The challenge. Children growing up in low-income urban neighborhoods have limited access to the resources and opportunities they need to grow into successful adults.
Working as a school nurse in a middle school in Camden, N.J., Robert Atkins, PhD, RN, saw the deficits but also the strengths and resiliency of the bright and engaging young people he worked with. The experience launched him on a quest to find out how neighborhood poverty and childhood personality interact to influence health and well-being.
An "outlandish" career choice. Graduating from Brown University in 1990 as political science major, Atkins was headed toward law school and a career in government and politics. A stint at a psychiatric facility for children and adolescents directed him toward a field he had never considered—nursing.
"At the psychiatric hospital, I realized there was a nurturing part of myself that I didn't know I had," Atkins said. "In our society, I don't think we give men many opportunities to be nurturing. We don't expect it. At the hospital, my job was to meet the needs of others. That was very rewarding and got me interested in health care."
Atkins assumed that he would go to medical school. "But when I talked to people about what I was doing—directly with the kids and helping them get better by providing health education and health promotion—people said, 'Oh, it sounds like you should consider nursing.'
"It sounded outlandish at the time, but the more I heard it, the more I considered it," he recalled.
He enrolled in an accelerated BSN program at University of Pennsylvania. His goals were clear—to work with children. "I did not want to work in a hospital," he said. His first job out of nursing school was as a school nurse at a middle school in Camden, N.J., a city of about 80,000 near Philadelphia.
Where trouble finds you. Camden is just a 15-minute drive—but a world away—from the affluent Cherry Hill, N.J., neighborhood where Atkins grew up. "In Cherry Hill you have to look for trouble," Atkins says. "In Camden, trouble finds you. You could go down the wrong street, talk to the wrong person, and you either become a victim or get caught up in something you shouldn't be in. It's hard to find good things to do."
Working in Camden opened Atkins' eyes to what was happening in high-poverty, urban settings. "These kids, who were so empathetic and fun, and bright and thoughtful, were not achieving and becoming healthy adults. But they were not that much different than I was as a kid. So what's going on here?"
What was going on was complicated, Atkins discovered, but part of it was simply a lack of opportunities. "In Cherry Hill, adults put resources into kids, and they look at kids as a resource. In Camden, kids are looked at as problems to be managed."
Getting to know their names. Atkins and his colleague Dan Hart, EdD, professor of psychology at Rutgers University's Camden campus, decided to do something about it. They started a youth-development program called STARR (Sports Teaching Adolescents Responsibility and Resiliency) in 1995. STARR is now part of the Rutgers Center for Children and Childhood Studies that Atkins directs.
Atkins had played soccer at Brown, so STARR opened up a soccer league to kids hanging out on the street with nothing to do. "They did not care a hoot about playing soccer," Atkins said, "but they did care about being in a program where there were adults that were caring and consistent and got to know their names and joked with them."
The program expanded to include regular cultural and recreational outings and summer camp in Vermont. STARR volunteers also helped connect young people to jobs and free or low-cost health insurance for which they were eligible. This led Atkins and Hart to launch another program, Healthy Futures for Camden Youth, which aimed to improve children's access to health care. Central to the program was the door-to-door canvassing of neighborhoods throughout the city in order to enroll low-income and immigrant families in the health insurance programs that are prerequisite to obtaining care. See the website for more information. See results of a canvass here.
Launching a research career. Atkins' experiences in Camden set the tone for his future career as a nurse researcher. He earned a master's degree in nursing at Rutgers University (he did his coursework in Camden) and in 2004 completed a PhD in health studies at the Department of Public Health at Temple University in Philadelphia.
Returning to Rutgers as a professor in the nursing school, he applied for and was admitted to the first cohort of the Robert Wood Johnson Foundation Nurse Faculty Scholars program in 2008. Read more about the program in the Progress Report.
Being a scholar has helped accelerate his research into the effects of urban poverty on child and adolescent health and development. Atkins' work explores three questions about the health and development of youth living in high-poverty neighborhoods:
- How do social and institutional processes influence the health and well-being of youth living in high-poverty neighborhoods?
- How does childhood personality influence the emergence of health-damaging behaviors in adolescence?
- What do youth in high-poverty neighborhoods do to promote, maintain or restore their own health?
In one of his studies, Atkins applied three personality types to children growing up in poverty—resilient (well-adjusted), overcontrolled (prone to anxiety) or undercontrolled (prone to impulsivity). Undercontrolled and overcontrolled children, in general, tend to have poorer outcomes in health and well-being than children with resilient personalities.
Atkins found that children with these two personality types who grow up in poverty tend to show the more extreme aspects of their type. "Kids with these personality traits often interact with their environment in ways that push them further outside of where they could be successful," Atkins said. "For example, they may tune their teacher out, and then the teacher tunes them out too."
The findings have implications for any environment where kids are under stress, Atkins said. "We need to think about how to create environments for kids that are not toxic, that are not stressing kids out in ways that are detrimental to their intellectual functions and their physical health. What my work is showing is that their psychological well-being and their personality development are at risk too."
Gaining confidence as a leader. Along with supporting an ambitious research agenda, the RWJF Nurse Faculty Scholars program has given Atkins the tools to step confidently into leadership roles both inside the university and beyond. He credits the program's leadership training and mentoring with his recent appointment as the acting associate dean of Rutgers' new school of nursing in Camden and as director of the university's Center for Children and Childhood Studies. The STARR program, which set Atkins on his path, is now part of the center.
"One thing that RWJF did was put us in a position where we could talk like leaders and present ourselves as people who are leaders," Atkins said. "I attribute a lot of what happened to me at Rutgers to being an RWJF scholar. I can take a seat at the table because I belong at the table."
Courtney Lyder, PhD, RN, dean of the UCLA School of Nursing, served as Atkins' national mentor during his stint as a Nurse Faculty Scholar and watched Atkins grow as a leader. "He found a voice and, with conviction, the true area of science he wanted to contribute to," Lyder said. "It was a major transformation in his thinking, in his confidence that what he is doing is absolutely correct."
Atkins hopes to use his growing influence within the university to continue to make a difference in Camden. "Our Camden campus is focused on taking university resources and applying them to community problems," he said. "The university cannot be a cure-all for what ails a city, but in terms of education—in the school of nursing and around community health—there is a lot we could do to make a difference in the lives of children and families living in a place like Camden."
Connecting the dots. Atkins wants to create community health rotations in Camden's elementary schools, so that nursing students have the kind of exposure he had to the many career possibilities open to them.
"Schools are so much a part of the lives of kids," Atkins said. "If we could get nursing students to do things around health promotion, eating and physical activity, health literacy, they would see the great kids and families that are here in Camden. And they would see that, hey, there is so much I can do as a nurse in the community."
What Atkins learned working in Camden could have a wide-ranging impact on policy and practice. "This program teaches Nurse Faculty Scholars that the work they do, the questions they ask in their research can bring about change, whether the change is at the unit level, a clinical hospital ward, a hospital, a city, a state, or a nation. What they do matters," said Lyder.
"That is what I saw with Bob," said Lyder, "that he was able to connect the dots and say, 'I am affecting an impoverished population in New Jersey, and this has implications not just for little New Jersey, but for urban areas around this country and potentially globally."
RWJF perspective. The Robert Wood Johnson Foundation Nurse Faculty Scholars program offers three-year career development awards to outstanding junior faculty. By providing mentorship, leadership training, and salary and research support to young faculty, the program aims to create the next generation of national leaders in academic nursing and to strengthen the academic productivity and overall excellence of nursing schools.
The program has admitted 54 scholars in four cohorts—15 each in 2008 and 2009 and 12 each in 2010 and 2011. The scholars represent 44 U.S. colleges and universities.
RWJF Program Officer Maryjoan Madden, PhD, RN, notes, "Nurse Faculty Scholars is a very important program within RWJF's Human Capital Portfolio where we are focusing on workforce issues, leadership and diversity within the health care professions. There is a shortage of nursing faculty and through this program we are creating a cadre of leaders in academic nursing who will teach the next generation of nurses.
"This is a relatively young program for us—we have just graduated our first cohort. The overall effects will not be known for many years, but already the quality and productivity of the scholars is obvious. As one indicator, nine scholars have been elected to the American Academy of Nursing, the most prestigious honor in nursing. Achieving this milestone so early in their careers is a tribute to their skills as researchers, nurse scientists and teachers—and to the mentoring and leadership development the program has provided.
"Although much of our focus is on enhancing the leadership capability of the individual scholar, we know that scholars benefit the university in terms of research dollars, prestige and influence," said Madden. "That's one reason we have tried to reach beyond the tier-one research universities. By choosing scholars from schools that are not research-intensive, we can help develop the rest of the faculty and strengthen the school."
While the need to address disparities in care is well known, few strategies for reducing disparities have been studied systematically.
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