Nurse Education Today 43 (2016) 2327

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Nurse Education Today

journal homepage: www.elsevier.com/nedt

The continuing quest for parity: HBCU nursing students' perspectives on

nursing and nursing education
Costellia Talley a,, Henry Talley b, Janice Collins-McNeil c
a
Michigan State University, College of Nursing, 1355 Bogue Street, Rm 247, East Lansing, MI 48824, USA
b
Michigan State University, College of Nursing, 1355 Bogue St., Room #A120, East Lansing, MI 48824, USA
c
Winston Salem State University, Department of Nursing, Winston Salem, NC 27110, United States

a r t i c l e i n f o a b s t r a c t

Article history: The benets of a diverse nursing workforce are well-recognized, yet, the attainment of a sustainable, competent
Received 24 July 2015 and diverse nursing workforce continues to be a global challenge. In this qualitative study, we describe nursing
Received in revised form 21 March 2016 students' perceptions on nursing and nursing education at a Historically Black College/University (HBCU).
Accepted 18 April 2016
Focus groups were conducted with 16 graduate and undergraduate nursing students. Four themes emerged:
Available online xxxx
communication, lack of resources, support systems and professional socialization. Mentoring and civility were
Keywords:
identied as factors important to enhance a diverse workforce.
Diversity 2016 Elsevier Ltd. All rights reserved.
Global nursing
HBCU
Nursing
Nursing education
Student perspective
Minority

1. Introduction work environments, the increasing complexity of health care delivery,

By the year 2035, there will be a worldwide shortage of healthcare
workers, totaling 12.9 million (WHO, 2006, 2014). These ndings have
enormous implications for nursing, because nurses are front-line
healthcare providers and have a direct impact on shaping the health
status of patients, globally (Kulwicki, 2006). Evidence indicates that a
well-trained, diverse nursing workforce improves health care quality,
patient outcomes, healthcare access, and decrease health disparities
(Institute of Medicine, 2004, 2011; Sullivan Commission, 2004).
The globalization of nursing creates an interconnected workforce
that crosses international boundaries, systems, structures, and processes
to provide care to and improve the health outcomes of people around the
world (Jones and Sherwood, 2014). To illustrate, 8.1% of the nursing
workforce in the United States is internationally educated (USDHHS
and HRSA, 2010). By the year 2060, 57% of the United States population
will be racial/ethnic minorities (United States Census Bureau, 2012). Like-
wise, by the year 2020, some London boroughs will have ethnic majority
populations, and eventually the entire Greater London area (Bains, 2006;
Coleman, 2010). The global demand for nurses is fueled by an aging pop-
ulation and nursing workforce, a shrinking applicant pool, unfavorable
and international nurse migration (Ford and Stephenson, 2014; Nichols
et al., 2010).
As the global demands for nurses increase, it is important that we
address nursing workforce issues. According to Nichols et al. (2011)
nursing leaders of today must be prepared for a nursing practice
environment inclusive of local, national, and global work issues. For
example, 41% of nurses under the age of 50 left nursing for workplace
related issues (e.g., stressful work environment, poor management,
and burnout) (U.S. Department of Health and Human Services and
Health Resources and Services Administration, 2010). To improve nurs-
ing workforce diversity, we must move beyond just counting numbers
to addressing factors that inuence not only recruitment, but retention.
The purpose of this study is to describe nursing students' perceptions on
nursing and nursing education at a Historically Black College and
University (HBCU). We dene perception as the process of making
meaning about others based on one's own subjective social and cultural
perspectives (Warren, 2015). HBCUs t within the changing land-
scape of higher education because of the diversication of their student
population in terms of race/ethnicity (Gasman, 2013). Their percep-
tions can provide insight to better understand employment, integration,
and assimilation of a global nursing workforce.

The authors have no nancial or proprietary interest in the materials presented herein.
Corresponding author.
E-mail addresses: talleyc@msu.edu (C. Talley), talley@msu.edu (H. Talley),
mcneiljc@wssu.edu (J. Collins-McNeil).

http://dx.doi.org/10.1016/j.nedt.2016.04.006
0260-6917/ 2016 Elsevier Ltd. All rights reserved.
24 C. Talley et al. / Nurse Education Today 43 (2016) 2327
2. Literature review
HBCUs are institutions established prior to 1964 for the main
mission of educating African Americans. Since that time, the enrollment
rate of White nursing students at HBCUs has increased to 31% (National
League for Nursing, 2009). Students that attend HBCUs are generally
from a wide range of cultural and socioeconomic backgrounds and are
often low income, rst generation, and Pell Grant eligible (71%)
(Gasman and Conrad, 2013). The HBCU in this study, is a North Carolina
public, master's level coeducational (a constituent institution of the
University of North Carolina) university with a diverse student enroll-
ment (72% African American; 17% white; 2% Hispanic; 9% other;
Undergraduate and Graduate; Fall 2012).
Although initiatives to increase nursing workforce diversity have
been implemented, the numbers continue to be low. For example,
African Americans account for 6% of the U.S. registered nurse (RN)
workforce (American Association of Colleges of Nursing, 2015), despite
being 13.2% of the population (U. S. Census Bureau, 2014). Similarly,
Latinos constitute 15.5% of U.S. population, but 5.4% of RNs (Institute
of Medicine, 2015).
The limited increase of underrepresented nurses has been attributed
to attrition, limited pipeline, and limited opportunities for advancement
(Xue and Brewer, 2014). The cause of disparities in the healthcare work-
force is complex, but includes: lack of supportive environments, racism
and discrimination, stereotyping (Hall and Closson, 2005), alienation
and loneliness, nancial difculties (Moyce et al., 2015; Wheeler et al.,
2013) and the lack of diversity among nursing faculty. Among baccalau-
reate and graduate level nursing faculty, 7.1% are African American and
2.3% are Latino. This study explored HBCU nursing students' perception
of nursing and nursing education.
3. Methodology
Homogenous focus groups with undergraduate and graduate
nursing students were used to explore their perceptions about nursing
and nursing education; facilitated by an African American moderator
(HT) and note-taker (CT), who have experience in qualitative research
methodology. Homogenous groups allow for cultural and language
concordance, and maximizes the groups' cohesiveness and openness
when discussing sensitive issues (Greenwood et al., 2014). Eligible
were students enrolled in a pre-nursing or nursing program, 18 years
of age or older, able to speak and write English and willing to
participate.
3.1. Procedures
With Institutional Review Board approval, a purposive sample of 16
participants was recruited via email, word of mouth, with the assistance
of a faculty member from the HBCU. Authors used semi-structured
topic guides to generate discussion about the students' perceptions of
nursing and nursing education. Participants completed a short demo-
graphic questionnaire. Sessions were digitally recorded approximately
120 min. The note-taker noted nonverbal actions (e.g., crying, head nod-
ding) that could not be recorded.
3.2. Data analysis
Analysis was focused on students' perception of nursing
and nursing education. Recordings were transcribed verbatim and
the coding team independently analyzed each transcript and
assigned codes to words, phrases, and sentences. Independently
generated themes were reviewed and a nal coding scheme was
adopted.
4. Results
A total of 16 students (undergraduate = 11; graduate = 5)
participated in the sessions; most were female (12), African American
(14), and not married (10), ranging in age from 22 to 40 years. Five
were rst generation college students and 2 were rst generation
high-school graduates. Four major themes emerged; two were catego-
rized as barriers to nursing and nursing education: communication
and lack of resources. Two were deemed to be reective of facilitators
of nursing and nursing education; support systems and professional
socialization.
4.1. Communication
The focus group process enabled students to identify and make
sense of shared perceptions; for some, the groups were emotional.
One student remarked:
I don't know why I'm crying so much. I think it's the questions that
were being asked and just the ability to analyze some of the things.
4.1.1. Hopelessness
Students reported hopelessness in terms of requirements for entry
into advanced nursing program and that they would not be able to
meet their personal goals. One student made the following statement
about a presentation from a major university about their advanced
practice program:
He didn't even give us a ray of hope and he didn't show us any way to
move on. I went home that day so depressed, it's not possible. Everyone
was hopeless.
Students also felt that the majority colleges/universities believe that
HBCU's programs were not as rigorous as their institutions. Students
reported a perception of exclusion or weeded out (slang for eliminate,
get rid of). As one student explained:
I also feel like I've been kind of weeded out because I am an African
American student coming from an HBCU.
4.1.2. Discouragement
Some felt that majority universities do not commit to diversity
because of the limited number of minority students they admit. One
student stated:
and if they do reach out to the minorities it's one or two minorities
and that's all that's in the program, and we're done with that.
Discouragement from colleagues, clergy, and management was also
reported affecting participants' differently. One student said:
I was the one who, individuals would tell, I wasn't good enough to go
and pursue a master's degree; I was the same undergraduate student
who thought I could never get into ICU and I actually went into ICU as
an undergrad.
4.1.3. Workplace violence
Graduate students reported lateral and vertical violence from co-
workers and supervisors; dened as repeated, offensive, abusive,
intimidating, or insulting behavior, abuse of power, or unfair sanctions
that makes recipients upset and feel humiliated, vulnerable, or threat-
ened, creating stress and undermining their self-condence (Vessey
et al., 2010). Studies report bullying rates of 31% for nurses in the U. S.
(Simons, 2008); 44% in Britain (Quine, 2001); and 57% in Australia
(Curtis et al., 2007). Workforce violence between peers is termed lateral
violence; between different power levels, vertical violence (Waschgler
 C. Talley et al. / Nurse Education Today 43 (2016) 2327
et al., 2013). One student recounted her experience with a nurse
manager:
they've been beat down so much and told so much based on
evaluations from other nurses or management that they're incompe-
tent. And so after a while when you tell me that over a period of time I
begin to believe what you say. Well I didn't believe it, just to let you
know (Vertical violence).
4.1.4. Discrimination
Students experienced and viewed racism and discrimination as
synonymous; especially in terms of opportunities, promotion, and
professional development. One student stated:
When I rst came onto the healthcare scene, as an African American
male, I was treated different than my Caucasian counterparts. I was
passed up on different opportunities Sometimes blatantly, sometimes
it subliminal, but it's denitely there.
Another student felt that there were barriers in place to limit career
progression.
I myself have been a Certied Nursing Assistant for ten years. Every-
thing was smooth but the minute I set out to raise up my educational
level is when all these obstacles started taking place. so I go back
and get my BSN you got your education and you know you're
qualied; okay, why do you have this two year Associate Degree Nurse
being a manager and here I am with a BSN degree, you know it's racism
so they put limits on these jobs then you can't do nothing, so that's why
I'm here now getting my master's degree. So what else can you say, that,
no, you can't have this position when I have the education and the
experience for these positions.
Another student commented on his experience of discrimination
toward African Americans.
I have not personally experienced it but again, Ive seen my friends who
were African American become singled out because of their color. I do
understand that there is a certain amount of racism, culturalism that
goes on in the profession and I understand that there's a difference, I just
don't really know how to address it other than not participate in those
type of activities and hopefully my actions will speak loud enough for
themselves (statement made by a White student).
A Black African nursing student felt that she had to work twice as
hard for recognition and inclusion. Lack of recognition and inclusion
often lead to isolation and withdrawal from engagement in practice
(Likupe, 2015b). The Black African nurse provided this insight:
I realize that a lot of times there's so much segregation in class and it's
not just me; people from my country or from my culture all over, not
just in this school but in every other school so far agrees. All they say
is this, even the African Americans do it to us because we have a differ-
ent accent, probably do it unconsciously. But somehow we feel left out. I
literally have to run after most of my classmates to make sure that I'm
included, and after a while you say, you know what, I'm done with this.
4.2. Resources
Most students were nontraditional, which means that they met one
of the following characteristics: older age (25 years), delayed college
enrollment, nancially independent, work full time, attend college
part time, has dependents other than a spouse, and/or is a single parent
(Pelletier, 2010). Most students received a federal loan (12) to assist
with tuition yet still felt that the cost of an advanced degree was almost
an unmanageable burden. One student explained:
25
I don't want to be in debt for the rest of my life but I do want to further
my education, so that's one of my limitations.
4.2.1. Informational resources
While students were aware of the advanced practice roles in nurs-
ing, insufcient knowledge about the academic process and programs
were revealed.
I think that if we have information about schools being offered to us,
what we can do to perhaps go down that path, and also to speak with some-
body who's currently in the eld who can just say to you, hey, this is how it
is, this is what I've done, this is what needs to be done, someone that you
can relate to kind of give you that inner perspective.
4.2.2. Lack of minorities
Students related that diversity in the profession and having minori-
ties that looked like them makes a difference in their decision to
pursue an advanced degree. One student stated that:
I think it's really, really important that you see somebody from your
background in the profession that you want to be in or aspire to be in.
And so it's really important that you seek somebody of your color to kind
of bridge that gap.
and:
you learn so much about people when there's a good mix of people.
4.3. Facilitators
In addition to barriers, students suggested facilitators to help indi-
viduals from underrepresented minority groups and underserved
students seek advanced degrees.
4.4. Support systems
Participants identied support systems as important facilitators of
their education. Support systems included family, peers, and faculty;
stating that these systems are important because they provide encour-
agement, emotional and moral support. One student stated:
I don't know where I would be if I didn't have the encouragement from
my close knit study group and the faculty and my family.
Family support was identied as an essential component for
completion or the decision to pursue an advanced degree. A student
talked about the sacrices that family had made for him to pursue a
nursing degree:
I don't see how anybody does it without family support I know I
couldn't be where Im at today if I didn't have my mother to support
me, and say, just try your best. I think that's a big determinate for me
pursuing a higher education, my family's support (graduate student).
Faculty provided encouragement, situation-appropriate informa-
tion, and personal relationships; saying, faculty members encouraged
them to pursue advanced degrees on the rst day of the nursing pro-
gram. For some, particularly rst generation college students, faculty
was a tremendous source of support. A student said:
Im the only person in my family who's ever graduated high school
as well as college so I think the support of faculty plays a role because
to have a faculty that believes in you makes a difference. So that's your
support system, your faculty.
Another student described faculty as the enablers of a dream.
Most of us are still young when you're trying to gure out where it is
your next step is going to land, you always turn to those people that
26 C. Talley et al. / Nurse Education Today 43 (2016) 2327
meant the most to you, which is, in my opinion, the faculty. They're your
enablers to accomplish those dreams and without them, we wouldn't be
right here (rst generation student).
Students spoke about the importance of peers in terms of study
groups and having someone that is going through the same thing that
they are going through. A student stated that:
for me, personally just to have the friends there to encourage you
when you want to quit...
Another stated:
My nursing friends have become like family to me and they're really
there for me. They have my back and I have theirs and we study
together, we ght, we make up, but we're like family and it's made a
difference in making it this far.
Students identied the need for professional socialization in
terms of mentors and role models by individuals that are currently
in the eld.
4.5. Professional socialization
Students spoke of the need to be mentored by students currently in
graduate nursing programs, by individuals that are currently in the
advanced practice roles that they wish to pursue, and by someone
from their racial/ethnic background. For some, mentors and role models
were used interchangeably with key components being: respect, trust,
and appreciation of each other (Eller et al., 2014). A student made the
following statement, in terms of having graduate level students as
mentor/role models:
I have had the opportunity to work with graduate level students and
they have really inspired me as far as going to grad school. Because I
look up to them as my big sisters and they give me advise on what to
take and what not to take and they have really reached out to me.
Another student made the following statement about having
someone in the profession as a mentor/role model:
As an African American male nursing student, we are limited with
resources and role models are a great part of some of our lives, especial-
ly someone of that culture. If you've got a blueprint of a mentor or
someone that has already accomplished that, that will give you a better
pathway to get there, I think role models play a really big part in life.
Students wanted to be role models for other students and for their
families. A student stated:
To have the undergraduates look up you, ask you, what do you think I
should do? And have that conversation with you and you tell them,
yeah, I think you would be better off being a CRNA, don't do nurse
practitioner and just have that trust.
Another student made the following statement:
Im the rst girl in my family on both sides of the family to go to
collegemy younger cousins who are girls look and say, hey, she's in
college. She went to college, she's getting another degree. So it's
important for me to do it for my family.
5. Discussion
This study examined nursing students' perceptions on nursing and
nursing education at a HBCU. The data in this study indicated that
racial/ethnic minorities and underserved undergraduate and graduate
students experienced hopelessness, isolation, discrimination, inequali-
ty, and workplace violence that were stressful experiences in their
lives. These type of experiences are associated with more stress, poor
job satisfaction, missed work days, lack of morale, lack of trust, and
decreased communication and substandard quality of care to patients
(Otiniano Verissimo et al., 2014; Villarruel et al., 2001). Students
and nurses who perceive that they are not valued may become
disenfranchised in their careers (Alexis and Vydelingum, 2009). Similar-
ly, workplace violence often leads to loss of self-condence and self-
blame.
Similar ndings were reported in international studies. For example,
in a study of Black African nurses and their managers in the UK,
nurses and managers reported discrimination, racism, and unequal op-
portunities in the National Health Service (Likupe, 2015b). Likewise,
Hispanic nurses report being overlooked and undervalued, having to
prove competency, and living with only-ness (Moceri, 2014). These
ndings suggest that discrimination and inequality among racial/ethnic
minority nurses is a global phenomenon (Likupe, 2015a; Moceri, 2014;
Nichols and Campbell, 2010). It is important that health care systems
recognize that discrimination and racism occur; despite the presence
of policies, and that it may affect the recruitment and retention of highly
qualied nurses and nursing students.
Our ndings were consistent with that of other studies reporting
that underrepresented minority students report nancial difculties
when pursuing nursing and advanced nursing degrees (Carthon et al.,
2015). Students also reported that there was a lack of information
available to help navigate the nursing arena. Studies have shown that
underrepresented minority and underserved students have a greater
difculty navigating college and universities, which contributes to
attrition (Armstrong and Hamilton, 2013; Lareau, 2015). Students
also reported that there was a lack of role models that looked like
them. Similar to Lareau (2015), our ndings suggest that programs
such as those designed to help students build relationships across
institutions (students, faculty, staff) that help them to learn the rules
of the game.
Professional socialization and support systems were perceived as
signicant facilitators of academic success in the nursing program by
undergraduate and graduate students. This nding is consistent with
that of Chen et al. (2014), who reported that a supportive campus
environment is predictive of student satisfaction at both HBCU's and
predominantly White college/universities. We found that faculty
members were important to participants, particularly those that were
rst generation college students. Similar results were reported by
Dapremont (2011), who found that 78% of Black nursing students
perceived that faculty support and encouragement affected their
academic success.
Students also recounted the importance of mentors and role models
from similar backgrounds for academic and professional success. These
ndings correspond with those of Amaro et al. (2006), which illustrated
that students felt that having mentors and role models would provide
them information about classes, strategies to improve their academic
success and also provide motivational support. Evidence suggests that
early and frequent exposure to the role is essential for minority students
to choose the profession. This includes the attainment of skills, knowl-
edge, professional identity, and an understanding of the cultural
norms and values that underpin practice (Holland, 1999; Howkins and
Ewens; Price, 2009; Price and Price, 2009). Studies have shown that fac-
ulty role models and mentors enhance the enrollment of underrepre-
sented minority students and peer support enhances retention
(Carthon et al., 2015). Mentoring should begin in elementary school
and continue throughout high school (Cohen et al., 2006; Lauver et al.,
2011). Encouraging students at a young age by providing information
on requirements, the benets of a nursing career, and effective role
modeling are important.
Participants also wanted to be a role model for others, feeling a
strong sense of obligation and motivation to undergraduate students
and to their families. These ndings lend support to previous studies
reporting the importance of mentoring and role modeling for
 C. Talley et al. / Nurse Education Today 43 (2016) 2327
underrepresented minority students. These ndings suggest that men-
torship programs in which students are allowed to gain exposure to ad-
vanced practice roles or professions may be useful to attract students to
these roles (Talley, 2008).
5.1. Limitations
This was a small study at one HBCU; therefore, generalization is
limited and may not reect all HBCUs with nursing programs.
6. Conclusion
The ndings from this study indicate that to increase the diversity of
underrepresented minorities and underserved populations into nursing
will require targeted recruitment and retention efforts, effective role
models, mentoring of both faculty and students regarding educational
preparation and nancial support. Strategies to adequately meet the
global imperative of a diverse workforce call for educational and health
care institutions to promote an environment of parity and civility,
where discrimination and incivility is not tolerated. With the increasing
number of non-African American students attending HBCU nursing
schools, studies are needed to address the impact on the African
American nursing workforce and the impact of education at an HBCU
on the cultural competence/sensitivity of non-minority students. To
address the needs of racial/ethnic minority and underserved students
will also require a more diverse faculty mix. Aside from addressing
these issues, the ndings suggest that there is a need for programs
that fosters or enhances underrepresented minority students' and
faculty ability to learn the rules of the game. Recommended strategies
include modeling programs that have been effective in the recruitment
and retention of racial/ethnic minorities and underserved populations
(Brown and Marshall, 2008; Goeppinger et al., 2009).
Acknowledgements
The authors want to acknowledge the invaluable contributions of
the students and faculty of the participating programs. Your time com-
mitment and open dialog during this study will make a difference in the
lives of so many others.
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