By 2050, the projected Hispanic population within the United States is 102.6 million, or 24% of the nation’s total population (U.S. Census Bureau, 2007). Considered the largest and fastest growing minority population, the Hispanic population’s health care needs will continue to create significant demands on the current system. Having nurses who are not only bilingual but also understand Hispanic culture is imperative when interacting with Hispanic populations. Currently, Latino students account for only 5.3% of nursing school enrollment (National League for Nursing, 2006), with an even smaller percentage graduating. High attrition rates coupled with difficulties in recruiting will continue to negatively affect the nation’s health. This metasynthesis aimed to identify facilitators and barriers for Hispanic nursing students along their journey to success.
Unfortunately, Latinos have the lowest educational attainment of all groups. According to the U.S. Census Bureau (2003), more than one quarter of Hispanics had less than a ninth-grade education (27%), compared with only 4% of non-Hispanic Whites. Among the distinct Hispanic groups, Cubans have the highest high school completion rates with 34.8% and Mexicans the lowest with 26.7%, in comparison to 33% of non-Latino Whites (Chapa & De La Rosa, 2004). The numbers are even more disturbing when we delve into higher education statistics. According to the 2006 U.S. Census report, only 10% of Hispanics (compared with 24.6% Whites) have a bachelor’s degree (Office of Minority Health, 2008). Although the number of Hispanics in higher education has increased over the years, they still comprise less than 10% of total enrollments for all types of programs (Chapa & De La Rosa, 2004). In the fall of 2000, 58% of Hispanics enrolled in college were attending 2-year institutions, compared with 36% of Whites (Arbona & Nora, 2007). Although used as a gateway to a bachelor’s degree by minority students, for many, obtaining a 2-year degree is often a terminal point. Solórzano, Villalpando, and Oseguera (2005) noted that according to the U.S. Department of Education, in 2001 only 7% to 20% (of Latino students) of the initial 71% (who entered with a desire to transfer) actually attained that goal. Lack of academic guidance, difficulties with transfer requirements, and competing institutional responsibilities (Arbona & Nora, 2007; Solórzano et al., 2005) often fail to direct these students to 4-year institutions.
With the rapid increase of the Hispanic population and the large number of young Latinos, the potential for future college applicants is high. More than one third are younger than age 18, compared with approximately one quarter of the general population. The median age of Hispanics is 25.9, compared with 35.3 of non-Latinos (Guzman, 2001). These data illuminate two important factors. First, there will be a large number of age-appropriate youth to enter higher education institutions. These numbers also signify that a large number of Hispanics who fall within childbearing range (Chapa & De La Rosa, 2004) exists and therefore has the potential to contribute to the already fastest growing minority population. This ensures the fact that Latinos will continue to comprise a large portion of the educational system.
Another challenge facing Hispanic students is the severe lack of Latino representation in academia. The already low percentage of Latinos graduating from higher institutions coupled with an even smaller percentage of those with advanced degrees has negatively influenced the existing pool of potential applicants. Although there is a general lack of minorities in faculty positions, there is an even greater disparity in relation to Hispanic faculty. In 2003, Latinos comprised only 3.4% of faculty in degree-granting institutions and only 0.8% of nursing faculty (National Center for Education Statistics, 2008). This fact has a major effect on Latinos in colleges, given that their ability to find a role model or mentor is often shaped by the availability of Hispanic faculty.
In reading, analyzing, and interpreting the various studies, it became apparent that success for a Hispanic nursing student was influenced by various factors. A journey metaphor was used to describe the experience for the students. Merriam-Webster’s online dictionary (n.d.) defines a journey as “travel or passage from one place to another, especially one covering a large distance or taking a long time.” Encarta’s online dictionary (n.d.) also defines a journey as “a process of development or a gradual passage from one state to another regarded as more advanced.” For these Hispanic students, their journey occupied years of their life and also included various stops (or important themes) along the way. Interestingly, in comparing and contrasting many of the themes, it was noted that what proved to be a facilitator for some was also presented as a barrier for other students (Figure). Five overarching themes that encompassed the journey taken by these students were identified (Table 3). Although certain stages seemed vital at the onset (e.g., preparedness and financial aid), various issues permeated their entire trek. The themes revealed along the journey are significant areas that saturated all aspects of the students’ life while in school. Separately each individual theme could also be considered a terminal stop for some along this journey.
Figure. Thematic Dichotomies: Areas Considered Either a Facilitator or Barrier by Hispanic Nursing Students.
Table 3: Individual Metaphors as They Relate to Five Overarching Themes
The process was, in most instances, initiated for a specific purpose. As described by Erika, a fulltime 33-year-old Puerto Rican student, “I think it was more because I wanted a better life. I always thought if I finish school, I’ll get paid better and I’ll be able to live better” (Rivera-Goba & Nieto, 2007, p. 44). Their journey usually occupied years of their lives, with many dedicating and sacrificing family, friends, and self along the way. Through this metasynthesis, a more extensive and in-depth view of this journey was achieved. With nursing in a shortage crisis, lack of minority faculty, and low numbers in Hispanic nursing school enrollments, perhaps this can be useful in planning future programs that can change the current trends.
For most journeys to take place, there needs to be a monetary means, and this educational expedition is no different. Many do not even attempt the journey because financially they do not have the means. Not surprisingly, financial support or lack thereof was a significant issue throughout all of the studies. Affordability and availability of financial aid was a major facilitator in the initial decision to enter nursing school, as well as a key factor in the outcome of these students. Because many families are from lower socioeconomic areas, they were unable to provide monetary support or the contributions were minimal. For many of these students to attend nursing school, they had to work to fund their education. Nursing school demands, coupled with outside employment, caused extreme stress for many participants. A nursing student who participated in the study by Rivera-Goba and Nieto (2007) explained:
Second semester junior year, I was stressed out. Those were really tough classes that semester, and I was still working 40 hours a week. And there was nothing I could do about that. I went to school almost every day. After I had clinical and class, I had to go to work and on weekends I had to work, so it was tough. Every week I have to make the same exact amount of money because if I’m off one week, then I’m screwed.
Nursing students remain employed not only as a means to support their education but also at times to lend a hand to family at home. Often pressure from work and school overburdened the students and caused them to withdraw from the program (Maville & Huerta, 1997).
If financial aid, scholarship, or stipends were provided, it significantly influenced academic success. For those students who were provided with monetary aid, it allowed them to work less at outside jobs. This in turn availed more time for studying and family obligations, which are extremely important in Hispanic culture. The study by Evans (2007) revealed that the stipend provided to the students was highly valued. Responses included:
- “I was able to fulfill my family obligations because the stipend allowed me to have some free time.” (p. 358)
- “Finances are what usually stop a Hispanic woman from attaining her goals. The stipend has helped me so that I don’t have to worry about that.” (p. 358)
Yet another area of concern is that many Hispanic students are unfamiliar with financial aid. The cumbersome applications often burden both young and older students. For those who are first-generation college students or those who have English as a second language, the process is even more taxing. Goetz’s (2007
) students were discouraged by the lack of financial aid knowledge provided to them:
No one told me about financial aid. I didn’t know until I overheard some students talking about their aid. I asked one of them about it and I contacted them. I had to do it on my own. Someone should tell people about it when we first start.
For students in nursing programs, the travel to and from clinical sites and the costs of books, uniforms, and tools are other financial burdens. Although tuition costs may be paid by grants and scholarships, these added expenses often are not. Programs should include tuition payment and stipends to help defray these additional costs. A stipend may also offset the need for other employment, increasing the available time to focus on studies.
As discussed earlier, high school graduation is a problem for many Hispanic youths. Unfortunately, those who do succeed often find themselves unprepared for the difficulty of nursing school. In addition to lack of preparation due to poor study habits and time management skills (Maville & Huerta, 1997), a lack of motivation and confidence offered by teachers and guidance counselors was cited as a significant barrier. For many, high school graduation was the sole expectation, as depicted by one of the participants in Gardner’s (2005) study: Juanita (discussing her high school experience) stated:
It didn’t prepare you for college at all. It didn’t tell us what to do to get into college or anything like that. The push wasn’t to go to college but just to get you to graduate from high school.
A participant in Goetz’s (2007
) study commented she felt Hispanic students were pushed to take noncollege preparatory classes:
I think they didn’t encourage the sciences as much for Hispanic students.… They say, ‘You’ve completed your three years of math, why don’t you take photography or some other fun thing.’
Participants in Jones’ (1992
) study also echoed similar concerns. They felt that public school systems (especially in urban areas) failed to help students’ career plan.
Again when you are talking about public schools in the inner city, they do a very poor job of guiding students. Normally you go to school, you show up, you’re a fair student; all of a sudden you’re graduating with a high school diploma. But along the way, because you didn’t get it from the family, the peer group, or the school, you find yourself a high school graduate, but you really have no plans.
As many began their journey in distinct schools around the country, regardless of the type of program (associate, baccalaureate, master’s), they cited academic problems as a stumbling block. Given that many are unprepared for the difficulty, they find the workload to be overwhelming and almost impossible to handle. They are in need of tutoring, study groups, and additional guidance that is often not available (Amaro, Abriam-Yago, & Yoder, 2006). In the study by Perez (2003), Susanna reflected:
It is so demanding. I don’t know if I’d known how hard this way, if I’d have done it.… I’m missing a lot and this is my first semester. The time demands drive many students away from nursing.
Mentor programs should include academic support (e.g., tutoring, time management, and prioritizing skills) and monthly meetings used as an opportunity for support and guidance throughout the student’s trajectory. The incorporation of key advisors providing specific direction regarding class selection based on the individual needs of the student may also help ease the transition. Involving a Latina or Latino coordinator would be ideal.
For many Hispanic students, family and cultural heritage are essential and irreplaceable aspects of their life. There is often an intense and almost overpowering sense of family obligation felt by the students, regardless of distance or other responsibilities they may have. These profound feelings are often not understood by faculty in schools of nursing, as students are expected to put nursing school first during their academic career. Having to place nursing school as a priority was viewed as a deterrent for many Latino students:
If you are not familiar with the culture, you wouldn’t understand a lot of the behaviors.… Is it the same for everybody? I don’t know. I know in my culture, family takes precedence over anything. The President could be coming to your house and if Grandma falls sick, you dump the President and go see Grandma. Having those strong ties, sometimes it’s difficult to explain that to other people.
Although often a source of great motivation and support, family obligations and responsibilities can become an obstacle. It was noted in the study by Maville and Huerta (1997) that for those who did not continue in the school of nursing, personal commitment and obligations to family members emerged as a significant reason. They sacrificed their own personal success for the benefit of their family, obviously hindering their academic progression. For others, the decision to start nursing school or pursue advanced degrees is often met with resistance. In an example provided by Gardner (2005), Maria’s family was not supportive of her decision to attend college. As the first one to pursue a college degree, she continued to have a tremendous amount of responsibilities at home, despite the 4-hour distance:
You have so many other things that you have to do in the house before you can pay attention to your studies, and I think that is maybe why so many people (minorities) drop out.… Every single month I travel to my house, pick up all their bills and I send them all out. I make sure that things are paid on time. I make sure that stuff gets done. Everything! I make sure that their cars are running. I make sure that they have car insurance. I make sure that the house is paid. My mom doesn’t know how much her house payment is. She doesn’t know how much anything is. She just calls me and it gets frustrating.
Balancing home, school, and work was a task with which many of the students struggled. Those who were younger with no children still had to find time to communicate and be involved with family members at home. Even more difficult to handle were those with children and families to take care of in addition to their studies. They often relayed feeling selfish about being back in school and guilty over missed time with their loved ones (Goetz, 2007). Because family is a priority and maintaining a close connection is essential, choice of institutions is often affected by proximity to family. Donata, a participant in the study by Perez (2003), explained her reason for declining a scholarship to an out of town school: “You don’t leave your family.… It’s important to stay close” (p. 115). This may be another reason associated with the high level of community college enrollees, allowing students to either live home or within close proximity of family.
Of importance is the fact that many of the Hispanic students enrolled in higher education are often first-generation college attendees. Therefore, although the majority of families are extremely proud of the accomplishments thus far, they are often unable to understand the level of difficulty involved. Families are often unable to comprehend the level of commitment necessary to succeed in their journey to obtain whatever level of degree sought. The study by Villarruel et al. (2001) identified various familial barriers:
- I didn’t have any support from him (husband)…and it was hard because I felt so guilty. (p. 248)
- It’s not that our families don’t want us to succeed; it’s that maybe they don’t understand how to succeed with some of the educational opportunities.… You have to go seek out those support systems through other areas. (p. 248)
Language barriers faced by both parents and students were also cited as barriers. A lack of English fluency often hindered the parents’ ability to help their children with matters related to school. Some students described difficulty in understanding concepts; others felt that translation from Spanish to English got in their way (Goetz, 2007). Many thought others perceived them to be “slow” or “stupid” because of this. A student in the study by Perez (2003) stated:
I think my heavy accent was focused upon. They (instructors) didn’t listen to what I would say. They concentrated on the fact that I was a primary Spanish speaker and therefore I could not do well in school.
Although some students felt discriminated against because of language, they did feel that this was a helpful resource used in the clinical setting. They were usually given Spanish-speaking patients and called on to translate for other students and even the teachers. Being bilingual allowed them to form bonds with patients who could not communicate with others.
Collaboration with campus cultural centers to provide opportunities to meet other Latino students across disciplines may foster the creation of additional support systems. Special discussions with Hispanic graduates and involvement with The National Association of Hispanic Nurses should also be incorporated into mentor programs in order for students to identify with others similar to them who have achieved success.
Despite the multitude of external influences that can affect outcomes of Latino students, there are also a number of institutional factors that can weigh heavily on either triumph or failure. This area seemed to have a significant effect on the students. Many cited unsupportive faculty, perceived discrimination by faculty and peers, lack of advisement, and scarcity of role models and mentors as barriers to their success (Goetz, 2007; Jones, 1992; Perez, 2003; Rivera-Goba & Nieto, 2007; Snyder & Bunkers, 1994; Villarruel et al., 2001). Many students discussed feeling different and isolated among their peers (Gardner, 2005; Gensemer, 2005; Jones, 1992; Rivera-Goba & Nieto, 2007; Villarruel et al., 2001). A student in the study by Jones (1992) stated:
It’s kind of lonely. I mean I walk in there and I am the only Hispanic student. So it’s kind of lonely because we tend to hang in groups. Every ethnic group finds their own little clique. And you sort of find a role model or someone who sort of is familiar, you know what I mean, you look for a familiar face, a familiar name.
For some, as the only Hispanic student in the class or as part of a very small percentage, they felt marginalized and separate. Some described their relationships with non-Hispanic classmates as superficial, uncomfortable, and unable to fit in with their peers (Goetz, 2007). A student in the study by Taxis (2006) said:
When I got here, I was in awe and just overwhelmed. It wasn’t until I got into the classrooms that I realized, hey I stuck out! You look around the room and it’s almost like you see all these people and you try to make a connection, visually, just to find someone who looks like you to sit close to or make some small talk with—someone who knew where I was coming from.
They encountered prejudice from classmates, who often were ignorant of their culture and values. In the study by Villarruel et al. (2001), a student stated:
I finished at the top, I went in with a 4.0 GPA and a high GRE and I still heard comments about how I got in, and all the resources that were available to me…and how I am sitting in somebody else’s space.
Another student stated:
There are 8 of us in clinical. Every one of them are younger than me, all White and sometimes I wonder… where do I fit in? I do not feel like I fit in anywhere.… I just feel like I do not have the connection to anybody or that I can really relate to anybody at school.
They also felt discriminated against by faculty. Participants in the study by Jones (1992) described a sense of being judged, feeling threatened, and feeling defeated by faculty. Similarly, a student in the study by Amaro et al. (2006) stated:
I was told that I would be kicked out of the program if there were any complaints at all against me, even if they weren’t really valid, just anything at all, I would be thrown out.
In an effort to try to network with others to navigate the college experience, many nursing students often sought the support of other minority students outside of the school of nursing. A significant part of the ALCANCE program (Evans, 2007) was facilitating the meeting of Hispanic students in the program despite cohort differences. This was viewed positively by participants, as reflected by comments such as “I didn’t feel as alone.” and “Being part of a smaller group that I had a lot more in common with was a great help. As the only Hispanic in my class, I was able to meet other Hispanics in the program” (Evans, 2007, p. 357). Other groups that encouraged connecting students of similar ethnic backgrounds were also viewed positively. In the study by Amaro et al. (2006), one student commented:
That [Hispanic Nursing Student Association] was the most influential thing I had in school because I was able to see people that were semesters ahead of me, you know, and see what they had gone through and hear about experiences they went through and then be able to help people that were at levels underneath me.
Keys to recruitment and retention of Hispanic nursing students were institutions that were viewed as helpful and accessible, with faculty that was caring, supportive, encouraging, and respectful (Evans, 2007; Gardner, 2005; Jones, 1992; Snyder & Bunkers, 1994; Taxis, 2006). Although nursing is a profession of caring, students’ experiences often were opposite. Many of the programs were described as rigid and demanding, and even hostile at times. One student expressed that nursing education’s inflexibility is a main problem with Hispanic retention:
Nursing says it wants students from diverse backgrounds, but all it really wants is to recruit students. Once the students are in the program, nursing wants them to be the same. Nursing education needs to address the inflexibility of programs to retain students. Instructors need to know and appreciate the experiences students come with.
Faculty-student relationships were also an integral part of either success or failure. Some talked about a lack of connection and support as a problem. Many of the Latinas who discussed their experience in nursing school discussed a “weeding out” process among the teachers, during which they felt diversity was targeted. One student said, “If you could get through her, you knew you could make it. It was make it or break it. And when I graduated, there were only three Latinas left in the class” (Amaro et al., 2006, p. 251). Jones’ (1992) participants discussed faculty who were like “boot camp drill instructors” (p. 212). This was identified as “immobilizing” (Jones, 1992, p. 213), especially for students who already lacked confidence in their success. They vividly described physical responses (e.g., perspiring, tremors, diarrhea, dizziness) caused by nursing faculty.
Latino students suspected that faculty did not acknowledge their individuality, yet they felt singled out and pressured to do more than other students. Cultural values were often misunderstood by faculty as negative behaviors and seemed to cause the majority of the oversights. In the study by Taxis (2006), a student commented:
I had a clinical instructor and at first I was very intimidated, so I always kept a distance. And at midterm [evaluations] I was told that I was lazy, and I was like, Lazy Oh my Gosh! I had never been called lazy before! I am a hard worker! I thought I was respecting my instructor by not interrupting, but she thought I was lazy because I wasn’t participating enough. It was just an assumption made about me.
Overall, faculty that made the extra effort to get to know the Hispanic student created an atmosphere that was more pleasant and enjoyable. One student said:
In general, the nursing professors I had were excellent. They were accessible, knowledgeable, and compassionate within reason. It helped me a lot when professors would just talk to you, make conversation, take an interest in you, it made me comfortable, I could learn better that way.
Students who experienced a sense of belonging to their programs ultimately succeeded.
Lack of Hispanic faculty was cited as a major barrier among many of the students. Minimal availability of role models in clinical and academic settings produced negative sentiments among students. Their desire for Hispanic faculty was to feel able to relate to someone with a similar background. They thought this would facilitate communication and enhance their ethnic pride. As discussed by Rivera-Goba and Nieto (2007), the availability of mentoring and role models was noted to be a critical aspect of Hispanic nursing student success. A student speaking of interactions with a Hispanic faculty member stated:
She has been the nicest, most personable. You’re not scared to go and talk to her. I’m not anxious about what I’m supposed to say or how I’m supposed to act.… I’ve had very frustrating experiences with other professors.
Schools can offer biannual newsletters providing cultural information, yearly mandatory diversity training, and guest minority speakers for staff development workshops. These venues can be used to increase awareness and promote understanding and sensitivity in relation to diverse population needs. The perpetuating cycle of lack of Hispanic faculty also has to be addressed. Throughout all of these studies, there was a cry from students for Hispanic role models and mentors at the college level. If the ultimate goal is to increase the number of Latino students successfully completing their nursing education, then you have to start with recruitment of similar faculty. Targeting master’s-prepared Hispanic nurses with enticing offers to pursue a doctorate degree; promoting graduate programs to undergraduate Hispanic students enrolled in baccalaureate programs, and recruitment through organizations like the National Association of Hispanic Nurses may alleviate some of the problem.
Ultimately, despite the various obstacles, there were many Hispanic nursing students who persisted and succeeded. They described an inner strength that spurred them on in their journey. Many provided descriptions of being self-motivated and self-determined. They were assertive and communicated their needs. Many were ambitious and had professional and personal aspirations that proved life changing for both themselves and their families. This drive was especially apparent in those who pursued advanced nursing degrees. And most importantly, those who succeeded were confident. They had been told by others that they possessed the ability to achieve something and they truly believed they could persevere and succeed in their journey.
Throughout her process, Goetz (2007) addressed the significance of gaining confidence. She emphasized the importance of words of encouragement and feeling valued. She stated that confidence can “help a person soar” or a lack thereof can “bring a person crashing to the ground” (p. 113). Many students who lacked confidence were often unable to supersede the obstacles they encountered. Teachers can provide encouraging words to boost the confidence of students and contribute to success. In the study by Goetz (2007), Yolanda described her turning point:
Sometimes all you hear is the negative. You did this wrong or you did that wrong. It would help if the instructors said positive things once in a while. After I failed the third test and I was thinking that I should just forget it and drop out, [the instructor] told me that she knew I could do it if I really applied myself. You know, I went into the last test knowing I was going to pass and I never failed a test in any of the classes after that.