Dr. Dapremont is Assistant Professor, University of Memphis, Loewenberg School of Nursing, Memphis, Tennessee.
Presented in part at the annual conference of The Council for the Advancement of Nursing Science in Washington, DC, October 4, 2008.
The author has no financial or proprietary interest in the materials presented herein.
The author thanks Nancy C. Mele, DSN, RNC, Associate Professor, Methodist Healthcare Llewellyn Legacy Professor of Nursing, ACL Technology Fellow, University of Memphis, Loewenberg School of Nursing, and Mona Newsome Wicks, PhD, RN, Professor and Associate Dean for Research, Robert Wood Johnson Executive Nurse Fellow, University of Tennessee Health Science Center College of Nursing.
Address correspondence to Jill A. Dapremont, EdD, RN, Assistant Professor, University of Memphis, Loewenberg School of Nursing, 207 Newport Hall, Memphis, TN 38152; e-mail: email@example.com.
According to the U.S. Census Bureau (n.d.), the total U.S. ethnic minority population in the years 2006–2008 comprised approximately 25% of the American population. The U.S. ethnic minority nurse population in 2004 was 10.6%. In the same year, Blacks comprised 12.3% of the U.S. population and only 4.6% of registered nurses (U.S. Department of Health and Human Services, n.d.). Although there have been calls for increasing diversity in the nursing workforce, little work has been focused on what affects the success of ethnic minority students (Wong, Seago, Keane, & Grumbach, 2008). By 2050, the Black population is expected to grow from approximately 40 million to 61 million, an increase of 71% (U.S. Census Bureau, 1996). According to the National League for Nursing (NLN) (2010), overall graduation rates from basic RN programs between 2006 and 2007 were approximately 60% for associate degree programs and 37% for baccalaureate programs. The graduation rate for Blacks in that same period was 10.4% overall for both programs.
The increasing population growth of racial/ethnic communities and linguistic groups demands a health care system that is both culturally and linguistically sensitive (Gardner, 2005a; U.S. Department of Health & Human Services, n.d.). A more diverse workforce increases health care access and quality in ethnically diverse populations (Beacham, Askew, & Williams, 2009; Etowa, Foster, Vukic, Wittstock, & Youden, 2005; Sutherland, Hamilton, & Goodman, 2007; Wong et al., 2008).
Although minority representation is rapidly approaching 26.3% in nursing schools, increased graduation is needed to keep pace with the projected growth of the nation’s minority population (American Association of Colleges of Nursing, 2010). The current growth rate of minorities in the health care workforce will unlikely meet the health care needs of a diverse population (Sutherland et al., 2007).
Although the current focus of the health care industry is on finding ways to address the nursing shortage crisis in general, efforts are also needed to attract and retain more Black nurses. This issue is important because the increasing Black population has elevated rates of certain illnesses and smaller rates of successful treatment (Gardner, 2005b). An added benefit to increasing the ethnic diversity of nursing is the tendency for nursing professionals from ethnocultural backgrounds to serve in diverse and underserved communities (Wong et al., 2008).
Retaining and graduating Black nursing students is important in increasing access to quality health care because minorities frequently seek medical care with providers who are of the same race or ethnicity. Thus, providers are needed who are culturally similar and sensitive to patients in medically underserved communities (Beacham et al., 2009; Martinez & Martinez, 2004). However, certain data indicate that minority students who are admitted to nursing programs drop out before graduation (Gardner, 2005a; Jeffreys, 2007). To enhance Black student success in nursing programs, further research is needed to identify the strategies used by Black nursing students who succeed in nursing programs.
This descriptive qualitative approach examined the lived experiences of 18 Black undergraduates who attended baccalaureate and associate degree nursing programs with predominantly White student populations. The strategies and events that students perceived as facilitating program completion were identified. Also, student integration into the nursing program was examined, which prompted further review of how persistence in nursing programs influenced the success of Black students in these programs.
Tinto’s 1975 Theoretical Model of Dropout, which addresses student’s persistence in higher education, was used to inform this study. Tinto developed the Theoretical Model of Dropout based on the notion that certain elements can influence students’ decision to persist or drop out of the college experience. He argued that the course of dropout from higher education can be viewed as a process that occurs between the individual, academic, and social systems. Social and academic integration are the major components of the theory, postulating that dropout can occur when the academic and social factors of the education system do not blend to integrate the student into the higher education institution. Tinto’s study did not control for race, gender, or age differences of participants. However, a more recent study by Wood, Saylor, and Cohen (2009) identified factors that contributed to persistence in ethnically diverse baccalaureate nursing students that included good study habits, persistence, and supportive social connections.
Although most students apply to nursing school with the intention of obtaining a nursing degree, some are not successful (Gardner, 2005a, 2005b). Tinto (1975) described how dropout from institutions of higher education could occur and his work was used in the current study to discover what might be occurring with Black nursing students as they enter the culture of nursing. Tinto argued that if integration into the college systems did not happen, then full commitment to college completion would not occur. Individual attributes that Tinto identified as contributing to success were family background and precollege experiences (i.e., grade point average) and academic and social attainments. Tinto also cited family support regarding expectations, praise, and interest in the student’s college experiences as important in college completion. He also found that interactions within the college environment (i.e., the academic integration that occurred through interaction with peers, faculty, and administration) were also important for student success.
Tinto (1982) later added to his Theoretical Model of Dropout by addressing the limitations of the initial study. Other areas that may affect attrition include the role of finances in student disengagement, transfer between institutions, and dropout among groups of students of different genders, races, ages, or social statuses. In the second study, Tinto (1982) concluded that institutions of higher learning bear some responsibility for student attrition and that more research is needed to help develop models and theories that address student attrition and persistence in higher education.
Further, Tinto’s 1993 study built on his theory by addressing how students’ interactions in the academic environment were enhanced through experiences at the institution, which included engagement with other students and faculty. He found that lack of integration can result in students feeling isolated and alienated from the university and affect students’ persistence and graduation rates. This finding was also supported by other studies (Gardner, 2005a, 2005b; Sutherland et al., 2007).
In 1997, Tinto continued his work in student persistence by exploring classrooms as communities, stressing the classroom as a place where academic and social involvement or integration will occur, further building on his Theoretical Model of Dropout. However, more studies are needed because student experiences may be influenced to some degree by the disciplines they pursue. The current study sought to explore the factors that contributed to the persistence of a group of heterogeneous Black nursing students in degree-granting nursing programs, further building on the work of Tinto and others. Thus, the primary research question that guided this study was: What were the perceptions and experiences that contributed to success for Black students in nursing schools with predominantly White students?
Design, Setting, and Participants
This descriptive qualitative approach surveyed Black undergraduate nurses, ages 18 to 50, who graduated from a predominately White associate or baccalaureate degree-granting nursing program between 2000 and 2006 in the midsouthern United States. A purposive sampling strategy was used, along with snowball sampling. Eighteen in-depth interviews were conducted by the primary investigator among 16 female and 2 male participants who represented four different baccalaureate and associate degree nursing schools. Twelve interviews were face-to-face, and six were conducted via telephone. Interviews lasted from 45 to 90 minutes. During data collection, participants experienced a variety of emotions and, at times, cried, laughed, joked, and even became angry as they discussed their experiences. Re-interviewing of 5 participants occurred to enhance and confirm the researchers’ understanding of responses or to add new information. The logic of in-depth, open-ended interviews was to learn a great deal about what Black undergraduate nurses perceived, remembered, and described as helping them be successful as they progressed from admission to graduation. Interviews yield information from individuals about their experiences, opinions, feelings, and knowledge. This is what Patton (2002) identified as the strength of this strategy.
An 18-question semi-structured interview guide (Table 1) was developed by the investigator and critiqued and revised by a panel of experts (N = 5) to ensure content validity and establish rigor and trustworthiness. The final interview guide was used for this study along with a data form to collect demographic information (Table 2). Also, re-interview questions were developed and asked (Table 3) based on theme development. Questions were developed using Patton’s (2002) chapter on the interview guide, within which the interviewer is free to explore, probe, and ask questions that elucidate and illuminate the particular subject.
Table 1: Participants’ Interview Guide Questions
Table 2: Participant’s Demographic Characteristics (N = 18)
Table 3: Participants’ Re-Interview Questions
Institutional review board approval was granted for this study from the affiliated universities. Next, the researcher purchased a list from the state Board of Nursing with the names of nurses who graduated between 2000 and 2006 and were determined to be eligible participants. Letters describing the study and requesting participation were sent to the eligible participants. A return stamped envelope address to the researcher was included in the mailing. After receiving confirmation that participants were willing to be interviewed, a schedule was created. More potential participants were referred by confirmed participants. These potential participants were contacted and scheduled for interviews if they agreed to join the study. A follow-up telephone call was made to individuals who agreed to participate in the study, indicating the date and time of their interview. Another telephone call was made the day prior to the interviewee as a reminder. Interviews were audiotaped and field notes were taken to ensure accuracy in transcription. This was done with the participants’ permission to ensure the accuracy of information. Participants were encouraged to be open and honest and were asked open-ended questions followed by probing questions when necessary to reveal experiences. Eighteen interviews were done until saturation was achieved. Finally, participants were informed that a follow-up call for re-interviews would be necessary for any needed clarification and confirmation of themes.
To present the participants’ true views, words and phrases were transcribed verbatim. However, if grammar used by a participant might confuse readers, the word sic was bracketed and italicized immediately after the error in the participant’s quote. Ellipsis points were used to omit words from a quote to improve understanding of statements made by participants. To increase understanding of raw interview data, words were occasionally added and placed in brackets. Also, punctuation was added to facilitate reading.
Data were managed through development of suitable classification or coding schemes. A thematic analysis and deductive a priori template of codes were used to make sense of the data (Crabtree & Miller, 1999; Fereday & Muir-Cochrane, 2006; Patton, 2002). The template for the coding was based on the research questions and theoretical framework. Some of the themes that emerged were peer support, interaction with White students’ study groups, family support, and faculty encouragement and support. The initial describing phase began with analyzing the initial interviews. Next, five re-interviews were conducted to confirm themes and further elaborate on perspectives. An editing organizing style was chosen for analysis (Crabtree & Miller, 1999). Overarching themes that best described the research questions were then created. A second reader analyzed a random sample of the data for themes and patterns. Connections were made through reflection and engagement with the code and categorized reports of interview transcript data and field notes. Finally, data from interview sessions were organized into a narrative report. Pseudonyms were assigned to all interviewees for reporting purposes and to maintain confidentiality and anonymity.
The overarching theme of the study was “It takes a community to create a nurse.” Within this community were peer support, interaction with White students’ study groups, family support, and faculty encouragement and support. Results reflect what Black students believed it took to successfully complete nursing school. Themes and representative statements for each category are provided.
Eighty-nine percent (n = 16) of participants stated their peers were a necessary support in nursing school. Participants often expressed the vital need to identify with other Black students, but later in their programs peer support was important regardless of race. These relationships developed through clinical experiences and group projects, often initiated by faculty. Other participants saw peer support from a different view. They felt it was necessary to relate and interact with Black students. Several participants voiced the desire to maintain positive relationships with their Black peers and feared a negative reaction about their behavior if they mingled with White students. Participants also expressed concerns about not wanting to offend other Black students by studying and interacting with White peers. The following statements represent Black students’ thoughts about their peer relationships:
- We didn’t form bonds that first semester, people were like [sic] checking each other out and who’s about what [sic].... You kind of sit back and see how people are and you gravitate towards people who are more like you. And later on in the groups, our clinical groups got to know each other better…. Towards the end we were really strong (laughing) in our study groups. (Brenda, older student)
- I had to play it cool me being a Black male in a White nursing program…. My students, my peers they, of course with us being Black…. We can always point each other out. We know who we are, and we get together and we have to support each other because we are minorities and minorities must always stick together…. We have to watch each other [sic] backs, because White folks do it. (Malcom)
- The school shouldn’t put people together, but to encourage that, to encourage the bonding of the students…because if I had of [sic] just stuck in my little box and stayed with only the people that I was comfortable with initially, then I would have missed out on all of that. (Carla, a recent graduate)
Black Students’ Interaction with White Students’ Study Groups
Although some participants stated they connected with their race for peer support, half of the participants said that they did not want to alienate White students because they believed these students had access to test information and that developing relationships with their White counterparts was beneficial.
Participants felt White students had access to more information than Black students did. In an attempt to equalize their chances of success, these participants viewed it as essential to develop relationships with White peers to obtain this information.
Some students said that knowing White peers could lead to a better understanding of class content. Several participants appeared to be offended and looked down as they said that interracial peer support needed to be initiated by White students and that when they were included, they felt excited about being accepted. The following comments expressed difficulties students experienced going outside their Black peer group:
- The Blacks…were good with me. Um [sic], they just didn’t stick around as much…after class and things like that. But if we had breaks, I would try to intermingle with both. Sometimes I would eat with Black students, and sometimes I would eat with White students. It was always segregated, so I kind of tried to kind of flip flop back and forth so nobody would think that I was trying to be White. (Keisha, a second-degree student)
- What really helped me pass in my final semester was that I got to know a lot of White [students].… [One]…[gave me access] to a lot of notes and that is something that I will say…is a key factor to having good relationships with everybody, not just [Black students], not just our peer group per se…because you never know what somebody might have that can help you out. (Malcom, serious)
- I think some people had more access than others.... My minority counterparts had less…so I found myself…leaning more towards the other side to get the information that I needed to get. (Deborah)
- That’s another thing, go outside the box. I did not do this till [sic] my last semester…[when] we started studying with people outside our race. It’s sad to say but they have information from people we did not have access to.... They knew to say you need to be focusing on this, this, and that. Studying with other people gives you a different perspective, so you know how questions may be worded…. It was just a different perspective…. It was the last semester when we started doing this, and I made A’s. It’s not that I had anything against them. It’s just you feel more comfortable with people you can relate to, I guess. (Jamila)
Relationships with White peers were initially feared but eventually developed to gain access to information that would promote success. This by-chance relationship or by-facility design resulted in relationship building that provided Black students with long-term benefits.
The second most commonly cited support was family. Eighty-three percent (n = 15) of the students stated family support was needed and necessary. Family encouraged these participants, supported them financially, listened to stories of being discouraged, and gave advice. Some participants articulated sentiments that family can be trusted and will tell the truth. One student said, “You will listen to someone you have known a long time before you listen to a stranger.”
Family support was an incentive for most participants to persevere when discouraged. Almost every participant stated how invaluable it was to have the support of family in their quest for a nursing degree, especially as they contemplated quitting their nursing program. The following are representative statements:
- As far as my emotional support, it was my husband, because if it wasn’t for him, I would not have been able to focus as much as I could on school…. If it hadn’t been for him, I couldn’t have made it through. (Lolita)
- I was going to give up…I was driving home and my thirteen year old had gotten all the kids together…and left me a message on the phone…singing “I don’t believe He [God] brought you this far to leave you.” And it was just unreal…. [Before that] I had kind of made up my mind…I was tired and I was just going to give up [quit] and get a job and go home. And after I had gotten that message, I will never forget that, oh okay this I can do. So that kind of set the tone. (Carmeka, crying)
Faculty Encouragement and Support
Faculty support and encouragement was important to participants—78% (n = 14) saw this as affecting success. Participants expressed many negative emotions while this theme was discussed. Many shared feeling discouraged when faculty support and recognition did not occur and voiced how deflated and unwelcome they felt when faculty did not acknowledge their presence.
Several participants shared that they considered withdrawing from their nursing programs due to family stressors or other situations, but some faculty recognized their distressed and encouraged them to reconsider their decision. Participants indicated a few words of encouragement can refocus a Black student and help them to continue and be successful in nursing school. The following quotes express students’ sentiments:
- One of my favorite teachers in nursing school…was so nurturing.... She pulled me to the side and she saw me struggling with [sic] class, and she said, “Carla, we don’t have enough minority nurses; you need to make it out of this program.”… So she kind of took me under her wing and made sure that I was okay. (Carla, excited)
- Yes I did feel encouraged because according to my friend…the whole aura of the program had changed. So a lot of the teachers would be there for advice or in clinical saying, “You’re doing a good job” or “Go help such and such.” Feedback [from] faculty was [sic] very supportive. (Jamila, proud)
- It was to the point I could pretty much ask them anything and they would answer. Not that I…[asked] that often but I never got the feeling that they didn’t want to help. (Jamila happy)
However, some participants stated they experienced increased motivation to succeed when they felt ignored by faculty. Most participants believed faculty can inspire a sense of confidence, reinforcing that students’ interactions with faculty can be empowering or deflating. Hearing positive comments such as “you can do it” encouraged most participants to succeed. In the absence of supportive comments and encouraging words, participants viewed faculty as not wanting them to do well.
A common trend noted was that participants from different nursing programs and geographical regions experience various degrees of supportive attitudes from faculty. The following quotes highlight the issue:
- When [White faculty] give short answers…when I’ve seen…[interaction] with a non-minority, a White person, and you’re helpful to them, and you’re giving them what they need, and you even have a smile on your face. You’re just very helpful, and then…[White faculty] get to me [Black student] and [they return] back into…[their] stern selves. And this is strictly business and [White faculty respond with] “yes and no” answers, short answers.
- White instructors did not like him…he was going to be the first Black male to graduate from the school…. I mean they just didn’t like this man…. He would like [sic] raise his hand to answer a question…and he would have his hand raised 5 or 10 minutes, and he would just be like “forget it”…. And someone else would raise their hand and they [instructors] would just call right on them. (Shavonda, expressing disbelief and shaking her head)
Discussion and Implications
In this study, peer, family, and faculty interactions often created environments that helped to foster participants’ learning and confidence. Participants stated support was received from their Black and White peers, and this support helped them integrate into the predominately White nursing program more successfully. As participants progressed in their nursing programs, they began to form relational bonds with their peers, White and Black, which enhanced their perception and understanding of the nursing content. When interaction with their various peers increased, this support was welcomed. These findings were supported by previous research that cited similar positive outcomes when Black and White students interact (Loke & Chow, 2007; Lundberg, 2003; Rhodes & Nevill, 2004). This study revealed how study groups aided the integration of Black nursing students in the nursing program. Helping these participants realize what they shared with their White peers was the common goal of a nursing degree.
Social interactions through contact with students and faculty also aided the Black students’ nursing degree program completion. Peer and faculty interactions created an environment that fostered learning and increased confidence and acceptance into the environment (Beacham et al., 2009). These findings were consistent with previous research findings that suggest student integration can contribute to success (Tinto, 1975, 1993). When these peer interactions did not occur in the current study, especially with White peers, participants voiced feeling unwelcome in White groups. Several studies support the need for students to feel comfortable in their education environment (Gardner, 2005a, 2005b; Sutherland et al., 2007; Tinto, 1975, 1993).
Participants listed family support as both financial and emotional. Family support for participants exerted a positive effect on their experiences. Black nursing students shared that family was vital to their perseverance in nursing school. This is in agreement with Higgins (2005) and Gardner (2005a, 2005b), who found that minority nursing students thought their parents were a strong support to keeping them in the nursing program. This confirms research by Tinto (1975) that college persisters seem to come from families where there is more praise, interest in college experiences, and support of the student’s efforts.
Participants voiced inspiring factors, such as not wanting to let down their parents, and expressed a desire to be successful as a motivating force for other family members. Participants with families of their own had a strong sense of obligation to provide a better life for them.
Advocating that came from faculty was invaluable to participants; some stated they did not know what they would have done without the support. Participants said that when faculty support was not given, they simply avoided the instructor and were not active in the learning process. Also, faculty interactions increased students’ self-esteem, aided their sense of acceptance into the nursing community, and affected success and retention rates, according to these participants (Gardner, 2005a; Shelton, 2003; Wells, 2003; Wong et al., 2008). Participants repeatedly voiced feeling validated by expressions of care from faculty and expressed appreciation for instances when they received faculty support.
Findings of this study suggested that Black nursing students valued certain support elements that enhanced their pursuit of a nursing degree. Peer support from both Blacks and Whites, along with family and faculty, were noted. After identifying and recognizing these supports, schools of nursing could design more comprehensive approaches on how to incorporate these supports into strategies for recruitment and retention efforts (Beacham et al., 2009; Wong et al., 2008). This qualitative study provided insight about the benefits of integrated study groups for Black student success and highlighted the importance of diversity within the study body (Wong et al., 2008). Suggested strategies to promote student success included implementing voluntary integrated study groups for student in the first semester of nursing school and beyond and establishing more integrated groups in clinical and group activities. In addition, nurse educators could become more knowledgeable about cultural differences to be more supportive to minorities entering nursing programs. Faculty participation in workshops that address cultural awareness would be first steps to developing better cultural sensitivity. Being aware of Black nursing students’ perceptions of what they have identified as supportive can help nurse educators better intervene and offer advice to this population of students to promote graduation.
Students repeatedly validated the faculty’s important role and their high respect for faculty. Faculty members can be positive role models to students who seem to be discouraged or defeated. Participants indicated that a few words of encouragement could refocus a student and help him or her to continue and be successful in school.
Furthermore, schools of nursing might work toward more structured forms of study programs, such as an advisor for study skills to help student as they enter a program and show students how to start and implement study groups. Faculty should consider having focus groups with graduates to determine what they are doing well and what changes are needed for this student population.
Limitations and Future Research
A limitation to this study was that one person primarily did coding and theme identification; only a subsample of study data were verified by another qualitative researcher. This analytical approach allowed consistency in data analysis but prevented validation of coding by multiple independent investigators. Thus, the multiple viewing perspectives should be used in future studies or analysis of these data to verify study findings. The current literature concerning minority experiences in predominately White nursing schools is limited. To better support these students, larger studies are needed to determine whether the factors that this sample of Black students identified as important could significantly predict student success generally. Also, more research is needed about how faculty interact and respond to minority students. Without the knowledge gained from this study and larger studies of Black nursing student success, it will be impossible to establish a more supportive and caring environment for Black nursing students. Evidence is needed to support the educational strategies used to ensure Black nursing student success, just as evidence is needed to ensure optimal patient outcomes.
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Participants’ Interview Guide Questions
|The following questions will guide the focus groups and individual interviews:|
|How did you feel about yourself as a nursing student while in your program?|
|What things helped you adjust to your first year?|
|What motivated you in your nursing program?|
|What types of support did you receive?|
|What types of support did you need more information about?|
|Did you feel encouraged in your program? How?|
|Did you feel discouraged in your program? How?|
|What types of relationships did you have with other students?|
|What types of relationships did you have with faculty?|
|What types of relationships did you have with support staff? Patients?|
|Who was in the nursing program with you and how was the fit?|
|What most impacted the completion of your nursing degree?|
|How do you view yourself now as a graduate?|
|Would you say you were a success as a student?|
|Was the program a success for you? How?|
|How would you change the program to help more students of color succeed?|
|What things would you continue because it was helpful to you or others?|
|What things would you discontinue because they were not helpful?|
Participant’s Demographic Characteristics (N = 18)
| 21 to 25||4|
| 26 to 30||4|
| 31 to 35||4|
| 36 to 40||2|
| 41 to 45||3|
| 46 to 50||1|
|Annual household income|
| 0 to $10,000||3|
| $10,000 to 20,000||5|
| $20,000 to 30,000||1|
| $30,000 to 40,000||1|
| $40,000 to 50,000||1|
| More than $50,000||7|
Participants’ Re-Interview Questions
|Describe the average week of study for you.|
|Tell me your routine for preparing for a test.|
|How important were study groups in your study routine and comprehension?|
|Were integrated study groups helpful? If so, how?|
|How important was prayer in your overall nursing degree quest?|
|Do you feel you could have been successful without a spiritual connection? Why or why not?|
|Was connecting to faculty important? If so, how?|
|Did Black faculty impact your experiences? If so, how?|