In the 2010 Future of Nursing: Leading Change, Advancing Health report, the authors recommended that the nursing profession diversify the current workforce to meet the needs of an increasingly diverse population in the United States (Institute of Medicine [IOM], 2010). Currently, the RN workforce is 86% female and 81.5% White, and the licensed practical and licensed vocational nurse workforce is 86% female and 56% White (Budden, Moulton, Harper, Brunell, & Smiley, 2016), which is not representative of the increasingly diverse population. Minority populations currently represent 37% of the U.S. population (Kaiser Family Foundation, 2016) and are projected to comprise at least 50% of the population by 2060 (United States Census Bureau, 2012). For example, the Hispanic population is anticipated to double from one in six residents to one in three by 2060. In addition, the African American population will continue to increase to approximately 15% and the Asian population is anticipated to double to 8% by 2060.
Ensuring a diverse nursing workforce that more closely represents the diversity of the U.S. population is imperative to providing culturally competent and equitable care, reducing health disparities, and optimizing health outcomes (U.S. Department of Health and Human Services, 2006). In the seminal 2003 IOM report, Unequal Treatment: Addressing Racial and Ethnic Disparities in Health Care, diversifying the health care workforce was identified as an important step in response to the many racial and ethnic disparities in the United States (IOM, 2010). The IOM (2010) has also found that a more racially/ethnically diverse health care workforce promotes stronger provider–patient relationships in non-White communities. Increasing the percentage of minority health care professionals is an important step to addressing health disparities within the United States. Indeed, many nursing organizations and other stakeholders in health care propose that recruitment of under-represented populations to nursing is essential for advancement of the nursing profession (American Association of Colleges of Nursing, 2019). To accomplish this goal, purposeful and strategic programs need to be integrated into secondary education to inspire young people to select nursing as a career. However, before these programs can be initiated, information about the current generation of adolescents' opinions and perceptions of nursing are needed.
Thus, the purpose of this qualitative descriptive study was to explore the perceptions and attitudes about the nursing profession among African American and Latinx adolescents living in a racially and ethnically diverse urban community. The four research questions were:
- What are African American and Latinx adolescents' perceptions of the nursing profession?
- What are African American and Latinx adolescents' attitudes about nursing as a career option?
- What are facilitators to choosing nursing as a career?
- What are barriers to choosing nursing as a career?
A literature review was conducted in CINAHL®, PubMed®, and Google™ Scholar databases, using a combination of keywords: nurse, nursing, career, profession, perception, attitude, adolescents, and teenager.
Nursing as a career option among high school students was first investigated in the early 1990s, when there was a critical nursing shortage and declining enrollment in nursing educational programs. In general, researchers found that few adolescents were interested in pursuing a nursing career (Grossman & Northrop, 1993; Kohler & Edwards, 1990; Marriner-Tomey, Schwier, Maricke, & Austin, 1990; Stevens & Walker, 1993). Adolescents thought there was little job security in nursing (Kohler & Edwards, 1990; Marriner-Tomey et al., 1990; Marriner-Tomey, Schwier, Maricke, & May, 1996) and that nursing did not provide the leadership, power, respect, or money that adolescents perceived was available in other professions (Marriner-Tomey et al., 1990; Marriner-Tomey et al., 1996; Reiskin & Haussler, 1994). Stevens and Walker (1993) reported other negative perceptions identified by adolescents—for example, nursing was women's work, nurses did not do important work, and nursing was not a real profession. Reiskin and Haussler (1994) found that African American and Hispanic females had the most positive perceptions of nursing among African American, Asian, Hispanic, and White adolescents. Unfortunately, none of the racial and ethnic groups viewed nursing as an ideal career choice.
More recently, investigators have examined perceptions about nursing and other health professions among middle-school students (Cohen, Palumbo, Rambur, & Mongeon, 2004), primarily ethnic minority high school students (Degazon & Shaw, 2007), and multi-ethnic populations of adolescents in the United States and Israel (Degazon, Ben Natan, Shaw, & Ehrenfeld, 2015). Across all three studies, findings were consistent: adolescents perceive nurses as caring individuals who work hard but earn little respect and salary and have little power.
The research has been limited to understanding adolescents' perceptions of nursing as a career choice. However, adolescents' decisions about career choices are not made in isolation and are influenced by their parents, friends, and what is drawn from the media, including television (Glerean, Hupli, Talman, & Haavisto, 2017). Our study expands on the current understanding about adolescents' views of nursing as a career and where their ideas were generated.
This study used a qualitative descriptive design. Qualitative design is an appropriate method for understanding individuals' perceptions or experiences. Unlike other interpretive qualitative methods, qualitative description provides an in-depth account while staying close to the data (Sandelowski, 2000). Institutional review board approval was obtained prior to study commencement.
Population and Setting
The target population was African American and Latinx adolescents who were between the ages of 13 and 19 years old living in a midwestern, urban community, of which 23% of residents are African American, 29% are Latinx, and 8% are from other minority populations (U.S. Census Bureau, 2018). Convenience sampling was used. Inclusion criteria included the ability to speak English, the ability to read and sign the assent form, and signed permission of a parent or legal guardian, as needed. All white, non-Latinx adolescents in the urban community were excluded from the study.
Several strategies were used for recruitment. The researchers worked with a local community partner to recruit participants through after-school youth programs, the Girls and Boys Club of Kansas City, Young Women on the Move, and the Community Partnership for Health (CPH) program at the University of Kansas Medical Center. Despite these multiple approaches for recruitment, the Young Women on the Move and the CPH program were the only organizations who had the capacity to support adolescents participating in the focus groups.
Young Women on the Move is an organization that provides comprehensive life skills for high-risk female adolescents who live in the urban core. Social workers and trained volunteers work with the adolescents through an after-school program, in-school visits, a culinary program, and a summer program. The after-school program includes mentoring, field trips, life skills, and guest speakers. Students also work in small-group sessions incorporating problem-based learning activities focused on a monthly theme, with the goal of promoting holistic healthy development.
The CPH program offers a Summer Internship for adolescents through a health careers pathways program. Students from underrepresented communities come together for hands-on, interactive skill building sessions that address critical stages in health disparities and population health research. During training sessions and community-based research projects, students are exposed to a wide variety of career opportunities in science, health, and technology. By bringing together local youth interested in health careers and focused on addressing health and social disparities in Wyandotte County, the internship program works toward building a community of health and encourages STEM (science, technology, engineering, medicine) careers. Current longitudinal program analysis shows that more than 40% of participating pipeline students enter a health career.
Four focus groups were completed, which was sufficient to reach saturation of the data. One focus group was conducted at the Young Women on the Move organization and three focus groups were held at the University of Kansas Medical Center. The focus groups were led by two University of Kansas School of Nursing faculty and a graduate nursing student. Participants between the ages of 13 and 17 years provided their parent's or legal guardian's written signed permission and their own personal written assent to join in the focus group session. Written informed consent was obtained from participants between the ages of 18 and 19 years prior to beginning each focus group. Participants were informed of the purpose of the focus group and that the session was going to be recorded. Semi-structured interview questions (Table 1) were used to obtain data. The focus groups lasted between 45 and 60 minutes. Pizza and soft drinks were provided at each session.
Semistructured Interview Guide
The audiorecordings were transcribed verbatim by a professional transcriptionist. Three members of the research team— two doctorally prepared nursing faculty and one graduate nursing student—completed the data analysis. One faculty member and the graduate student read the transcripts while listening to the audiotape to make sure the transcripts were complete and did not contain any identifying information. Through inductive data analysis, the narratives were read several times again to make meaning of the data (Elo & Kyngäs, 2008). The research team members independently reviewed the transcripts and developed meaning units that were further condensed into codes (Graneheim & Lundman, 2004). The three members together grouped the codes into categories and final themes.
Thirty-three adolescents participated in the study. Most (64%) were between 13 and 17 years old, 63% were female, and 57% were Latinx. Of the students who participated through the Young Women on the Move program, 100% were female, 67% were African American, and 100% were under the age of 18 years. As students shared ideas, other study participants often nodded in agreement and expounded on their peers' comments.
Four themes and seven subthemes were created from the narratives and organized around the research questions regarding perceptions of nursing, origins of perceptions, and barriers and facilitators to choosing nursing as a career. The four themes are: Nursing Is a Caring Profession But…; Formation of Ideas About Nursing Come From Personal Experience, Family, Friends, and the Media; Deterrents to Pursuing Nursing; and Incentives for Pursuing Nursing. Within the theme of Nursing Is a Caring Profession But…, there are three subthemes: lack of autonomy, demanding job responsibilities, and opportunities for career advancement. The four subthemes of lack of diversity, extensive education, nursing programs are expensive and acceptance is difficult, and external circumstances support the theme Deterrents of Pursuing Nursing.
Nursing Is a Caring Profession But…
Not surprisingly, all four focus groups identified the act of caring as being associated with the nursing profession. Some worded the action as “taking care of sick people.” Most often, the action was directed at the care of a sick patient. However, some adolescents identified the nurse's role in health management by identifying that nurses “make sure people stay healthy.” This was the most positive perception about nursing.
Lack of Autonomy. One subtheme identified in the analysis was nurses' lack of autonomy. This was commonly implied by the adolescents' perception that nurses work for the physician. A few participants identified the nurse's main responsibility as “helping the physician.” Although nurses handle physician-written orders as part of their practice role, most nurses within the hospital setting would identify themselves as working with physicians rather than for physicians. One focus group fixated on the lack of recognition for the nursing profession, identifying nurses as “doctors without MDs.” This perceived lack of power and respect mirrors the opinions of participants from the previously mentioned studies of the 1990s.
Demanding Job Responsibilities. The second subtheme identified from the first interview question is demanding job responsibilities, which includes physical demands and work schedule demands. Several participants identified a career in nursing as being physically demanding, noting that nurses are often busy at work and must be physically strong to do their job. Three of the four focus groups identified a nurse's work schedule as being a demanding job responsibility. Some referenced the long hours associated with 12-hour shifts; others spoke to the downside of having to work weekends and holidays.
Opportunities for Career Advancement. Several participants from the third focus group identified the opportunity for career advancement as something they associated with nursing. Because this subtheme did not appear in other groups, it is possible that the mention of career growth by one person sparked the response in other participants. However, the ability to move from a clinical nurse assistant, to a licensed practical nurse, to an RN, or to an advanced practice registered nurse was appealing to adolescents. Somewhat incorrect was the perception that nursing is first step to becoming a physician.
Formation of Ideas About Nursing Come From Personal Experience, Family, Friends, and the Media
Students' perceptions of nursing as a career stemmed from personal health care experiences, family and friends, and the media. Adolescents described ideas about nursing from their own personal experience. Some participants mentioned times when they themselves were admitted to the hospital or attended a doctor's office. Others spoke to experiences of visiting family or friends in the hospital. Many participants also had a family member who worked in the nursing profession. These participants' perception of nursing often came from comments their family members made about the nursing profession. Another key influencer in the participants' perceptions of nursing is the media. Shows such as Grey's Anatomy and Nurse Jackie were mentioned as examples of television programs that adolescents are paying attention to. These experiences seemed to leave an impact on the adolescents and their perceptions of nursing.
Deterrents to Pursuing Nursing
Study participants identified multiple barriers that could prevent adolescents from pursuing nursing as a career option. These include a lack of diversity within the profession, components of nursing education programs, and external circumstances.
Lack of Diversity. The lack of diversity, both racial and gender, within the nursing profession was consistently identified by participants in all focus group sessions. The male adolescents commonly identified with the lack of gender diversity, stating that nursing is “a career stereotyped for women.” Male adolescents felt uncomfortable pursuing nursing; they expressed concern about what others might think of them, given that nursing has historically been a woman's career. They also worried about being the lone male among peers at work. Female adolescents more commonly identified with a lack of racial diversity. One female participant admitted, “I would feel kind of scared to go into it [nursing]. I don't know, because every nurse I've ever had, ever, has been White.” One adolescent worried that if all other nurses were White, no one at work would understand her. This lack of diversity was also identified as a theme that would prevent adolescents from pursuing a career in nursing. Although most pointed out that this lack of diversity would not completely deter them from pursuing nursing, they did admit it would hinder their career decision.
Extensive Education. Extensive education required to become a nurse was commonly discussed when asked about thoughts of nursing. In general, this was identified as a large amount of schooling necessary to enter the nursing profession. Although many of the adolescents being interviewed expressed interest in a health science career requiring graduate education, multiple people voiced a concern about the difficulty of nursing programs and the amount of schooling required. This is somewhat surprising given that many of the focus group members were already planning for graduate education.
Nursing Programs Are Expensive and Acceptance Is Difficult. The cost of nursing school, and college in general, was of great concern to most of the participants. Several expressed worry about extensive student loans. Despite their age, most participants acknowledged a desire for financial security from their chosen fields. The second concern in this subtheme is program acceptance. The participants identified poor grades or ACT® scores as a struggle when applying to college, and particularly when applying to nursing programs.
External Circumstances. The final subtheme revolved around issues separate from nursing but that may interfere with nursing education or job responsibilities. These included concerns such as becoming pregnant. One participant identified that it would be difficult to attend nursing school and raise children at the same time. Another female adolescent expressed the desire to have a family and that having to work holidays and weekends might interfere with familial responsibilities. All concerns for external circumstances were expressed by female participants.
Incentives for Pursuing Nursing
Three main factors that would help an adolescent to pursue a career in nursing were identified. The first is financial aid. School expenses were a concern for all four focus groups. One participant pointed out that “scholarships specifically for minorities or men” might help increase nursing diversity as well. The second factor is use of mentors, which was expressed in several ways, including the desire for support in career choices from parents and teachers. Also, several participants expressed a desire to shadow a nurse in an acute care role. Shadowing a nurse could facilitate building a mentor–mentee relationship. The final factor is increased awareness and education about nursing. The adolescents wished to know more about the field of nursing, and they wanted information from teachers, counselors, and practicing nurses.
The findings from this study provide insight into minority adolescents' perceptions of nursing. Overall, they believe that nursing is a caring profession but also perceive there to be little autonomy and many demands. Participants are aware of the need for diversity within the profession; however, the current lack of diversity affects their decisions to pursue a nursing career. Adolescents agree they need more education about the role of nursing, and they are asking for information.
Students in these focus groups were not interested in nursing for a variety of reasons, ranging from image to the lack of power associated with the role. Students expressed more interest in positions of fame, power, and income. Considering the content depicted on television, the big screen, and social media, the students' focused interests are not surprising. Our findings support the need to enhance the image of nursing, eliminating the negative stereotypes often found in the media and to make nursing a more attractive career option. The profession needs to be promoted in a manner that is more appealing to adolescents.
Negative stereotypes of nursing continue to be perpetuated in the media. Television shows commonly paint a negative or untrue picture of nursing, which is unfortunate given the vast amount of good achieved by the profession. However, one supporter of nursing, Johnson & Johnson, has shown that positive media attention is possible. In 2002, Johnson & Johnson launched the Campaign for Nursing's Future, aimed at raising public awareness of nursing as a career, with a special emphasis on recruiting men and underrepresented minorities (Bednarz, Schimm, & Doorenbos, 2010). Given the world's growing reliance on social media, particularly among young people, an increase in these types of positive images within the media will greatly benefit diversity aims within the nursing profession.
Participants asked about scholarship opportunities. As mentioned, one focus group asked for information about nursing scholarships specifically aimed at minorities or male students. The U.S. Health Resources and Services Administration has done just this by providing federal funding for Nursing Workforce Diversity grants to colleges and universities (Melillo, Dowling, Abdallah, Findeisen, & Knight, 2013). These grants provide funding for increased nursing education opportunities to individuals from disadvantaged backgrounds. Given that participants identified educational costs as a barrier to pursuing nursing, more funding like the Nursing Workforce Diversity, from both public and private institutions, would encourage increased diversity within the profession.
Pilkington, Singh, Prescod, and Buettgen (2013) found that programs emphasizing the importance of a nursing role model may promote student consideration of nursing as a career choice. They note that mentoring is particularly useful for disadvantaged youth. This is consistent with the findings from our study. In fact, participants were asking for opportunities to shadow a nurse or have a nurse visit their school. One easy way to increase visibility of nursing is to promote the school nurse in secondary education settings. School nurses interact with children and adolescents, their parents, and educators, as well as the community (Brandt, 2002). School nurses can role model key characteristics of nursing, such as autonomy and leadership, which adolescents find appealing in a career yet do not attribute to the nursing profession.
Most of the study participants were recruited from a summer science and medicine program, which was directed at students who expressed an interest in a health care career. Many of these students excel in school, particularly math and science. This limits transferability of study findings to generic populations of adolescents. Additional focus groups should be conducted with students recruited from different programs and who express career interests outside of health care or who have not yet decided.
As the United States becomes more diverse, so will the need for a more diverse health care workforce, especially in nursing. Given that nursing is the largest health care workforce, the profession must be committed to preparing a workforce that more closely resembles the demographics of the populations it serves. To that end, secondary nursing education programs need to be intentional in their efforts to attract, recruit, admit, retain, graduate, and professionally transition a more racially and ethnically diverse student population.
These programs should include mentoring as one component. Literature identifies mentoring as one of the most commonly used strategies to promote academic success in under-represented students and first-generation college students (Brooks Carthon, Nguyen, Chittams, Park, & Guevara, 2014; Cowan, Weeks, & Wicks, 2015). Mentoring is found to be effective in retaining students, positively affecting NCLEX-RN® pass rates, motivating students, ensuring student independence, promoting professional competence, socializing students into the nursing profession (Botman, Hurter, & Kotze, 2013; Cowan et al., 2015), and developing professional identity. Mentoring also supports knowledge sharing, leadership development, skill and career development, and student engagement. The National League for Nursing (2016) affirms that it is imperative for institutional leaders to create an academic environment where diverse students can flourish. Creating such an environment can begin with developing student relationships through mentoring by faculty, practicing RNs, and/or senior-level nursing students. Because mentoring has been shown to be an essential component for success in these students, secondary and higher education systems should consider implementing additional mentoring programs.
To decrease health disparities, nursing must address its lack of diversity. Identified themes such as education requirements and costs, lack of autonomy, work schedules, and basic job responsibilities should all be addressed by educational programs looking to encourage nursing as a career option among adolescent minorities. Although many themes were repeated among focus groups, additional research is needed to reflect the perceptions of students with career aspirations outside of the health care arena.
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Semistructured Interview Guide
|Question or Prompt|
|Today we want to learn about your thoughts about nursing and your ideas about nursing as a career choice.|
| When you think of nursing, what is the first thing that comes to mind?|
| Where do you get your ideas about nursing?|
| Have you considered what type of career you want?|
| What are important things that you have considered when choosing a career?|
| Tell me more…|
| What other things…|