Journal of Nursing Education

Major Article 

Baccalaureate Nursing Education Experiences of African-Born Nurses in the United States

Mabel Ezeonwu, PhD, RN

Abstract

Background:

African-born nurses are valuable members of the U.S. nursing workforce. The majority begin their nursing education in community colleges and practice as licensed practical nurses/vocational nurses (LPN/VNs) and RNs before obtaining their Bachelor of Science in Nursing (BSN) degree. For African-born nursing students, the environment of 4-year institutions, although exciting and promising, may be overwhelming and challenging.

Method:

In this qualitative descriptive study, 25 African-born nurses who graduated from accredited RN-to-BSN programs over a period of 5 years were interviewed. Qualitative content analysis was used to analyze the data.

Results:

Several factors including flexible curricular designs and helpful campus resources supported students' educational experiences. Factors such as financial difficulties and difficult work–family–school balances challenged them.

Conclusion:

The BSN curriculum is especially rigorous and demanding for foreign-born minority students. Such programs must provide appropriate resources to support students who are new to U.S. education system. [J Nurs Educ. 2019;58(5):281–289.]

Abstract

Background:

African-born nurses are valuable members of the U.S. nursing workforce. The majority begin their nursing education in community colleges and practice as licensed practical nurses/vocational nurses (LPN/VNs) and RNs before obtaining their Bachelor of Science in Nursing (BSN) degree. For African-born nursing students, the environment of 4-year institutions, although exciting and promising, may be overwhelming and challenging.

Method:

In this qualitative descriptive study, 25 African-born nurses who graduated from accredited RN-to-BSN programs over a period of 5 years were interviewed. Qualitative content analysis was used to analyze the data.

Results:

Several factors including flexible curricular designs and helpful campus resources supported students' educational experiences. Factors such as financial difficulties and difficult work–family–school balances challenged them.

Conclusion:

The BSN curriculum is especially rigorous and demanding for foreign-born minority students. Such programs must provide appropriate resources to support students who are new to U.S. education system. [J Nurs Educ. 2019;58(5):281–289.]

This study documents the perspectives of African-born nurses on their baccalaureate nursing education experiences in the United States. More specifically, it describes how these nurses navigated complex academic pathways and baccalaureate nursing curriculums in the midst of financial, sociocultural, and institutional challenges, while also pointing out factors and resources that helped them succeed. The Institute of Medicine (IOM; now identified as the National Academy of Medicine) (2010) recommended increasing the number of nurses with Bachelor of Science in Nursing (BSN) degrees from 50% to 80% by 2020. This charge brings to the fore the unique challenges faced by nurses born in Africa in their pursuit of baccalaureate nursing education. The environment of 4-year institutions in the United States can be intimidating and often times overwhelming for foreign-born students, especially those from resource-poor African countries with English language barriers. Note that in this study, the term African-born nurse refers to a nurse who was born in an African country and is not a U.S. citizen by birth.

The U.S. Census Bureau (2017) estimates that of the 321 million people in the United States (World Health Organization, 2018), 60.7% of the population is non-Hispanic or non-Latino Caucasian, whereas the remaining 39.3% is made up of racial and ethnic minorities. Furthermore, foreign-born individuals account for 13.2% of the population. Reports show that of the 40 million people born outside of the United States, 4% (1.6 million people) are those who identify as being born in Africa, which had a population of only 800,000 in 1970 (Gambino, Trevelyan, & Fitzwater, 2014; Grieco et al., 2012). These swift and large demographic trends indicate that immigration and globalization can be powerful forces that have significant implications on health care in the United States. The demographic changes call for new strategies that increase the number of racial and ethnic minorities in nursing (Beacham, Askew, & Williams, 2009).

After assessing the progress made toward its Future of Nursing recommendations, the National Academies of Sciences, Engineering and Medicine (2015) called for further diversity in the nursing profession to better represent the patient population it serves. To this end, the IOM also noted that the most effective way to achieve workforce diversity is to increasingly diversify the pipeline of students pursuing nursing education. In fact, the American Association of Colleges of Nursing (2015) stated that diversity and equality of opportunities are core values of all educational systems, and qualified applicants must represent the cultural, racial, ethnic, economic, gender, and social diversity of the broader population.

The ultimate goal of increasing diversity in nursing is to reduce health disparities and advance health equity and social justice. An important variable in eliminating disparities is better representation of minorities among health care providers (Ferrell, DeCrane, Edwards, Foli, & Tennant, 2016). Minority providers, including foreign-educated and foreign-born professionals, are more likely to practice in underserved areas with minority populations and thereby improve their access to health care (Ferrell et al., 2016; Meghani et al., 2012). Jackson and Gracia (2014) posited that improving the diversity of the health care workforce strengthens the nation's health and increases overall access to quality health care and service.

African-born nursing students constitute a considerable proportion of the targeted nursing workforce, and their unique perspectives in the classroom help enhance cultural awareness and sensitivity and lead to greater understandings of certain patients' value systems. Anecdotal evidence shows that nursing is a top-tier profession of choice for African immigrants, particularly women in industrialized countries, which makes the RN-to-BSN program an excellent pathway to increase both the diversity of and the number of nurses with BSN in the health care system.

The majority of African-born nurses in the United States start their nursing education and careers from the bottom as certified nursing assistants, then as licensed practical nurses/vocational nurses (LPN/VNs) and RNs at community colleges in the United States, irrespective of their prior education levels in their countries of origin. This educational and professional path is unsurprising. Among different nurse categories, diversity is highest among the LPNs/VNs (National Academies of Sciences, Engineering and Medicine, 2015), and newly licensed LPNs/VNs are more likely to have diverse racial/ethnic compositions (Budden, Moulton, Harper, Brunell, & Smiley, 2016).

Although classified as and lumped together with African Americans including those born in the United States and in the Caribbean, African-born nurses have distinct backgrounds and experiences. Lee and Opio (2011) emphasized that Black Africans' experiences of discrimination are incomparable to racial discrimination directed toward African Americans since the former group faces challenges related to cultural differences, accents, and negative stereotypes about their countries of origin, all of which put them at risk of acculturative stress. Language and communication issues are key stressors for foreign-born nursing students (Fuller & Mott-Smith, 2017; Malecha, Tart, & Junious, 2012). They are conscious of their unique accents and respond to public speaking or speaking to large groups by engaging in what Malecha et al. (2012) described as “verbal retreats” (p. 301).

Furthermore, social and familial factors also place added pressure on these individuals. While studying the experiences of Black African international students in the United States, Boafo-Arthur (2014) found that adjustments to societal norms and interpersonal relationships created further acculturative stress for students who arrive in the United States with their families, considering that traditional African patriarchal family structures often lead to conflicts between spouses and between parents and children. Social isolation, alienation, loneliness, separation from friends and family, lack of support, and financial concerns are other common, interrelated factors that affect immigrants' well-being and academic success (Boafo-Arthur, 2014; Malecha et al., 2012).

Woodgate and Busolo (2018) also described some African immigrants' journey and settlement as chaotic, since some are influenced by their past experiences of homelessness, poverty, and living in refugee camps. In particular, they identified postmigration roadblocks related to inadequate educational opportunities, ongoing struggles with building relationships, discrimination, unemployment and underemployment, and unmet socioeconomic needs. These obstacles show that although people move physically away from places of danger to safer environments, they continue to reexperience dark moments of past struggles. Woodgate and Busolo (2018) also asserted that immigrants from predominantly war-torn countries find it challenging to let go of those experiences, especially if their mental health is affected by violent and traumatic episodes.

Although African-born nurses are not monolithic—Africa is a continent of 54 countries with colonial landscapes that represent Anglophone, Francophone, Portuguese, and Spanish backgrounds (Arthur, 2006)—the majority of them share similar tenets, such as upholding strong family values, caring for one another intimately, and highly valuing education. Immigrants from several refugee origin countries may have lower levels of formal schooling, but, overall, Black African immigrants in the United States are well-educated and have college completion rates that exceed most other immigrant groups and U.S. natives (Capps, McCabe, & Fix, 2012). The cultural prioritization of higher education is passed from generation to generation among most Africans (Arthur, 2000; Capps et al., 2012) and is no different for African-born nurses, even as they encounter personal and institutional challenges.

Several studies have examined different aspects of minority nurse experiences in academic and professional settings. Stressors and barriers to success for minority and ethnically diverse nursing students, including foreign-born students, have been extensively studied (Amaro, Abriam-Yago, & Yoder, 2006; Graham, Phillips, Newman, & Atz, 2016; Loftin, Newman, Dumas, Gilden, & Bond, 2012; Malecha et al., 2012). Loftin et al. (2012), for instance, documented barriers such as poor mentoring resulting from the lack of minority faculty in educational institutions. Meanwhile, Graham et al. (2016) explored the systemic issue of bias in faculty grading practices when managing the clinical education of baccalaureate minority students: in short, faculty members struggle to decide whether to pass or fail students who are often viewed as outsiders in nursing education. Ackerman-Barger (2010), on the other hand, examined specific barriers related to minorities engaging with faculty made up predominantly by White women. Lifelong familial and geographical barriers that prevent ethnic minorities from succeeding in nursing have been also studied (Metcalfe & Neubrander, 2016).

Predictors of academic success among underrepresented minorities in nursing have been explored, including mentoring programs (Crooks, 2013; Williams, Bourgault, Valenti, Howie, & Mathur, 2018), improved institutional climate and social interactions to reduce discrimination and bias (Williams et al., 2018), and availability of scholarships (Cowan, Weeks, & Wicks, 2015). Condon et al. (2013) showed how recruitment and retention through individualized preentrance preparation programs improve baccalaureate nursing students' study skills and self-confidence. Meanwhile, the use of peer study groups was documented as an academic success strategy for Black nursing students (Dapremont, 2014). Some studies have examined the experiences of specific ethnicities such as Hispanic nursing students in the United States (Alicea-Planas, 2017) and international nursing students from Nepal, China, India, Iran, Nigeria, and Trinidad in the United Kingdom (De, 2010). However, research studies on the RN-to-BSN experiences of students born in Africa and live in the United States are nonexistent. This study fills this gap in research.

Method

Research Design

This descriptive study used qualitative content analysis to analyze the views of African-born nurses on their RN-to-BSN education experiences in the United States. Data were collected through semistructured face-to-face and telephone interviews. The RN-to-BSN program described in this study was an intensive, 1 day per week face-to-face program that allows full-time students to graduate in four quarters and part-time students to graduate in seven quarters.

Recruitment and Sampling

This study recruited a sample of 25 African-born nurses who completed their RN-to-BSN degree between 2010 and 2014 at a public university in the U.S. Pacific Northwest region. Inclusion criteria for participants included the following: must be 18 years or older, graduated from an RN-to-BSN program, and born in an African country. Detailed information about the study was provided to all participants, and any questions they had were answered. Face-to-face interviews were conducted with participants at agreed-upon times and locations of their choice, and informed consent was provided and signed prior to interviews. For telephone interviews, participants' rights were read to them, and verbal consent was obtained prior to interviews. Approval for the use of human subjects was obtained from the Institutional Review Board of the University of Washington. All study protocols adhered to the institution's ethical principles.

Data Collection

Participants were identified through nursing program advisers at the university. Potential participants were contacted by the researcher through e-mails and telephone calls that requested their participation in the study. Arrangements for interviews were made thereafter. Semistructured interviews using open-ended questions were used to solicit detailed responses from the participants. Key interview questions included the following: “What challenges did you encounter during your RN-BSN program?” and “What factors enabled you to navigate the program successfully?” Each interview lasted 30 to 60 minutes and was audiorecorded with the participants' permission. Two participants declined audiorecording and detailed notes were taken instead.

Data Analysis

All recorded interview data and notes were transcribed verbatim and then reviewed by the researcher for accuracy. The data were analyzed using qualitative content analysis procedures and processes outlined by Elo and Kyngäs (2008) and Graneheim and Lundman (2004). The interview transcripts were condensed into one text that constituted the unit of analysis. Important sentences or statements and keywords or phrases were identified and highlighted as meaning units that characterized the participants' educational experiences. Categories and subcategories of data were created by sorting common ideas in the text and carefully coding them based on their differences and similarities. Ultimately, themes and subthemes related to participants' challenges and factors that supported their progress through the program emerged and accounted for key study findings.

Findings

Although this study was open to all RN-to-BSN graduates from all parts of Africa, its participants represented sub-Saharan Black African countries. Eighty percent were married, and 88% had children. Their years of residence in the United States ranged from 9 to 25. Seventy-six percent of participants acquired their LPN licenses before obtaining their RN diplomas in community colleges, but all participants obtained their LPN and/or RN diplomas in the United States prior to starting their BSN programs. One third of the participants were men, and the rest were women. The participants' professional nursing practice backgrounds varied and ranged from long-term care, primary care, and medical–surgical nursing to specialties such as labor and delivery, intensive care, and mental health. Although some of the participants struggled with English language when they first arrived in the United States, they had since become fluent and comfortable with the language. Table 1 presents the participants' detailed demographic information.

Participant Demographic Characteristics (N = 25)

Table 1:

Participant Demographic Characteristics (N = 25)

RN-to-BSN Education Challenges: Individual

Challenging Work–Family–School Balance. Most participants emphasized the struggles they experienced while juggling classes, family needs and expectations, and work. Every one of them worked during their baccalaureate programs, with their commitments ranging from one full-time job to three jobs. Only two participants reported that at one point, they went from full time to part time because they found that taking two classes per quarter was too stressful.

While studying and working, participants were also responsible for keeping commitments to family, not only catering to the needs of immediate family members living in the United States, but also maintaining the welfare of those they left behind in their native countries. This explains why, for most participants, working multiple jobs was a necessity. One divorced mother stated, “In addition to school, I had to continue two jobs to support myself and family back in Africa.” Similarly, another participant said:

I worked more than full time. It was intense even though it was a once-a-week program. I have to work to pay the bills. I have to study other days. The main thing was that I had to take care of my mom, brothers at home, my family. Exams and quizzes were very difficult.

All participants concurred that the stress of trying to succeed in the baccalaureate program was huge, and additional job and family responsibilities left them with little or no time for self-care and rejuvenation.

Financial Difficulties. All participants expressed that while in school, they had concerns about not meeting their financial obligations. Although they worked long hours, they lamented that the money they made did not meet their financial needs, which included tuition, living expenses, and the needs of immediate and extended family members in Africa. The majority of participants identified not qualifying for financial aid or receiving limited aid as a factor that delayed their application to the BSN program, as well as the reason behind extra hours they had to work to pay their tuitions. One participant noted, “There was no financial aid. It was difficult. They were allowing two payments for tuition for each quarter. Maybe better to do three payments instead of two.” Another participant who also completed her Master's of Nursing degree said, “The tuition was much. I am now with lots of student loans to pay.” In fact, one participant who qualified for tuition exemption as a state employee noted that her program would not accept her tuition exempt status, which forced her to pay out of pocket.

Challenges in Academic Writing, Technology, and Digital Communication. Baccalaureate nursing programs' expectations and requirements for writing were challenging for the participants. One nurse compared the BSN program to the Associate Degree in Nursing (ADN) program, stating that the former was more research based and required more writing than the latter. A significant number of participants came from their countries of origin with limited English speaking and writing skills; as one participant explained, “I know English a little bit, but the academic English was higher level for research. It was new to me.” Furthermore, RN-to-BSN programs' heavy reliance on technology and different digital media platforms for research, communication, and presentations were foreign to participants, most of whom grew up in rural villages and environments with minimal economic and academic resources. One participant shared, “When I started, I did not know the sequence of writing an academic paper. It was hard to navigate the computer and the library. Everything was connected to the library, CINAHL, websites to get articles from….”

Another participant detailed her experiences and observations this way:

Africans were not exposed to computers and research and search engines. We learned them here and cannot compare with people born here. Minorities can get help on this, but they end up plagiarizing without knowing it. I remember, in my ADN program, I heard about a student…that got in trouble for plagiarizing without knowing it.

The majority of participants agreed that they felt stress when having to complete writing assignments and share their work with peers through media presentation platforms such as PowerPoint®, Prezi, iMovie®, and Google documents.

Language Barriers, Discrimination, and Psychological Intimidation. Sociocultural adjustment was a top challenge identified by all participants, the majority of whom were first-generation immigrants from countries where American English is not the primary language (some could speak and write perfect British English). Issues related to having African accents were at the forefront of all the participants' challenges. They explained that they encountered difficulties during informal conversations with peers, faculty members, and staff, as well as during formal class discussions and presentations. One participant summarized her frustrations and experiences this way:

It doesn't matter how intelligent you are. Immediately, they hear your accent, you are put in a corner, you are put in a category, and you are not being heard. But inside you, you believe you are intelligent. And some peers are not accepting. Some teachers can roll you under the bus.

Meanwhile, another explained, “Sometimes pronunciations during class presentations are where a lot of us get their marks down. All of us are good at taking tests. We are not public speakers. In fact, we fear public speaking.” Other participants also stated that they felt intimidated when they had to speak in front of their peers and instructors. Participants explained that these social and cultural experiences affected their confidence in the BSN program and that African nursing students were not always accepted by peers and instructors. For instance, many participants shared the common experience of being excluded from and avoided by peers when having to form small groups in class. One said, “I felt like an outsider in the school. It was hard to know anybody in the school when you are a minority.” Meanwhile, others felt they could not rely on classmates to help them, especially when they needed updates on classes they missed for personal or family reasons such as childcare issues. One participant stated, “The [other] students were horrible to me and that made it worse because I have no one to turn to.”

For such reasons, the BSN experience was not ideal for many participants. One stated:

It is the challenge of fitting in. You have to work harder. Some people will be mean and remind you of being a minority. I guess this is part of life. This was stressful. They use the opportunity to bully you and you feel like you cannot do it even though you can.

He further lamented that these experiences have followed him in his work within hospital settings.

RN-to-BSN Education Challenges: Institutional Challenges

Limited Elective Options. Two thirds of participants wished they had more electives to choose from in the RN-to-BSN program. They explained that because the program was designed on the 1-day-per-week model, they found it difficult to identify appropriate electives that were offered on the same day as their core courses. Furthermore, although some electives were offered through other departments, most took place on different days than their nursing classes. As such, many participants were forced to choose from a limited pool of electives that they were disinterested in or that were irrelevant to their work. One participant stated rather sarcastically, “My elective was about films and I took it because it was the only thing available, not that it was meaningful to me or my career.” In addition, this participant had to attend school twice per week because her elective, like many others, was scheduled for more than once per week. For most African-born nursing students who must take on two to three jobs to succeed and remain in the program, even an extra day of classes creates enormous scheduling conflicts and increases the financial burden.

Unapproachable Faculty and Staff. Several participants commented that some of their instructors and advisors were unapproachable and unsupportive, even describing them as “condescending.” They experienced general fear and uncertainty towards how a professor might react to them and their questions; thus, their questions and concerns often went unresolved. One participant observed the following: “Africans are more hesitant to ask questions and we are more hesitant to use available resources such as library resources and writing center. But you have to ask questions to get clarifications for things you don't know.” Another participant pointed out that, as an undergraduate coming from a smaller community college campus, she was intimidated in general by larger institutional settings and the unapproachable staff only exacerbated her fears. Meanwhile, two other participants noted that some professors were unavailable to meet with students in person to discuss their questions and progress in the courses. Another stated, “I felt I was getting out of the topic for one of my courses. I did not get enough help. I get referred to different places.”

Limitations in Program Design. Although the once-per-week program design was praised by most participants, they still acknowledged it presented unique challenges. They were often overwhelmed by the struggle to navigate the American education system and its various technologies while also juggling academics, work, and family. These intensify their burdens. One participant noted, “For core classes, I spent the whole day reading. So exhausting. At the end of the day, your brain is dead. You don't make meaningful contributions to the later classes.” Other participants' comments included the following: “It was fast. Navigating the program was difficult. The program was too much for one year. The full-time program was a bit too much. Two core classes per quarter was a stretch. Coordinating classes with work was tough. The reading materials were a lot but interesting. After work, I get on the computer to do assignments, so some assignments were late.” Half of the participants also pointed out that there were not enough hybrid and online courses, even though some of them were uncomfortable with digital tools. They needed these options because they were constrained on time and required alternative methods to finish coursework.

Not Enough Diversity Amongst Faculty and Students. A common theme mentioned by all the African-born participants was that they did not meet enough faculty members or other students who looked like them, understood them, or shared their experiences. One participant noted, “It was hard not having more faculty to identify with.” Another participant stated, “I lacked seeing a lot of African people. I wished there were mentors and older students that could talk to new students.” They agreed that an African Nursing Students Association on campus would've been helpful in connecting them with students and mentors of similar backgrounds who might have spoken to them about program expectations. One participant said, “If I had the opportunity to meet already existing African students through mentorship, it would have been helpful.”

RN-to-BSN Success Factors: Individual

Self-Determination. Determination was one of the main success factors identified by participants. They noted that they had come a long way literally and metaphorically, and failure was not an option. To that end, they explored every opportunity and did their best to succeed in the RN-to-BSN program. One participant stated, “I have to work very hard, I cut some work hours to get to assignments and homework.” Another said, “I talked to a lot of people that went through the program and I was mentally prepared. I became more confident.”

Support From Family and Like-Minded Peers. Participants reported that their families were their ultimate strong and steady support systems, and their peers were also critical to their success. Some noted that they used their peers, particularly fellow Africans, as study buddies. One participant said, “Having someone to identify with, including fellow students and faculty who look like me and share the same experiences as me, was very helpful.” Many participants appreciated their abilities to work with small groups of Africans who often met on and off campus. Although some noted that small groups sometimes distract from focused study and learning, a quarter of participants agreed that they were useful in helping them to understand subject matters.

RN-to-BSN Success Factors: Institutional

Practical Program Design. The majority of participants appreciated the flexible 1-day-per-week class schedule, as well as online and hybrid designs that incorporated small group projects. They confirmed that the RN-to-BSN program appealed to them from the start because its model allowed them to continue working to support their families and their education. One participant stated, “The class was once per week, two classes on one day. It would have been difficult if my classes were done more than one day a week.” Although online and hybrid courses pose technological problems especially for African-born students, they were still appreciated by the majority of participants who worked full time while attending the full-time program. Professors' willingness to incorporate small-group projects into the coursework also eased the participants' workload.

Supportive Faculty and Staff. Although participants had negative experiences with some faculty members, they still identified certain professors, academic advisers, librarians, and writing center staff as their core support system throughout their program. Seventy-two percent of participants recognized professors as one of their top reasons for successful graduation, describing them as encouraging, understanding, flexible, patient, open, responsive, supportive, helpful, fantastic, and best. One participant noted, “The professors were very encouraging. Some tell you that you can do it.” Another said, “The professors are the best ever. They are open, you are welcome to ask questions and come during office hours. I have never been more appreciative of professors unlike those in the associate degree program who scare you away.” One participant even noted that she returned after her BSN program and completed her Master's of Nursing degree because faculty encouraged her and provided her with moral support. Participants especially appreciated opportunities to work one-to-one with professors and to occasionally submit assignments past due dates without penalty. They also acknowledged academic advisers who guided and encouraged them as they navigated through their programs.

Helpful Campus Resources. Participants also stated that campus resources, such as the university writing center and library, addressed their specific academic challenges, including understanding the process of writing academic papers and identifying scholarly resources via different search engines. They reported that designated librarians worked with nursing students to support and instruct them on how to conduct literature searches and write research papers. The writing center and its staff were similarly beneficial. One participant described the writing center as her “best resource” and noted the convenience of being able to submit her paper to the center online instead of going to school. Another emphasized that he also made use of the writing center and “would recommend it to any other minority student.” Other factors that were described as determinants of the participants' success and timely graduation included the ability to secure financial aid such as loans and small-sized classes.

Discussion

Even after leaving their countries of origin, African immigrants continue to honor their cultural values in the United States. They deeply care for the institution of marriage, procreation, and the extended family system, in addition to education as the pathway to social mobility and economic advancement. They engage selectively with their host society (in this case the United States) and confine their activities to carefully constructed zones that are mainly educational and economic, which are vital for their survival (Arthur, 2000). This study shows that, for African-born nurse professionals in the United States, these values are critical elements of their identity and provide interwoven structures of both strength and vulnerability.

Although family is a source of social support, the burden of balancing work, family, and the academic demands of the baccalaureate nursing program takes its toll on the students. Previous studies concur that although family (immediate and extended) support is essential to nursing students' success, it is also a source of stress, given that the students must cater to their family members' emotional and financial needs while attending school (Amaro et al., 2006; Metcalfe & Neubrander, 2016; Veal, Bull, & Miller, 2012). However, other support networks, such as friends and classmates, also provide solace and connectedness from which nursing students draw strength to cope with challenges (Condon et al., 2013; D'Cruz & Noronha, 2010).

Students' experiences of noninclusive institutional climates have significant effects on their academic experiences and outcomes. Many of this study's participants faced a range of bullying behaviors that are prevalent in academic and clinical settings. The American Nurses Association identifies social isolation and exclusion as characteristic of bullying and emphasizes that bullying violates the ethical principle that is paramount to nursing, which is to respect the worth, dignity, and human rights of all individuals (Longo, 2012). Graham et al. (2016) also confirmed that bias and discrimination are issues in nursing programs, and prejudicial and discriminatory practices of clinical faculty affect minority students negatively. Furthermore, underrepresented, older, and nontraditional minorities experience further microaggression and are more likely to be dissatisfied with their program if they feel isolated and marginalized (Murray, 2015; Williams et al., 2018). This study demonstrates that students' encounters with such covert and overt discrimination from peers and faculty based on their ethnicity, culture, and language translated into isolation, fear, and poor participation in curricular activities.

In fact, this study also shows that minority students of African descent often lack confidence in their own capabilities, because they feel ignored, excluded, overlooked, undermined, alienated, unheard, unacknowledged, and unrecognized. These results align with findings from a previous study, which found that actions that create self-doubt often force victims to believe that they are not good enough (D'Cruz & Noronha, 2010). In a seminal analysis of levels of racism, Jones (2000, p. 1213) referred to this feeling and behavior as “internalized racism,” which is characterized by an erosion of an individual's sense of value or intrinsic worth and the inability to believe in oneself. These experiences and perceptions have tremendous effects on individuals' psyches and academic outcomes.

One of the major contributors to this self-doubt, as the current study found, was the fact that African-born RN-to-BSN students (including those who speak and write perfect British English) encountered reactionary negative responses from their peers and instructors when they spoke or presented in class with imperfect American English. First-generation Africans in the United States have unique, pure, and natural accents that incorporate their dialectical heritage; however, their accents and their inabilities to speak and sound “American” both directly and indirectly usher them to the back seat of every classroom.

The unwelcoming attitudes and judgments of instructors and peers set the stage for that steep drop in African students' confidence level, which often manifests in their lack of participation in class discussions. Fuller and Mott-Smith (2017) confirmed that difficulties in verbal communication experienced by diverse nursing students stemmed not so much from their English abilities but from the attitudes of the people they were speaking to; ultimately, these students lose their confidence and withdraw from further communication once they feel disrespected. Compelling evidence from past and present studies show that people of other ethnicities and cultures do not actively participate in class due to their fear of being judged based on their language abilities.

This study further indicates that the majority of African-born nursing students are unfamiliar with the U.S. education system and the rigors of the baccalaureate program. Ackerman-Barger (2010) noted that without prior exposure to study expectations or rigors of nursing school, traditionally underrepresented students are at an unfair disadvantage in any program. This study shows that new classroom technologies pose problems for African-born students, and even while having to make adjustments they still preferred hybrid and online instructional modalities over face-to-face modalities, mostly because of the flexibility they afforded to students to work while attending school. Glogowska, Young, Lockyer, and Moule (2011) also found that nursing students are enthusiastic about the flexibility and convenience provided by online and hybrid courses, even if they are difficult.

Although digital communication may present challenges to African-born students who are both migrants to the country and to certain technologies, Autry and Berge (2011) emphasized that digital pedagogy is necessary in providing students with a broad range of technology tools that allows them to construct their own understanding and knowledge. The authors pointed out that for nursing professors to facilitate smooth and sensitive learning, they must ensure that cultural expectations and tools for success are passed on. To this end, appropriate supportive measures such as writing centers and library resources must be provided to all students, especially foreign-born minorities.

According to the findings of this study, RN-to-BSN students from Africa have difficulty qualifying for most financial aids and there are limited scholarship options for them because they work and often make just enough income to disqualify them for aid. Previous studies provide evidence that the financial barrier is a critical deterrent to academic success for underrepresented groups (DeWitty, Huerta, & Downing, 2016; Loftin et al., 2012; Metcalfe & Neubrander, 2016). Furthermore, Williams et al. (2018) emphasized that to increase nursing diversity, barriers to financial resources must be broken down.

Financial support from agencies and philanthropic foundations is key to promoting diversity and supporting ethnic minorities as students make their way through their nursing education. For instance, successful programs such as the discontinued New Careers in Nursing's collaborative scholarship program with the Robert Wood Johnson Foundation and American Association of Colleges of Nursing eased financial burdens for minority students in accelerated undergraduate and graduate nursing programs, in addition to offering mentoring and preemersion programs that helped recipients learn study- and test-taking skills (DeWitty, et al., 2016; Robert Wood Johnson Foundation, 2012). The Health Resources and Services Administration's (HRSA) Nurse Corps Scholarship Program also provides funding for a student accepted or enrolled in a diploma, associate, baccalaureate, or graduate degree nursing program (HRSA, 2019a). Other school-based scholarships and loans such as Scholarships for Disadvantaged Students (SDS Program), Loans for Disadvantaged Students (LDS Program), and Nursing Student Loans (HRSA, 2019b) exist for disadvantaged students; however, none are specific to RN-to-BSN students or African-born nursing students.

Finally, targeted investments in institutional resources and curricular adjustments are central to the academic success of marginalized nursing students. This study finds that although African-born nursing students and other minorities experience bias and discrimination at school, their professors, advisors, librarians, and writing center personnel have strong, positive influences on their academic experiences and outcomes. Previous research concurs that strong and sensitive academic advising is essential to minority students, and faculty and staff play important roles in student success (Condon et al., 2013). However, as Graham et al. (2016) reported, nursing faculty in the United States are primarily White women; thus, nursing programs must make uncompromised commitments to unbiased and open-minded instruction and assessment. This study also shows that most nursing faculty grossly lack diversity, and minority students struggle to find mentors and make connections with professors. This emphasizes the dual need for more diverse faculty members and for more students who will eventually contribute to a more diverse nursing workforce that matches the U.S. population.

Key Recommendations

Although it is up to adult learners, including African-born students, to decide how much responsibility they can realistically take on and how effectively they manage their baccalaureate programs, it behooves their host institutions to alleviate certain systemic barriers. African-born nursing students and all underrepresented minorities must be respected and supported in all programs and not cast aside merely as statistics in diversity discussions.

Thus, this study outlines the following key recommendations for RN-to-BSN programs:

  • Nursing program administrators must promote welcoming learning environments that challenge faculty and staff to not judge ethnic minority students' abilities based on their language skills. Said faculty and staff must demand that their students do the same by setting the standard as role models.
  • Nursing faculty must actively participate in the “Adopt an Immigrant Student” program. This out-of-the-box idea aims to facilitate informal interactions within the student-and-instructor dyad on a more personal level. Its goal is to provide professors with a deeper understanding and appreciation of the struggles faced by immigrants when pursuing nursing degrees in foreign and often hostile environments. Because it takes both learning and energy to adjust to U.S. culture and its higher education system, the program encourages faculty to reflect on cultural understanding, to be attentive to students' needs, and to validate their experiences.
  • Nursing faculty and staff must actively participate in at least quarterly implicit bias workshops that genuinely cultivate deep and respectful cultural understandings of all their students' needs. In addition, faculty must assess their own bias through Project Implicit (2011), an online platform used to assess conscious and unconscious preferences for more than 90 different topics, including ethnic groups.
  • Nursing program administrators must recruit and retain more minority faculty (Murray, 2015; IOM, 2010; Graham et al., 2016; National Academies of Sciences, Engineering and Medicine, 2015), including African-born members who can understand and mentor minority students according to shared experiences, values, and perceptions.
  • Nursing program administrators must recruit and retain more diverse students (Amaro et al., 2006; IOM, 2010; Murray, 2015; National Academies of Sciences, Engineering and Medicine, 2015; Sullivan, 2004), including African-born students who can form a strong network of social support for each other.
  • Nursing program administrators must explore funding opportunities that are designated to ethnic minorities and make them known and accessible to students.
  • Current studies and publications on Africa and African nurse diaspora are lacking. Future research and documentation of African-born nurses' academic and work experiences in the United States must be supported to increase their visibility as future nurse leaders, independent of American-born African Americans.

Conclusion

Although African-born nursing students in RN-to-BSN programs constitute a relatively small subset of students in various nursing programs and subsequently the nursing workforce, the implications of this study's findings extend beyond this population and speak to the broader challenges of access to higher education for ethnic minorities and other marginalized populations. African-born nurses represent diversity in the profession, and they work at all levels of the U.S. health system and in academia.

Progress has been made in efforts to attract minorities into nursing, and, when the environment is supportive, minorities such as African-born nurses have proven to thrive. However, their experiences in academia—the pathway to their professions—can always be further diversified, enhanced, and made accessible. Students who work hard to advance their education and have the potential to become global nurse leaders must be welcomed and supported by their programs, its faculty, its peers, and its staff—not be frightened and psychologically pushed out by them. For effective learning to occur, teaching strategies used by professors must align with all nursing students' learning styles regardless of their backgrounds, so every student, minority or not, can succeed academically and meet the nursing workforce demands.

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Participant Demographic Characteristics (N = 25)

CharacteristicValue
Gender
  Male8
  Female17
Age range30–53 years
Years in the United States (range)9–25
Marital status
  Married20
  Divorced3
  Single2
Parental status
  Children22
  No children3
Number of years as a nurse (range)2–20
Nursing degrees/diploma prior to BSN
  Licensed practical nurs/vocational nurse19
  RN25
Country of origin
  Côte d'Ivoire1
  Ethiopia5
  Eritrea1
  Gambia6
  Kenya3
  Nigeria3
  Somalia3
  Uganda2
  Zambia1
Work background
  Medical–surgical (general surgery, cardiac, orthopedic)6
  Labor and delivery3
  Intensive care unit/pediatric intensive care unit/telemetry5
  Oncology1
  Mental health2
  Primary care/family practice1
  Community health/correctional1
  State department of health1
  Educator1
  Nursing home/long-term care4
Authors

Dr. Ezeonwu is Associate Professor, School of Nursing and Health Studies, University of Washington Bothell, Bothell, Washington.

The author has disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Mabel Ezeonwu, PhD, RN, Associate Professor, School of Nursing and Health Studies, University of Washington Bothell, 18115 Campus Way NE, Box 358532, Bothell, WA 98011; e-mail: mezeo@uw.edu.

Received: October 05, 2018
Accepted: February 20, 2019

10.3928/01484834-20190422-06

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