants would discuss what they learned from the program. Also, this session would be when the participants and team members complete the post-implementation survey. There were several tools used to measure the program evaluation. Both quantitative and qualitative measures were used to evaluate the outcomes. Before starting the program, participants completed a pre-implementation survey that included a five-question three-point Likert-style scale to gain insight into the participant's interest in healthcare careers, knowledge of healthcare careers, career plans, and the requirements for classes/college (see Appendix D). One open-ended question was included to gain insight into what the participants hoped to gain from the program. Secondly, the Career and College Readiness Scale in Middle and High School Students evaluated the participant's career/college self-efficacy (Anderson-Butcher et al., 2016). This tool was used as it was the most recent tool that has demonstrated validity and reliability for evaluating career/college self-efficacy in middle school. A post-implementation survey using the same questions and self-efficacy scale would be given to assess the change in responses before and after the program. Four open-ended questions are utilized to obtain personal accounts of their favorite and least favorite part of the program, anything to change, and what they learned from the program (see Appendix E). The participants were also requested to state their demographic data, including age, race, grade, and gender. The students were given the option “prefer not to answer” for race and gender. After each session, two three-question Likert improvement scales were used to trend the changes in knowledge and interest in healthcare careers (see Appendix F). There was a space for comments or questions on the post-session evaluation. A team member post-implementation final evaluation was also utilized (see Appendix G). The evaluation included five three-point Likert scale questions and three open-ended questions. The value of the evaluation was to gauge the opinions of the usefulness and success of the program, along with suggestions for change in future project implementation. Discussion of the Data Collection Process The participant surveys were kept anonymous by creating passwords at the beginning of the program. All surveys had a password identifier for the project leader to trend and evaluate the program's effectiveness. Survey participation was voluntary but encouraged by the project leader. All surveys were printed and given to the participants to fill out. At the end of each session, 15 minutes were available for the participants to complete the surveys. The team members' post-implementation survey was voluntary, anonymous, and conducted at the program's end. Implementation Plan The project site champion and the site Unit Director assisted with the organization of the implementation plan. The initial timeline for implementation was adjusted to a later start date due to recommendations from the site champion and Unit Director. The implementation plan was based on Pitt County’s fall academic school year. The proposed timeline from recruitment to the last session was the week of September 5, 2022, until the week of November 21, 2022. The Unit Director was consulted about the best day of the week and time for the program. The program was planned for Tuesday, Wednesday, or Thursday from 4:30 pm to 5:30 pm, except for sessions four and nine. Session four was planned for either October 13th or 14th on the participant's early release day or teacher workday. Session nine was scheduled for November 10th or 11th on the participant's early release day or Veteran’s Day holiday. Throughout implementation, the team members and project leader planned weekly PDSA meetings. The PDSA meetings were intended to discuss what was efficacious and could be improved for the project leader to adjust before the next session. Depending on team members' schedules, weekly meetings were planned for after the session or virtually another day of the week. Timeline In February 2022, the project planning was initiated and continued until September 2022. One meeting was held with the Unit Director before the start of implementation to confirm dates and project plans. One recruitment/informational session was held on September 7th, 2022. The project was planned over 10 weeks, but due to organizational calendar changes, it was conducted over nine weeks from September 21st, 2022, until November 16th, 2022. However, all sessions were implemented as the last two sessions were combined into the last session. The data was analyzed and summarized from November 2022 until April 2023. Appendix H shows a tentative detailed timeline. Section IV. Results and Findings Results The Healthcare Careers Exploration Club program was implemented over nine weeks, including 10 sessions and one field trip. After each session, the team leader tracked participants' weekly attendance and self-reported perceptions of improvements in healthcare career knowledge and interest. Biweekly PDSA meetings were conducted, and alterations were made based on the responses from the meetings. The program was altered based on session evaluations and scheduling conflicts. Table 2 presents a revised post-implementation curriculum plan. Table 2 Health Careers Exploration Club, Weekly Curriculum Lesson Title Activities Purpose Session 1: Discovering Your Place in the World of Work Introduction, Ice Breaker Reality Check, Interest Finder, Health Careers Jeopardy Game Introduce the program to students and the different occupations that encompass the healthcare field. Introduce financial literacy. Session 2: Linking Your Strengths and Interest to Possible Careers Holland Code Ratings, Holland Code Game Students will evaluate their own strengths and interest. Help the students identify with occupations of interest within healthcare using the Holland Code. Session 3: Getting to Know My Barriers and Supports to My Career Path Opportunities and Roadblocks Game Students will learn about community resources and recognize support for career achievement. Help the students identify barriers and think about solutions. Session 4: Healthcare Education Program Visit Simulations Apply your knowledge to real-life scenarios. Session 5: Healthcare Career Panel Guest Speakers Interact with role models and learn more in-depth about healthcare careers. Session 6: Getting a job! Job Research Select one healthcare career and research job requirements, salary, and education requirements. Interact with role model. Session 7: Career Poster Poster Creation Set personal goals. With the knowledge obtained throughout the program share your career story. Session 8: Health Science Fieldtrip Campus Tour Apply your knowledge to real-life scenarios Session 9: Career Story Sharing/ Skills Building Tell us your story Practice oral presentation skills. Session 10: Content Wrap-Up Group discussion Summarize the club and how key elements that will help you succeed in your career development plan. Note: The sessions are based on Project HOPE (Ali et al., 2017). This is the post-implementation outline. Initially, eight one-hour on-site sessions, one field trip to the local community college, and an extended site visit from the healthcare education program were planned for the program. The enrollment goal was to have a minimum of five participants with a maximum of 10. Before the program's implementation, the team leader conducted one interest meeting on-site. The Unit Director also spoke to youth who could not attend the interest meeting held by the team leader. Seven members chose to participate in the program before the first session. One member started after the first session, which totaled eight students enrolled in the program. However, one student withdrew from the program, and two other students did not attend any sessions. The adjusted enrollment for the project was five participants. The average attendance per session was 4.44 participants, ranging from three to six students per session. Each of the five students attended 77% of the sessions. Session three (Getting to Know My Barriers and Supports to My Career Path) had the highest attendance. Session nine (Career Story Sharing/ Skills Building and Content Wrap-up) had the lowest attendance. The barriers to attendance during implementation were sickness, other after-school commitments (sporting events), and early pick-up, which were out of the participant's control. No one student attended every session of the program. The program was initially targeted at youth in seventh through ninth grade. However, the program was offered to sixth through tenth-grade students due to interest and advisement from the unit director and site champion. The literature review found multiple avenues to support the use of CTE education in afterschool programs that were highly beneficial to youth, especially those from rural and lower SES. However, while evidence supports the benefits of CTE-based education, it lacks standardization, affecting the reproducibility of such programs' conduction. Project HOPE curriculum served as the best curriculum to implement the project due to the similar target population and numerous evaluations/redesigning of the project based on findings. Project HOPE, with the incorporation of SCCT, SPD, and multimodal approaches, helping the participants envision themselves in a healthcare career, had the best outcomes in increasing interest/knowledge in healthcare careers and self-efficacy (Ali et al., 2017 & 2021; Garrison et al., 2021). Other interventions that provided substantially impacted interest/knowledge of healthcare careers and self-efficacy were the use of role models, personal interactions with those from healthcare backgrounds, and technology/simulations in healthcare (Bidwell et al., 2019; Boekeloo et al., 2017; Makransky et al., 2020; Rosser et al., 2018). The findings from the program are congruent with the supporting literature that SCCT, SPD, and multimodal education techniques through traditional and nontraditional curriculum, role modeling, and technology/simulation are effective at increasing interest, knowledge, and self-efficacy in healthcare careers. Outcomes Data The following data was based on the adjusted enrollment of five participants after one student dropped out and two did not attend sessions. The average age of the participants was 12.6 years, ranging from 11 to 15 years old. 40% of the students were in sixth and seventh grade, and 20% were in the tenth grade. No eighth or ninth-grade students participated in the program. 60% of the participants were male, and 40% were female. 80%, four participants, identified as black, and 20%, one student, identified as white. The outcome measures for this project included the participant's perception of increased knowledge and interest in healthcare careers and increased college/career readiness self-efficacy. Participants evaluated their perceptions using a three-point Likert-style scale after sessions one through nine (see Appendix F). After session nine, the students were also asked to complete a more thorough program evaluation (see Appendix E). Lastly, the students were asked to complete the same college/career self-efficacy tool, a seven-question Likert-style scale questionnaire, before and after program completion (see Appendices D and E). After session one, 50% of the participants rated their knowledge and interest increased. The participants reported a 100% increase in knowledge and interest after session two; however, there was a downward trend in sessions three and four. Session four had the lowest ratings of improvements in knowledge and interest, at 25%. Participants' increase in knowledge and interest began to rise again from sessions five through nine. The participants reported a 100% increase in perceived knowledge and interest from sessions six through nine. Appendix I depicts the graphical representation of the participants' outcome measures during each session. Each participant's weekly ratings were tracked throughout the program using Excel. The five consistent participants demonstrated improved knowledge and interest in healthcare careers. Most participants reported from sessions one through four that their knowledge and interest in healthcare careers were about the same or improving. One participant reported no improvement in knowledge or interest after session four. All the participants reported their knowledge and interest improving from session six to the end of the program. Appendix J depicts the graphical representation of the outcome measures of all the participants' college/career self-efficacy ratings. Out of the five consistent participants, 80% reported that their self-efficacy related to their college/career readiness increased by completing this program. The one participant that had a decrease in self-efficacy went from 100% to 97%. Discussion of Major Findings The goal for the number of participants enrolled was met at five students. Initially, more participants were enrolled but ultimately selected to leave the program. The goal for individual attendance was 75%, and each student attended 77% of the program sessions. Afterschool events and early pick-up were the main reasons for missed sessions. The originally attended age range of participants was not met due to participation enrollment extension. There was a lack of interest in the eighth and ninth-grade students, which could be attributed to prior implementation at the site in the same age range. The project aimed to serve individuals from minority ethnic backgrounds or those under-represented in the healthcare workforce. The majority of the participants were male, comprising 60% of the total. As males are under-represented in the healthcare workforce, recruitment of this diversity can improve healthcare workforce equality. The participant's race was indicative of the organization's population, with 80% identifying as African American or black. While most of the participants were from an under-represented ethnicity, no other under-represented minorities were included in the program. There was a gradual decrease in knowledge and interest from sessions three to four. Session three’s focus was identifying barriers and strengths to accomplishing one's goals. Session four focuses on cardiopulmonary resuscitation training and the anatomy of the heart, lungs, and kidneys. These sessions were not specifically directed toward learning about healthcare careers but served as a knowledge foundation. The exit ticket specifically asked if knowledge and interest in healthcare careers improved. The participants might not have connected the relevance of session four to the application of healthcare careers. Furthermore, in session three, which was about barriers and strengths, the team leader did not have the extra staff support to run the stations, and the game ran longer than anticipated. Understaffing allowed less time for the team leader to debrief on how identifying strengths and barriers would help with the success of achieving career goals in healthcare. Overall, the goals were met, as 100% of the participants reported improved knowledge and interest in healthcare careers over the last four sessions. The goal for increases in college/career self-efficacy was met, as 80% of the participants reported increased self-efficacy. A significant finding was that one student had a 60% increase in self-efficacy from before starting the program to after the program. One student reported a decrease in self-efficacy; however, the student went from 100% to 97%. This could represent a flaw in the questionnaire used to evaluate self-efficacy and should not be considered when evaluating the program's effectiveness. Overall, the program exceeded the expectations initially set. Section V. Interpretation and Implications Costs and Resource Management Cost Benefit Analysis The project's overall cost for implementation was minimal and included materials for lessons, snacks/prizes for the participants, and field trip transportation. There were expenses, such as prizes and snacks, that were not mandatory for the implementation of the project, which were used at the digression of the team leader. The organization had the resources necessary to conduct the program at no cost, like dry-erase boards, tangrams, laptop computers, and television with a high-definition multimedia interface (HDMI) cable to view PowerPoint and videos. These resources are vital to the organization and would be replaced based on the organization's budget. The average total cost of these items is under $400, and the organization has various partnerships with companies to provide supplies at discounted costs. The largest expense for the program was field trip transportation, which the organization covered. The trip cost included the bus, gas, and driver fee. Appendix K provides a detailed budget for the program implementation. The team leader was the program's facilitator, which had no associated cost to the organization. Ideally, this program would remain a volunteer-filled position, decreasing the cost of the program’s implementation. However, a paid staff member could implement the program as the content is now established. A designated staff member could implement the project throughout the organization, traveling to the various sites and conducting the project. The only preplanning needed for the program would be arranging the field trip, guest speakers, and adjusting the workbook schedule to coordinate with the dates of events. This would require minimum time and could be done during the designated staff member's daily work schedule. The drawback of this would be that the program facilitator would not have a background in healthcare, which might affect the overall benefit of the program due to a lack of expertise in the field. The project could be implemented at a larger scale across the organization due to the low cost of implementing the program. Prizes and snacks could cut costs, as participants receive food daily provided by the organization. The participants, organization, and community benefitted from the program this DNP project provided. The program provided unique opportunities for students to learn about healthcare career options and career planning at no cost. By attending the program, students can improve potential health outcomes by being aware of academic and career trajectories. The project aligned with the organization's values, mission, and vision by exposing the participants to opportunities that improve career education and academic achievement. The project also strengthened the ECU College of Nursing (CON) partnership with the organization. This DNP project was the second time the curriculum was implemented, which positively impacted the population they served. The success and positive influence helped support the program's expansion within the organization. The project also formed an interdisciplinary relationship between the local universities School of Medicine (SOM), ECU CON, and the organization with the healthcare education program session. The healthcare education program, run by SOM, and the project's goals align and seek to increase interest in health science careers. Interdisciplinary collaboration gives the participants different perspectives on healthcare. The project also formed a collaboration with the local community college. The community college has an expansive list of healthcare careers that the participants might feel are more attainable due to the cost of attending and the shorter timeframe to attain a degree and entry into the workforce. Furthermore, the project benefitted the community by positively influencing under-represented individuals in the healthcare workforce. The thought was that if these students decide to pursue careers in healthcare, they could help close the gap in under-represented populations within healthcare, which would positively influence patient outcomes. Resource Management All sessions, except the field trip, were conducted at the project site. The program was given a space with chairs, a television (with HDMI cord), and tables to perform the sessions. Each participant had access to a laptop Chromebook provided by the site for some sessions. Two recruiters directed the field trip from the community college, who provided a tour of the Health Science building. The participants could visit various simulation labs/environments across the healthcare divisions represented by the college. The various exposures included the radiology department, dental assistant lab, respiratory therapy lab, physical and occupational therapy assistant simulation department, paramedic simulation truck, and hospital simulation unit. Implications of the Findings There is no formal structure for CTE planning and education within public schools. Also, due to the lack of resources, CTE education is not always offered within the public school system, especially in rural and underserved areas. The rural and underserved populations already have limited college and career education access. Furthermore, there is a disparity in middle school CTE, which forces the participants to make decisions about electives in high school without any knowledge about the importance of electives. This project introduced underserved rural middle school youth to healthcare career opportunities and education/skill requirements. After each session, participants were asked questions to evaluate how the lesson could help them seek a future career. The students were also asked directly and indirectly about their college/career self-efficacy. Students rated their college/career self-efficacy before and after the implementation of the project. Additionally, the lessons required the students to reflect on their thoughts about obtaining a healthcare career and how they would achieve it. Implications for Patient/Population Areas of this DNP project which could help the participant's health outcomes include employment and education. The lessons started broad and, throughout the program, were narrowed down to determine the individual's goals for obtaining a career in healthcare. The participants were asked to evaluate lifestyle choices, like what type of housing, car, traveling, and family they wanted in the future, and correlate what careers aligned with the goals and aspirations they had in the future. The participants employed critical thinking throughout the program to reach the final goal, the healthcare career of their choice. The program's design helped the participants identify goals and career interests and correlate them to achieving a healthcare career. Implications for nursing practice This project was unique as it worked with an interdisciplinary team outside the healthcare workforce to improve population health by addressing social determinants of health. The nursing profession considers all aspects of a patient's life that could cause poor health outcomes, and education and employment are large contributors to this. The project seeks to improve the diversity of the healthcare workforce and the health outcomes of the participants and the community they will serve. The DNP Essentials are also upheld and demonstrated by the ability of the nurses to work with interdisciplinary teams to improve social determinants of health by employing a career exploration club like this project (see Appendix L). Impact for Healthcare System(s) The project aids in improving the healthcare system by improving the health of the individual and the community by introducing underserved youth to career exploration in healthcare. At the individual level, the program introduces career exploration to an under-represented population in the healthcare sector to improve academic achievement, job security, and financial stability. These factors directly impact the ability to obtain healthcare, utilize preventive healthcare services, and maintain healthy lifestyles. Preventative healthcare is cheaper than treating medical conditions once they are developed. By targeting under-represented youth, the program could improve the diversity of healthcare, thus improving communities' health by enhancing cultural competencies in healthcare. Sustainability This was the second DNP project implemented in the organization, with high success rates, strengthening the program's sustainability. The project site champion and Unit Director have expressed interest in partnering and expanding the program. The program can be reproduced in any of the sites within the organization and has supported evidence of the short-term success of the program. Furthermore, the program could be dispersed outside the organization, as the content applies to all middle/high school youth. Dissemination Plan The project dissemination plan includes a presentation of the project and poster at the ECU CON on April 11, 2023, to fellow students, faculty, and guests. The project paper will also be published in The ScholarShip, a digital graduate student work source. Section VI. Conclusion Limitations The literature review revealed that afterschool programs were valuable resources for CTE-based learning. Despite literature supporting these programs, the afterschool setting has barriers and limitations to including them in their organization. The most significant limitation is seen with attendance due to other afterschool activities, like sports and clubs, and early pick-ups from the program. Another limitation that did not significantly contribute to this implementation was sickness-related absences. During implementation, there were high numbers of influenza, respiratory syncytial virus, and COVID-19 among school-aged children than seen in previous years before the COVID-19 pandemic. However, among the targeted population, these illnesses did not affect attendance as much as initially thought but do have to be considered when conducting the programs as the sessions build on each other. Furthermore, the organization had multiple last-minute changes in their calendar days that limited the availability of scheduling special events and ultimately cut back on time available during these sessions. The healthcare education program session was initially planned for a teacher workday, where the participants would be on site for the entire day, allowing more devotion to the length of the session. During implementation, the organization changed its policy on days they would be open and deemed teacher workdays and non-major holidays non-operational. Furthermore, the field trip was intended to take place on a non-major holiday or teacher workday; however, it was scheduled for an early release day due to availability at the college. Retrospectively, if the initial plan had been in place, the organizational changes could have affected the field trip impairing the content that would have been learned from this session. The goals of healthcare education program and the college tour field trip were to provide the participants with hands-on experience in healthcare careers and provide resources for obtaining higher education. Another limitation that should be considered is the timing of the afterschool program and the content of the program. While afterschool programs can successfully perform CTE programs, the content must be engaging. While most sessions included games and involved the students performing hands-on tasks instead of lectures, students reported tiredness impacting their engagement during the program. While necessary, some of the program's content was not as engaging as other sessions. Most students were more interested in hearing from healthcare professionals from various backgrounds. There were multiple opportunities for the students to hear from healthcare professionals, but not all were in areas where each participant was interested. The original plan was to have content-based learning and guest speakers each session; however, because of the timing of the session, this was not a feasible goal. Another drawback was that the content of the program stayed the same. Thus, retaking the program the following year would not be as beneficial, and re-implementation at the same site the next year would not be conducive to the project site. This point highlights why there are low enrollment rates of eighth and ninth-grade participants during this project's implementation. Lastly, some of the sessions required multiple facilitators to improve the flow of the session. Due to staffing and volunteer issues, many sessions were conducted solely by the team leader. During sessions that recommended multiple facilitators, time could not be spent discussing the implications of the session to healthcare careers; however, the small group made these sessions feasible. In a larger group of participants, staffing needs to be considered before implementation in improving the debriefing sessions and helping the participants make connections. Facilitators Compared to the previous implementation, one of the largest facilitators was lifting COVID-19 restrictions at the project site. The initial project required volunteers to attend a mandatory two-hour COVID-19 training to be allowed on the site, ultimately eliminating the ability of guest speakers to present on the site. This implementation allowed guest speakers to visit the site twice without prior training. Another facilitator of the project was the community college tour. Many students were not interested in attending a university and were more interested in associate degrees or certificate jobs. During the community college tour, the students gained insight into all the various certificate and associate-level careers offered at the local community college. The recruiters also made a point to elaborate on the clinical ladder that careers in healthcare possess, which was also highlighted in various sessions throughout the program. Lastly, the largest contributor to the project was organizational support and the willingness to develop a partnership with local higher-educational institutes. The organization has already expressed interest in continuing the partnership with ECU CON. Additionally, the organization is willing to partner with other local institutes, like the community college and other healthcare science divisions at ECU. This would aid in dispersing the project to multiple sites, providing more opportunities for the targeted population. Recommendations for Others Participants were asked after the last session if they would be interested in continuing to participate in the HCEC program and if they would suggest their peers join. Three of the five students, 60% of the participants stated that they would like to continue the HCEC program. The two students that did not answer yes to continuing the program reported that they did not know if they were interested in continuing. There is still some possibility they would continue with the program depending on the content for the subsequent implementation. All five students said they would recommend the program to a peer. Lastly, the Unit Director and Project Site Champion agreed they would like to continue the HCEC program on their site and within the organization. Not many changes would have to be made to continue the program. The program's cost is minimal for implementation, making implementation at a larger scale more feasible. Furthermore, the site had many necessary materials to conduct the program. Overall, the most significant conflict was scheduling on the level of the organization, school calendar, and guest speaker/field trip availability. The resolution to scheduling conflicts is advanced planning on behalf of the team leader and project site remaining flexible, and having alternative plans. Guest speakers might have to request time off to participate in the session. Furthermore, advanced planning for the field trip would ensure that the group can get on the schedule for the best day for the institution, the organization, and the school calendar. For the project to succeed at an alternative site, the Unit Director must take extra time in their normal job routines to accommodate meetings with the team leader and adjust the participant's regular afterschool routine once a week during the implementation. The consistent theme from the feedback from the participants was having more guest speakers and field trips, which was also a recommendation in the initial project implementation. Time constraints of an afterschool program are the primary barrier for this to succeed. Alternative options to help combat the time constraints include a healthcare careers fair, virtual meetings with healthcare professionals, project implementation over the summer, and off-site visits during non-operational hours. A healthcare careers fair would be an opportunity to expose the participants to many healthcare professions. However, this is an enormous undertaking and would require collaboration with another volunteer, such as a student, college, or healthcare system, to be successful. One of the main goals was exposing youth to healthcare individuals with similar backgrounds; however, this took extra time and special consideration when planning session four and should be considered in the future planning process. Due to the smaller group size, opening the fair to all middle and high school members at the organization would increase the outreach and exposure to under-represented youth. Another suggestion would be to include virtual meetings or pre-recorded videos of individuals from healthcare fields to help combat taking time off from work. The drawback of pre-recorded videos is that the participants cannot ask questions. It was not specified whether the organization would adapt the new operational hours implemented during the project's implementation, where the organization would not operate on teacher workdays and non-major holidays. This change makes scheduling off-site visits more difficult again due to time constraints. A suggestion would be to have the off-site visits during non-operational hours or in the summer. The most feasible option would be conducting the program during the summer since the participants are on-site all day. Summer implementation could occur multiple times a week and be performed earlier when the participants are less tired and more attentive. This would help with attendance and combat early pick-up. Lastly, the college/career self-efficacy tool should be modified to accommodate the interpretation of ratings for the targeted population. A five-point Likert-style rating scale was used to rate self-efficacy during this project implementation, which affected the overall data reported for self-efficacy. This project had to report that only 80% of the participants had increases in college/career self-efficacy, despite the one decrease in rating their self-efficacy at 97%. This is an insignificant finding caused by an error in the design of the evaluation tool. Making the tool more straightforward and decreasing the rating ambiguity for the targeted population could help improve outcome data and reporting of nonsignificant data. Recommendations Further Study The goal of the team leader and project site champion is to continue implementing the HCEC and expound upon the program utilizing feedback from future participants. Ideally, the project would be dispersed to other sites within the organization. Four other sites are within the organization in Pitt County and five in surrounding counties. Future recommendations for project implementation in the organization would be to circulate the HCEC program through each site due to the content remaining the same. Despite prior participants reporting interest in continuing the HCEC program, no youth re-enrolled in this project implementation. The participant numbers were lower than the initial project implementation. If the project had been implemented in another site within the organization, it might have reached more of the population. Circulating the project through the organization would help prevent lower enrollment numbers and reach more of the targeted population per implementation. Moreover, partnering with another DNP student, local community college Health Science Division, ECU health science divisions, or ECU Medical Center to conduct a healthcare careers fair would be an ideal way to consider the participants' feedback from the previous two implementations. The local community college expressed interest in having the participants of the HCEC return for a healthcare career fair in the spring, which could be a continued partnership with the program and organization. The program could be implemented in other settings, such as summer programs, and benefit any middle or high-school student. CTE education has shown to be a foundation for the youth to gain more insight into career exploration. A gap in the project that was found to be a positive influence in the literature review was the use of mentors. Sources of mentors would require further partnerships in the community to include a diverse group of mentors that can identify with the participant's background. The use of mentors serves to help the youth formulate ideas about their potential success and aid in improving their self-efficacy. Sources of mentors could be high-school students in the Health Science Academy, health science students in community college, or the university. Final Thoughts The purpose of this Doctorate of Nursing Practice (DNP) project was to provide early intervention in promoting self-efficacy toward career development through healthcare exploration courses in at-risk middle school youth. 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