Nursing school faculty and administrators can relate to a scenario in which the academic performance of students brings them to attention early in the program. Whether it is a review of standardized test scores or the first examination grade in a course, nursing faculty are adept at determining signs that a student may be at risk for difficulty. Although many students meet these criteria, students from diverse cultural backgrounds, often the first in their family to attend college, frequently have academic difficulties and face unique challenges in our institutions. They may have trouble navigating the academic and social landscapes of a university, even if they were successful in high school. Without early identification and meaningful intervention, these students frequently drop out. Yet, it is these students who must thrive if nursing is to fully address the challenges of its increasingly diverse population.
The need to strengthen diversity within the nursing workforce cannot be overstated. In 2007, 34% of the U.S. population and 17% of the RN workforce came from minority backgrounds (American Association of Colleges of Nursing [AACN], 2011). Although all nurses can achieve a level of cultural humility, nurses who come from diverse backgrounds can more readily address the nonmajority values and beliefs of clients from similar cultural backgrounds. Strategies designed to close that gap and advance cultural diversity within the nursing workforce, with primary attention directed toward identifying best practices for recruiting and retaining students in schools of nursing, should be a priority. Promoting inclusivity requires an intentional welcome to those who may be vulnerable to discrimination on the basis of their race, ethnic or national origin, religion, color, age, gender, disabilities, marital or parental status, socioeconomic status, veteran status, or sexual orientation. It is not enough for an organization to simply claim that it “welcomes all.”
Collectively, the current evidence describing recruitment and retention approaches targeted toward students from diverse backgrounds suggests only modest success in promoting inclusivity. What becomes apparent in reviewing the literature is that the focus of such programs has been to provide academic and financial resources to students that will help them overcome roadblocks to their success (Noone, 2008). Little is said about approaches that go beyond the goal of program completion. A more highly evolved inclusivity strategy would use professional socialization and reflective learning to maximize student potential and develop leaders who can champion the cause of a truly diverse nursing workforce. Such strategies would also stimulate culture change within the organization.
The term deficit thinking (Freire, 1993), initially coined in the 1960s as a response to entrenched pedagogical orthodoxy in primary and secondary education, has current relevance in today’s collegiate setting. Deficit thinking attributes the difficulties encountered by students from diverse backgrounds in succeeding academically to the personal and socioeconomic differences (i.e., limitations) they bring to the academic setting and identifies students as being at risk rather than at potential. Rarely is this explicitly expressed by faculty. Rather, these notions are imputed by faculty over time and a culture of blame ensues. When viewed in the obverse, the deficit model can be applied to faculty and to those notions that many consider as just and equitable, but the model may be neither just or equitable nor meet students’ needs.
In considering academic programs that embrace cultural diversity, we recognize that there are two opposing perspectives on how to achieve success. The first and predominant approach is to design programs and provide resources to help students from diverse backgrounds fit into the normative culture. This approach uses the deficit model. The second approach is to create a culture that embraces differences. In advancing cultural diversity within our own student body at a private, research intensive university in the northeastern United States, we have encountered unforeseen challenges that can limit student and organizational success. On reflection, we attribute this in part to our emphasis on providing resources rather than addressing the more daunting task of changing the culture. This article describes the lessons learned from our endeavors to successfully implement programs that support developing diverse nurse leaders through the lens of three key challenges—labeling, incentivizing, and relevant advising.
Certain factors, such as being a first-generation college student, coming from an underresourced school system, having a socially or economically disadvantaged background, and using English as a second language, have been associated with academic difficulty in college (Gilchrist & Rector, 2007). Placing a label of being academically at risk on students comes with several considerations. First, it is important to consider what definition is used for the label, why it being used, and who decides the criteria for the label. Further, labeling a student as high risk can produce a conundrum of possible positive and negative outcomes. Decisions must also be made regarding whether to inform students of their status.
Labeling, Stereotyping, and Stigma
Labeling begins when a person identifies another as different from oneself. Labeling theory suggests that there is a tendency among majorities to label minorities negatively (Becker, 1997). Minorities include anyone with characteristics differing from the group norm. In nursing, this includes men, non-White racial and ethnic groups, and individuals with disabilities. At the individual level, mostly everyone carries assumptions and biases. It is important to acknowledge and work through these. At the group or institutional level, societal assumptions and biases can be institutionalized so they are a part of the larger environment (Hall & Fields, 2012; Schroeder & DiAngelo, 2010; Sullivan Commission, 2004). When a particular group is in the minority, the individuals within that group can feel like outcasts, different from others, and unable to succeed due to internal or external forces. In the more extreme form, labeling leads to negative stereotyping and associated stigma. Stigma occurs when undesirable characteristics are linked to a person on the basis of group or individual characteristics (Becker, 1997). The individuals or groups who decide on the label also establish the criteria used to determine who receives the label and its associated connotations. For example, recognition that students of color often meet one or more of the criteria can lead to stereotyping that all minorities will have academic difficulties, or worse, that all are intellectually inferior. Faculty can, based on their own experiences with at-risk students, place that label on students indiscriminately and communicate lowered expectations to students (Guyll, Madon, Prieto, & Scherr, 2010). Thus, faculty can use their experiences with students who are not successful to negatively profile students. When this occurs, it is virtually always harmful because sociocultural factors that are associated with risk are not uniformly present in every individual who has those factors. In addition, there is frequently a power differential in labeling. When the individuals who designate the label are in leadership positions and are part of the group norm, the ramifications of their actions are far reaching.
Defining and Communicating At Risk
Discussions of definitions of at risk are important to communicate with everyone who comes in contact with students. Assessment of risk is not a static measure nor is it based on a single factor. Just as high achievers in high school can be designated at risk in college, students who could be designated at risk during their first year may experience academic success and not continue to have that designation. Using objective criteria that are clearly defined can be useful in avoiding stereotyping and unnecessary labels. Meanings of labels must be discussed to ensure that a consistent definition is used and that the label itself is not used in a way that could bring harm. Labeling needs to be linked with the provision of services and the creation of an environment designed to foster student success through systemic change. Discussion should involve all faculty and emphasize underlying assumptions and prevailing group norms in society and nursing regarding differences (Schroeder & DiAngelo, 2010). Soliciting and sharing feedback from current and former at-risk students about their experiences and ideas for change is also an effective strategy for enlightening faculty.
Although the nursing literature typically focuses on identifying students at risk for academic difficulty (Capper, Frattura, & Keyes, 2000; Gilchrist & Rector, 2007), the education literature espouses a nondeficit-based perspective that applies the label to classrooms or learning environments (Harry & Klingner, 2007; Henderson & Milstein, 2002). Such a perspective takes the onus off the student and places the responsibility for meeting student needs on the instructor and the learning environment (Chan & Ting, 2012). This approach acknowledges the link between sociocultural factors and academic success and recognizes that students from a sociocultural background that most closely resembles the culture of the school will perform better at the school (Burrello, Lashley, & Beatty, 2000; Capper et al., 2000). The challenge is to transform the environment so that each student has learning experiences that fit his or her background and experiences and makes academic success a shared goal.
Professional Responsibilities for Programmatic Success
Labeling our environments as at risk for certain students is consistent with the holistic lens of nursing that values individuals and person-centered care. Labeling enables administrators to dedicate resources to transform and shore up the environment. It shifts the paradigm from an individual level to a community-based approach to student success. Critical appraisal of the environment, such as a recent effort at the University of Washington in Seattle (Schroeder & DiAngelo, 2010), can reveal systemic barriers to inclusivity and set the groundwork for minimizing the negative consequences of labeling.
Developing support and resource programs for at-risk students is a common strategy (Degazon & Mancha, 2012; Evans, 2007; Gilchrist & Rector, 2007; Wilson, Andrews, & Leners, 2006). Caution is warranted because these programs can marginalize, blame, and stereotype students who are encouraged or required to participate, especially in difficult economic times when resources are not available to all students (Capper et al., 2000). However, the programs can be beneficial by providing students with a nexus of support from faculty and peers. Participation in programs before the academic year begins gives students a jump start, just as participation in programs during the academic year provides students with a helping community. Care must be taken to ensure that the added support does not fill students’ schedules to the point of discouraging participation.
Labels can bring negative connotations that must be recognized and addressed. Students who were admitted to a competitive school of nursing may have known academic success in high school and may have been recognized as being smart and top students. A sudden designation of being at risk can lead to dissonance. For many students, the label of at risk is taken to mean a personal flaw or acknowledgement of an inadequacy. If the label is vastly different from previous self-perceptions, the student may not take advantage of the resources that are critical to easing the transition and fostering academic success.
Another consideration in the balance is the decision regarding communicating the at-risk status to students. Should students be told they are labeled as being at risk, and if so, how should they be told? Self-fulfilling prophecy theory suggests that telling someone he or she is at risk could actually reinforce the behavior that led to the label and breed a “why try” attitude (Guyll et al., 2010). Social labeling can lead to psychological labeling when the individual begins to believe and accept the label others provide. It can feel like permission to not do well and be perceived as a weakness or deficiency in self, especially for students who were successful in previous educational situations. This could lead to decreased self-esteem and to an increased focus on differences, which could make someone feel less capable and result in poor academic performance (Link & Phelan, 2006).
The counter argument would be that not apprising students of their risk is harmful. The logic is that without an appreciation of the risk, it is harder to develop plans and strategies to avoid and successfully overcome the risk. It can be helpful to provide a rationale for the risk along with information about available resources and services. Faculty can use the analogy of social determinants of health to enlighten students about societal and educational factors that influence academic performance. This approach moves the focus from an individual level to a socio-cultural level that the student could not control in the past but may be able to successfully navigate in the present. Students can view the problem from a macro level and begin to recognize external factors that have contributed to academic difficulties, such as attending a high school without honors or advanced placement classes (Bednarz, Schum, & Doorenbos, 2010). In addition, students can be helped to see that their current environment can foster success. This approach builds community and a sense of not having to solve problems alone.
An incentive is a gift or promise for better performance; incentivizing refers to the process of using these to help entice individuals to want to accomplish selective tasks to the best of their ability. Incentive theory and incentivizing strategies are linked to basic economic principles. Incentive theory is one of a number of motivation theories and is based on the premise that people are motivated to do things because of perceived rewards (i.e., return on investment). Incentives may be tangible (extrinsic) or intangible (intrinsic) (Fryer, 2011). The key to students performing well is a strong commitment to academic study; motivation is requisite for their success. Students who are grade-oriented are extrinsically motivated, whereas students who take a genuine interest in learning are intrinsically motivated. Although it is relatively easy to determine whether students are motivated, the underlying antecedents to their behaviors may be more difficult to discern. In fact, students may not fully appreciate what their motivating factors are. Regardless, incentives can play a major role in their success. Arguably, the most powerful tangible award for many in western society is monetary. Intangible things, such as pride of accomplishment and feeling good about oneself, are also important.
Using Incentives in Education
In recent years, a major concern in primary and secondary education is how to close the achievement gap between disadvantaged and more privileged students. Among approaches being investigated is incentivizing students with cash payments. Numerous studies have investigated the effect of providing financial rewards to students who complete certain tasks. The results have been mixed and are often controversial and frequently politicized. Roland Fryer, a leading researcher from the Educational Innovation Laboratory at Harvard University, conducted an integrative review of over 250 such studies, in addition to his own research. He concluded that financially rewarding superior academic behaviors ultimately leads to better academic performance than rewarding academic outcomes (Fryer, 2011). Focused, learning-based incentive programs (e.g., attendance, paying students per book read) lead to better results than simply paying students for good test scores. When the emphasis of incentivizing is on performance rather than outcomes, it helps students who are unable to sufficiently assess what is required to be academically successful at the beginning of their course of study, despite being motivated by the incentive. The incentives require students to determine strategies for success and improve their academic performance by developing study skills or becoming more comfortable seeking help.
Incentives are not new to nursing education. For decades, graduate students have been incented to pursue their academic studies full time on receipt of tuition or stipend support from grants awarded to universities by federal agencies. Although not labeled as incentives, such awards fulfill this purpose, with the emphasis on outcomes (graduation). Stipends are now being used in undergraduate programs for students from disadvantaged backgrounds. A primary purpose of stipends is to help students with unexpected personal or family situations that may otherwise hamper their academic progress. Stipends also can be powerful incentives, depending on how they are awarded. If eligibility for stipends is solely tied to academic progression, their effectiveness in helping students achieve academic success while developing intrinsic motivation for learning is diminished. When stipends are awarded to students with requirements for engagement in a series of programmatic activities and commitments, better academic outcomes may result, provided other necessary wrap-around services (e.g., mentoring) are in place.
Making Incentives Meaningful
Incentives must be meaningful to students on several levels. Success first requires active student engagement. Students must understand the incentive and associated requirements and be given the opportunity to opt in or out of the program, recognizing the need for free choice and potential consequences of their decisions. Formal contracting with students underscores the students’ commitment while explicating any monitoring controls and consequences they will experience if they do not meet contractual agreements. The best extrinsic incentives are unrestricted monetary gifts or financial proxies (e.g., gift cards), as students may use them toward what they perceive to be their greatest needs, even if those needs differ markedly from the ones identified by program administrators or faculty (Fryer, 2011). In designing an incentive program, meaningful, measurable benchmarks that are tied to behavior rather than to academic outcomes are paramount. These may include obtaining the set of required textbooks, regularly meeting with one’s advisor, attending peer support groups, attending professional meetings, or engaging in community health promotion activities. Some may be mandated and others may be chosen by students in accordance to their interests. Because affective learning often takes place from participation in programmatic components, such as professional or community engagement, intrinsic incentives also result from a student’s accomplishments, recognition, and vision for future contributions and successes. If the external incentive is withdrawn, this approach reduces the risk that the students’ motivation and performance will flounder.
In nursing, true incentivizing of students for professional role responsibilities goes beyond economic principles. It requires that students know that others are concerned and caring about their success. Caring is always specific and relational; it is not context free. Caring creates possibility (Benner & Wrubel, 1989) and can be achieved through program design that includes specific structural components that are tied to any cash incentive administered by engaged faculty and administrative personnel. Together, they help protect students against vulnerability by creating safe places for students to flourish in the absence of risk.
Student advising is a critical aspect of any educational experience. When done well, advising can be transformational for the student and rewarding for the advisor. Developing a model of academic advising that promotes inclusivity begins with an understanding of the philosophical perspectives, organizational issues, and societal barriers that affect the student–advisor relationship.
Philosophical Perspectives: Prescriptive Versus Developmental Advising
Traditional academic advising is philosophically prescriptive and aims primarily to ensure that the student adheres to the curriculum plan. In a prescriptive model, all students are treated the same way, and emphasis is placed on program requirements rather than on individual needs, strengths, and learning styles. If paralleled by deficit thinking, prescriptive academic advising focuses on ways to rectify student deficiencies rather than build on proficiencies. Prescriptive advising that centers on lists of requirements to be met and resources to be sought does not acknowledge the attributes the student brings to the organization and may in fact stifle development and convey the message that being different is a liability.
A more holistic perspective that eschews deficit thinking is that of developmental advising. In their review of the theoretical foundations of academic advising, Hagen and Jordan (2008) summed up the developmental approach as “focusing on the needs of the student in determining how the advising interaction shall transpire” (p. 20). In this model, the nature and quality of the relationship between the advisor and the advisee is more egalitarian. The advisor, who is inherently in a position of power, begins the relationship by creating an environment that encourages the advisee to discuss his or her background, personal strengths, and goals. Likewise, the advisor shares enough information about his or her academic and personal journeys to build trust, facilitate role modeling, and work toward a role transition from advisor to mentor. Developmental advising requires multiple points of contact across a semester. The closeness of the relationship evolves over time and unfolds in a natural progression. Topics include life roles, adjustment to college, and career options, with an emphasis on the uniqueness and wholeness of the advisee rather than the deficits to be overcome.
Organizational Issues That Affect the Quality of Advising
Several things can prohibit the development of a strong system of advising in institutions of higher education. Assignment of advisees to advisors may occur in an alphabetical or random fashion, with no attempt at matching. Advisors may be faculty members with minimal related experience, part-time faculty members who spend little time on campus, or trained staff that lack knowledge of the challenges and opportunities in the nursing profession. Due to the current faculty shortage, a lack of advisors from minority backgrounds must be a common phenomenon, given that 12% of full-time nursing school faculty and 27% of students in entry-level baccalaureate programs are from minority backgrounds (AACN, 2011).
If an overall commitment to diversity and inclusivity is not evident in the mission and activities of the institution, it will be difficult for individuals to provide advising that reflects those ideals. An organizational commitment to advising is also essential. If there is inadequate training, resources, evaluation, and oversight of advisement, both the student and advisor are left feeling uncertain about the process or its desired outcomes. Likewise, a lack of acknowledgement and administrative approval of the faculty time commitment required will preclude effective developmental advising.
Societal Barriers to Relevant Advising
Our increasingly diverse society imposes a number of barriers that can have an impact on student advising. Students from underrepresented minority groups and those who are the first in their family to attend college may bear disproportionate burdens that put them at risk for poor performance and perhaps influence the advisor’s perception of their ability to succeed. For example, financial need may cause stress and result in a student’s need to work during optimal study times or advising hours. Their parents may be less involved and able to provide support or participate in events on campus and communicate with advisors when appropriate.
Racial, ethnic, and gender tensions on campus may adversely affect the learning environment and the quality of the advisor–advisee relationship. A university’s response (or nonresponse) to such tensions sends a message to everyone on campus. An advisor may believe that he or she is free from prejudices and careful about language, yet unwittingly practice microaggressions that severely undermine the advisor–advisee relationship. Microaggressions are those behaviors or events that may seem trivial or ambiguous but are insulting or oppressive to their recipients (Sue et al., 2007). For example, comments such as “You are doing surprisingly well” or “You are so articulate” may be perceived by minority or first-generation college students as a reflection of the advisor’s low expectations or acceptance of stereotypes.
Strategies to Improve Advising and Promote Inclusivity
Academic advisors can have a powerful impact on the self-perception and personal and professional development of the advisee. The advisor must proactively seek opportunities to connect with the student and recognize that the relationship will evolve more readily when the meetings take place in neutral territory, such as in the outdoors, lounge areas, or a cafeteria, and when the agenda is not solely focused on course planning or academic progress review. Incentives for student participation in advising are helpful at first; once the relationship is established, they are rarely required.
Current events or tensions on campus can stimulate meaningful conversations about the challenges of inclusivity. Simply acknowledging the generation gap that inevitably exists between advisor and advisee sets the stage for embracing differences. The advisor does not need to have all the answers or even much wisdom about the issues; openness to the advisee’s point of view communicates caring and appreciation for diversity. The advisor needs to engage with a spirit of openness and will likely be amazed at how much he or she learns during these conversations.
Advisors have the ability to reduce or prevent the effects of microaggressions, which are more challenging for the advisee to cope with than blunt discrimination because they are not readily labeled, are often unpredictable, and may be difficult to address (Salvatore & Shelton, 2007). The advisee is likely to be able to provide examples of microaggressions if asked. Open, welcome conversation about microaggressions allows the advisor and advisee to strategize about ways to address them.
To create a culture that embraces diversity, faculty must actively reflect on the impact of their own privilege. A powerful narrative by Peggy McIntosh (1988) called White Privilege: Unpacking the Invisible Knapsack demonstrates that unearned power is conferred systematically to those in the majority or dominant group. When members of a dominant group think of their lives as morally neutral, normative, average, and ideal, work to benefit others is seen as work which will allow “them” to be more like “us.” In education, this translates to a situation in which faculty and advisors may have simplistic perceptions and unrealistic expectations of minority students.
Several attitudes and behaviors can be recognized by successful developmental advisors as potentially hazardous to the advisee. Simplistic perceptions of minority and first-generation college students as being motivated by a desire for career or class upward mobility may preclude advisors from promoting activities such as student clubs, study abroad, and participation in faculty research. Erroneous judgments about nonverbal behaviors, such as lack of eye contact, may be perceived as disrespect when it really reflects the advisee’s embarrassment about academic performance or uneasiness in the advisor’s presence.
Eschewing the deficit model and viewing students as at potential rather than at risk promulgates high academic expectations. The ability to appreciate the deep meaning of diversity may require the advisor to engage in self-reflection and reject the notion that students from minority backgrounds are oppressed, disadvantaged, and apt to fail. It may also require that the organization utilize nontraditional approaches to education and take measures to remove obstacles and create opportunities for all students.
Several factors can affect the quality of the advisor–advisee match. Assigning advisors on the basis of racial and ethnic background does not guarantee a successful pairing. A culturally sensitive advisor is a good listener and an inquisitive learner, and an advisor with a background different from the student can easily establish a meaningful and trusting relationship if caring and respect are communicated. It is often these crosscultural interactions that do the most to promote inclusivity.
Directly seeking input from diverse students can be fruitful and inform faculty development for advising and teaching. The formation of a Diversity Advisory Board that includes local nurse leaders from minority groups, faculty, and students and that meets each semester where the discussion is frank and informative can stimulate participants to put more effort into promoting inclusivity. For example, in our school, we decided to hold student focus groups led by a minority faculty member. When asked directly to talk about their experiences, students will provide tremendous insight into the microaggressions they perceive. These data can be reported back to faculty and openly discussed under the guidance of an enlightened faculty member. Another successful strategy was to form a book club, where both novels and nonfiction texts that feature cultural themes are discussed in an informal setting. Students were also able to create a brief faculty development video about their personal stories. This provocative, real-life description of barriers encountered by minority students in society, in the classroom, and in the clinical area sparked meaningful conversation and provided faculty with insights and the courage to bring up the subject in advising, in the classroom, and in clinical settings.
Let us return to our opening scenario of students whose behaviors bring them to our attention early in the program. The outcomes can be different when programmatic efforts include appropriate labeling, meaningful incentives, and developmental advising. The learning that occurs through embracing differences, sharing insights, and confronting stereotypes for students and faculty alike better prepare us all to address the health care needs of an increasingly diverse population. A climate of inclusivity within a university is the key to the success of disadvantaged and nontraditional nursing students and sets the stage for program initiatives to be effective.
The notion of inclusivity is intrinsic to the discipline of nursing and is consistent with its educational philosophy. Institutional culture change that promotes inclusivity develops in response to an intentional embracement of diversity. Faculty must engage in open discussions about definitions of labels, underlying assumptions about student aptitudes, and strategies for ensuring student success. Most importantly, faculty must actively solicit and seriously consider the students’ accounts of their experiences and perspectives about the changes that would make the climate more welcoming.
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