Nudging Healthcare Students Through a Pandemic

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Shortages in the U.S. healthcare labor force, which were already on the horizon before the COVID-19 pandemic, are coming faster and looming larger than anticipated. First, most of the baby boomers will retire by 2030, gutting the labor pool and gradually increasing the population of Americans with serious healthcare needs. Second, the pandemic has driven away workers due to stress, burnout, and fear. Finally, enrollments have plummeted by nearly 15% at community colleges, the primary trainer of U.S. healthcare workers.

This is why myself, along with colleagues Dr. Betsy Sparrow from Persistence Plus and Dr. Lois Joy from Jobs for the Future, studied one strategy to shore up cracks in the community college healthcare pipeline. Our research, published last week in the Journal of Postsecondary Student Success, showed that a series of evidence-based nudges, delivered via text message, boosted re-enrollment among this critical population. Moreover, these nudges reduced racial equity gaps, another pressing issue impacting both the robustness of our labor force and the health of our communities of color.

Nudging healthcare students

We partnered with the allied health program at Delaware’s sole community college, Delaware Technical Community College (DTCC). Allied health, which includes fields such as dental hygienist, radiologic technologist, and histotechnician, is both DTCC’s largest program and the one with the highest attrition. Together, we designed a summer nudge intervention that encouraged DTCC students who intended to enter the allied health pathway to re-enroll for Fall 2020, a precarious time in the course of the pandemic given the continuing spread of COVID-19 and the lack of vaccines.

We tested our intervention using a randomized controlled trial, with 3,299 eligible DTCC students randomly assigned to either receive nudges or serve as controls. Treated students, who received an average of 17 text messages over 8 weeks, re-enrolled at a significantly higher rate than students in the control group (74% vs. 71%). More importantly, nudges disproportionately benefited those students typically underserved by allied health programs. Specifically, nudges significantly boosted re-enrollment among Black students (75% vs. 68%), as well as male students (74% vs. 63%), reducing racial and gender equity gaps in persistence each by almost 90%.

Leveraging behavioral science in healthcare pathways

One takeaway from our research is the importance of behavioral science in persistence messaging. Our nudges primarily focused on helping students connect their personal values to their educational and career goals. For example, 77% of respondents told us “helping people” was their primary reason for going into healthcare, and we nudged them to reflect on how their coursework served that self-transcendent purpose. When asked how they’re already using their skills to support others, one student shared how they’re helping a friend cope with having twins in the NICU. Another student seeking an associate’s degree in nursing drew inspiration from family: “My grandmother was a phlebotomist my mother was a CNA my aunt is a nurse practitioner so nursing has always been in my family and the passion for health care has always been in my family.”

While economic benefits are always a driving force behind education, we mustn’t neglect the pro-social benefits, especially for helping professions such as healthcare. Interdependent values often benefit those students historically underserved by higher education, including Black and Latinx students, first-generation students, and students from lower-income backgrounds. Tying students’ coursework to their sense of familial and community interdependence helped to motivate re-enrollment during such a challenging time. Thus, from recruitment to graduation, colleges should make sure to convey the intrinsic, self-relevant rewards of working in healthcare, not just the external ones.

Nudges for returning students

We also found that nudges inspired many DTCC students who had taken a break from their education to return. Some students in our sample were enrolled at DTCC in Fall 2019 but not Spring 2020, meaning they were on hiatus immediately before our nudging commenced. Among these students, 68% returned after being nudged compared to 55% in the control group. As one student shared with us at the end of the study, “I took a break over the summer because of health and yesterday I enrolled for my classes. That was in part the constant communication and support from DTCC.”

As community colleges nationwide strategize around how to get students to return, our research suggests a few ideas. First, messaging that prompts students to reflect on why they attended college in the first place, rather than just reminding them about things like payments due and registration deadlines, may be just as influential for recruitment as it is for persistence. Second, text messaging may be the best method to connect with students who are on the fence about returning. Not only is texting light-touch, reducing the threat of “nagging,” but by nudging intermittently over the course of the summer, we afforded ourselves multiple opportunities to connect with students when they were in the right mindset to re-enroll.

Looking ahead

Our study also adds to the growing body of evidence about how nudging can help community college students, countering the issue that too little nudging research is conducted outside of four-year, R1 institutions. Given community colleges' key role in feeding both the middle-skills labor force and four-year universities, as well as increasing economic mobility and equity, we need to better understand how behavioral science can improve recruitment, retention, and transfer pathways at these institutions. Alongside our prior work showing the benefits of nudging early-career community college STEM students, our new study underscores what nudging can do in this space. While we continue to research how best to use nudging to support community college students, we encourage practitioners to test these strategies in their own local contexts and share what they learn, accelerating our collective knowledge on how nudging can help more students succeed.