Journal of Nursing Education

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Research Briefs 

Hmong American Women Crossing Borders in Nursing Education: Two Case Studies

Avonne A. Yang, MSN, RN, CNE; Tama L. Morris, PhD, RN, CNE

Abstract

The Hmong population in the United States is rapidly growing. Cultural differences between this population and the American health care system lead to health disparities. These differences are exacerbated by the shortage of Hmong American nurses. The shortage may be related to difficulty in navigating the U.S. education system. The purpose of this study was to examine the perceived impact of Hmong culture on Hmong American women’s nursing education. Data analysis identified four themes that were confirmed by participants: support factors, entrepreneurism, positive outcomes, and cultural expectations. On the basis of these themes, schools of nursing can positively influence Hmong American women’s education by providing information sessions for their families regarding school expectations, allowing flexibility in meeting course requirements, increasing the number of Hmong and minority faculty members, and providing language assessment and support programs for English language learners.

Abstract

The Hmong population in the United States is rapidly growing. Cultural differences between this population and the American health care system lead to health disparities. These differences are exacerbated by the shortage of Hmong American nurses. The shortage may be related to difficulty in navigating the U.S. education system. The purpose of this study was to examine the perceived impact of Hmong culture on Hmong American women’s nursing education. Data analysis identified four themes that were confirmed by participants: support factors, entrepreneurism, positive outcomes, and cultural expectations. On the basis of these themes, schools of nursing can positively influence Hmong American women’s education by providing information sessions for their families regarding school expectations, allowing flexibility in meeting course requirements, increasing the number of Hmong and minority faculty members, and providing language assessment and support programs for English language learners.

Ms. Yang is Lecturer, School of Nursing, University of North Carolina at Charlotte, and Dr. Morris is Chair, BSN Program, Presbyterian School of Nursing, Queens University of Charlotte, Charlotte, North Carolina. At the time this article was written, Dr. Morris was Assistant Professor, School of Nursing, University of North Carolina at Charlotte, Charlotte, North Carolina.

The authors have no financial or proprietary interest in the materials presented herein.

Address correspondence to Avonne A. Yang, MSN, RN, CNE, 4018 Durham Lane, Charlotte, NC 28269; e-mail: avonneyang@yahoo.com.

Received: January 22, 2010
Accepted: July 07, 2010
Posted Online: January 31, 2011

The Hmong, Southeast Asian refugees, experience health disparities that may be linked to traditional beliefs and cultural practices (Pinzon-Perez, 2006). In light of the Institute of Medicine’s (2003) call to reduce health disparities through workforce diversity, more Hmong American nurses are needed. However, traditional Hmong culture places low value on education for women, and Hmong American women must balance the worlds of mainstream U.S. culture and traditional culture (Vue, 2007).

Literature Review

In the Hmong world, barriers to women’s education include limited personal freedom, early marriage, family responsibilities, and lack of knowledge about how higher education affects family responsibilities (Garrity, 2002; Ngo, 2002; Vue, 2007). In addition, Vue (2007) described reverse discrimination of some Hmong women by others within the culture because these women were considered too westernized.

In U.S. society, tangible family support, such as provision of child care, and intangible family support, such as verbal encouragement and permission to attend college (Garrity, 2002; Vue, 2007), helps Hmong American women persist in higher education. Hmong American women are motivated by economics to persist in higher education (Garrity, 2002; Vue, 2007). However, they encounter barriers of racism, prejudice, stereotyping, discrimination, language difficulties, and uncertainty regarding which adaptation strategies will be successful against barriers to integration (Ngo, 2002; Vue, 2007). Kiang (2009) found that Southeast Asian students’ persistence in U.S. higher education were motivated by their hardships as refugees, gender discrimination, family roles and responsibilities, and racial discrimination in U.S. society. Similar to Kiang’s (2009) findings for Southeast Asians, Vue (2007) found that some Hmong American women used barriers as motivation to persevere and succeed educationally.

Discrimination is a common thread in the few studies that have focused specifically on Asian American nursing students or included some Southeast Asian students in samples. In Zhan’s (2009) study, Asian American nursing students were discouraged from becoming nurses, blamed for speaking accented English, ignored when they sought academic help, and evaluated unfairly in social and academic situations. The need to have Asian faculty to serve as role models was underscored by Ho and Dinh (2009), who concluded that Asian faculty are beneficial to Asian American students because they serve as both “living proof” that Asians can succeed in their disciplines and as positive images to negate Asian American students’ perception that being an ethnic minority carries a negative connotation (p. 87). Other than Yang’s (2009) essay on being a Hmong nursing student, there are no published studies on the nursing educational experience of Hmong American women. The purpose of this study is to examine the perceived impact of Hmong culture on Hmong women’s experience in nursing education.

Research Framework

The framework for this study was the Students’ Multiple Worlds model (Phelan, Davidson, & Cao, 1991). This model is an analogy to the way Hmong American women navigate between multiple worlds. The model posits that students must negotiate the borders of family, peer, and school cultures. It also describes four patterns for crossing from one world into another: congruent worlds with smooth transitions, different worlds with manageable border crossings, different worlds with hazardous border crossings, and impenetrable borders with insurmountable border crossings.

Method

Following approval by the institutional review board, three female Hmong American nurses were recruited for the study by one of the authors (A.A.Y.), who is fluent in both English and Hmong. Participants were selected from a list generated through word of mouth, known contacts, and referrals by Hmong American professionals, respected Hmong American elders, nursing faculty, and the participants themselves. Inclusion criteria were immigrant, female Hmong American registered nurses; age 18 years or older; and graduate of a registered nurse program in the United States. Those who had been adopted as a child by a non-Hmong family were excluded. Consent was obtained after the study was verbally explained in the participant’s language of choice. Two women completed the research; the third withdrew.

An interview guide was used to conduct two audiotaped telephone interviews with each woman—the first to collect data and the second to validate findings. Interview questions were asked in English. Participants responded in both Hmong and English. The interviewer transcribed, translated, and analyzed the interviews for themes using Colaizzi’s (1978) descriptive method, with which significant statements and phrases were extracted, meanings were formulated and clustered into themes, and themes were validated by participants. The second author (T.L.M.), a woman of European descent who is experienced with multicultural education, reviewed the data to verify the themes before they were presented to participants for validation. Both participants agreed that the themes reflected their experiences.

Results

Description of Participants

Blia and Shoua (pseudonyms) were in their late thirties and each had lived in the United States for more than 29 years. Both attended primary and secondary schools in the United States and graduated from baccalaureate nursing programs in midwestern states. Their first spoken language was Hmong, although both were bilingual in English and Hmong. Shoua was single while a nursing student; Blia married while in nursing school. At the time of the study, they both resided in metropolitan areas of a midwestern state with a relatively large population of Hmong Americans.

Themes

Four themes emerged in the study: support factors, entrepreneurism, positive outcomes, and cultural expectations. Positive themes reflected facilitated border crossings, whereas negative themes represented challenges to border crossing and success in nursing education.

Support Factors. The participants perceived support to include role models, encouragement, a supportive family, and a supportive nursing faculty, all of which promoted educational success. One form of intangible support was verbal permission from parents to pursue higher education. A second was parents’ verbal permission to delay marriage. Tangible support was given by nursing faculty who were willing to take the time to help the participants academically and serve as role models. Participants believed that role models promoted success because they reflected to participants that they too could become nurses. As Shoua stated:

And I think the other thing [a reason for success], is also, my aunt…. She was a nurse…[and she] encouraged me to become a nurse, and she told me about her experiences…. She’s a…great role model.

Entrepreneurism. Participants perceived themselves to be entrepreneurs because they were among the first Hmong students to major in nursing. They took a risk and as a result had to constantly make decisions about crossing the borders between the Hmong and U.S. cultures. For example, the Hmong expected Blia to cook and clean at traditional ceremonies, but when this disrupted her studies, she had to decide whether she would cross the border of the Hmong culture by disregarding these duties or stay within its borders by performing them. Either way, there was no guarantee of educational success or family acceptance.

The women’s entrepreneurial spirit strengthened their resolve to use adaptation strategies to overcome the challenges of traditional Hmong cultural expectations, the English language, and the nursing major itself. According to Shoua, they overcame challenges and became leaders for their children:

I had to change…to reach the goals that I want instead of reaching the goals that they [Hmong people] want…. And, so, [for] my daughter…I want to change that, too. I would not encourage [her] to get married at an early age.

Positive Outcomes. In summarizing their experiences, participants expressed satisfaction at having become nurses because they were able to serve Hmong American patients, achieve economic success, and provide encouragement to other young Hmong Americans to become nurses. Both participants actively encouraged other young Hmong Americans to pursue a nursing career. Shoua stated:

I’m really happy that I…was able to work with a lot of Hmong patients…. There are a lot of things you can go into with nursing…. I’m really happy to have become a nurse.

Cultural Expectations. Although participants believed they had achieved positive outcomes, along the way they faced cultural expectations that made border crossings difficult. Role conflicts resulted from school responsibilities competing with the responsibilities of wife, mother, and daughter-in-law, such as childrearing, cooking, and cleaning, including helping relatives cook and clean during traditional ceremonies. As Blia noted:

Shaman rituals [occurred] every weekend…. And I’m like, I can’t go with you. I have to study…. He [the husband] understood. So…I didn’t have to play my daughter-in-law role and stay and cook.

Discussion and Implications

Case studies examine single units to illuminate a phenomenon, so although their findings are not generalizable, comparisons can be made with similar situations, and implications for the two participants in this study can be extended to similar students in similar situations (Burns & Grove, 2005). Participants perceived that role models, encouragement, a supportive family, and supportive nursing faculty helped them succeed in nursing school. When families supported the participants’ choice to pursue a higher education, they created congruence between the family and school cultures, making it easier for participants to negotiate the borders of family and school cultures. Similarly, the existence of Hmong American role models gave the students a sense that their home culture was congruent with the world of nursing, given that the presence of Hmong nurses gave living proof that Hmong people could succeed in nursing. As Ho and Dinh (2009) noted, Asian faculty show Asian students that they can succeed. Clearly, more Hmong American nurse educators or, in their absence, non-Hmong faculty are needed to serve as role models.

In attempting to cross into the U.S. world, Blia faced the challenge of complex English words and Shoua struggled with a difficult nursing major. Based on this information, interventions to facilitate border crossing for Hmong students who are English language learners could include language support programs and pilot study groups or pilot tutoring groups tailored for them.

Participants were satisfied that they had fulfilled expectations to serve the Hmong American community and achieve economic independence. They also received satisfaction from providing advice and encouragement to other young Hmong Americans regarding pursuit of the nursing profession. These findings indicated that they had successfully crossed borders, but despite their successful outcomes, the cultural expectation for women to stay close to home limited these women’s choices of nursing programs, extracurricular activities, and social life with peers. Shoua said that the expectation to fulfill family obligations limited her social life on campus. Past research has shown that Hmong American women perceived the cultural expectation for women to stay close to home to be a barrier to education (Garrity, 2002; Ngo, 2002; Vue, 2007). Similarly, the cultural expectation for women to marry early negatively affects education because married women’s roles as wife, daughter-in-law, and mother require cooking, cleaning, and childrearing, which compete with school responsibilities and cause role conflicts (Garrity, 2002; Vue, 2007). However, these conflicts were resolved for both of these women because their families were supportive and excused them from traditional role responsibilities.

Past studies revealed that one barrier to Hmong American women’s education is the family’s lack of knowledge about how higher education affects family responsibilities (Garrity, 2002; Ngo, 2002; Vue, 2007). Therefore, a strategy to support Hmong American students would be to extend information sessions to their families, including information about the expectations for U.S. nursing students. Because Hmong American women must continue in multiple worlds during their education, faculty should also consider flexibility in course requirements to allow them to meet the expectations of both the nursing program and the Hmong culture.

Although the implications of this study appear to be logical strategies for working with minority students, the findings suggest that common sense strategies were not implemented for the study participants. The findings from this study identify issues that Hmong American nursing students have in common with other Asian American students, suggesting areas of the school culture that can be changed. It is not just Hmong culture that affects women’s education. Because the school culture itself influences border crossings and affects Hmong American women’s success in nursing programs, faculty and administrators can help these women cross borders to increase the number of minority nurses and thus improve the health of minorities.

References

  • Burns, N. & Grove, S.K. (2005). The practice of nursing research: Conduct, critique, and utilization. St. Louis, MO: Elsevier.
  • Colaizzi, P.F. (1978). Psychological research as the phenomenologist views it. In Valle, R.S. & King, M. (Eds.), Existential foundations of psychology (pp. 48–71). New York, NY: Oxford University Press.
  • Garrity, C.A.M. (2002). Hmong women in a nontraditional college: The replacement of fragmented backgrounds with American individualism (Master’s thesis). Available from ProQuest Dissertations and Theses database. (AAT 3056589)
  • Ho, I.K. & Dinh, K.T. (2009). Mentoring Asian students toward entering the health professions. In Zhan, L. (Ed.), Asian American voices: Engaging, empowering, enabling (pp. 77–90). New York, NY: National League for Nursing.
  • Institute of Medicine. (2003). Unequal treatment: Confronting racial and ethnic disparities in health care ( Smedley, B.D., Stith, A.Y. & Nelson, A.R., Eds.). Washington, DC: The National Academies Press.
  • Kiang, P.N. (2009). A thematic analysis of persistence and long-term educational engagement with Southeast Asian American college students. In Zhan, L. (Ed.), Asian American voices: Engaging, empowering, enabling (pp. 21–57). New York, NY: National League for Nursing.
  • Ngo, B. (2002). Contesting “culture”: The perspectives of Hmong American female students on early marriage. Anthropology & Education Quarterly, 33(2), 163–188. doi: doi:10.1525/aeq.2002.33.2.163 [CrossRef]
  • Phelan, P., Davidson, A.L. & Cao, H.T. (1991). Students’ multiple worlds: Negotiating the boundaries of family, peer, and school cultures. Anthropology & Education Quarterly, 22, 224–250. doi: doi:10.1525/aeq.1991.22.3.05x1051k [CrossRef]
  • Pinzon-Perez, H. (2006). Health issues for the Hmong population in the U.S.: Implications for health educators. International Electronic Journal of Health Education, 9, 122–133. Available from the American Association for Health Education Web site: http://www.aahperd.org/AAHE/
  • Vue, P.P. (2007). Factors that contribute towards and/or impede Hmong women from obtaining a higher education degree. Available from ProQuest Dissertations and Theses database. (AAT 3280548)
  • Yang, A. (2009). Coming home to nursing education for a Hmong student, Hmong nurse, and Hmong nurse educator. In Bosher, S.D. & Pharris, M.D. (Eds.), Transforming nursing education: The culturally inclusive environment (pp. 103–128). New York, NY: Springer.
  • Zhan, L. (2009). Diversity research initiatives: Reflection and thoughts. In Zhan, L. (Ed.), Asian American voices: Engaging, empowering, enabling (pp. 91–106). New York, NY: National League for Nursing.
Authors

Ms. Yang is Lecturer, School of Nursing, University of North Carolina at Charlotte, and Dr. Morris is Chair, BSN Program, Presbyterian School of Nursing, Queens University of Charlotte, Charlotte, North Carolina. At the time this article was written, Dr. Morris was Assistant Professor, School of Nursing, University of North Carolina at Charlotte, Charlotte, North Carolina.

The authors have no financial or proprietary interest in the materials presented herein.

Address correspondence to Avonne A. Yang, MSN, RN, CNE, 4018 Durham Lane, Charlotte, NC 28269; e-mail: .avonneyang@yahoo.com

10.3928/01484834-20110131-05

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