As demographics in the United States become increasingly more diverse, the demand for culturally competent nurses is crucial to providing high-quality health care to diverse populations. By 2055, people of color will be the majority in the United States. Despite demographic changes, minority nursing students continue to remain disproportionately underrepresented in the nursing profession (McQueen & Zimmerman, 2004). A survey administered by the Health Resources and Service Administration, the National Sample Survey of Registered Nurses (Budden, Zhong, Moulton, & Cimiotti, 2013), found that Black nurses represent only 4.9% of RNs in the United States, whereas Latino/Hispanic nurses account for only 2%. In 2013, the National Council of State Boards of Nursing and the Forum of State Nursing Workforce Centers found that nurses from underrepresented racial and ethnic backgrounds represented 19% of nurses nationwide and that African Americans made up only 6% of nurses (National League for Nursing, 2016). Since 2013, there has not been a comprehensive analysis of diversity in nursing that updates these numbers.
This article highlights the contributions made by historically Black colleges and universities (HBCUs) to the nursing profession, as well as the challenges faced by HBCUs as they make these important contributions. This article presents an overview of the history of nursing programs at HBCUs. Next, collaborations between HBCUs and non-HBCUs are discussed. Current data are presented related to nursing programs, including contributions, at HBCUs and, in comparison, at non-HBCUs. Next, recruitment and retention issues pertaining to Black nurses and HBCU nursing programs are explored. Then, challenges faced by HBCU nursing programs are discussed. Finally, recommendations for research and practice are provided.
The establishment of the American Nurses Association (ANA) in 1896 was aimed in part at making the nursing profession more attractive to women. At the same time, the expansion of professional nursing schools created opportunities for students to pursue three types of nursing programs: licensed practical nurse (LPN), RN, and a Bachelor of Science in Nursing (BSN). Although these efforts created more opportunity for White women as hoped, women of color experienced institutional racism in the profession (Barbee, 1993). Many states did not yet allow Black women to join the ANA. In response, Black women created the National Association of Colored Graduate Nurses. They accepted both LPNs and licensed vocational nurses, unlike the ANA which only accepted RNs or graduate nurses. Despite these small educational gains, Black women continued to face racial barriers that hindered them from receiving a nursing education.
HBCU Nursing Schools
In an effort to address the low representation of underrepresented minorities in the nursing profession, HBCUs have worked diligently to create educational opportunities for nursing students (Brathwaite, 1999; Brown, 2014; Brown, 2008; Brown & Marshall, 2008; McNeal, 2003; McQueen & Zimmerman, 2004; Merrill et al., 2006; Singleton & Rami, 2002; Talley, Talley, & Collins-McNeil, 2016). Similar to the original mission of HBCUs, HBCU nursing schools were created to enroll African Americans who dreamed of becoming nurses but had no other educational options given the discrimination at the nation's colleges and universities. Some of the first HBCUs to adopt nursing education divisions were Florida A&M University, Tuskegee University, Hampton University, Howard University, and Dillard University (Hine,1982). Tuskegee University was the first HBCU to establish a nursing school, in 1892. At the time, it was called the Tuskegee Normal School for Nurses and it provided a 2-year program focused on teaching African Americans to care for the sick. By 1908, under the leadership of famed leader Booker T. Washington, the school had a 3-year nursing program (Minority Nurse, 2013). It would not be until 1953 that Tuskegee University would graduate its first group of BSN recipients and with this accomplishment, it became the first HBCU to graduate BSNs.
Founded in 1918, Prairie View A&M University College of Nursing in Houston, Texas, was the first nursing school west of the Mississippi to admit Black students. In fact, the first degree offered by the University was a 2-year nursing degree. In 1928, Prairie View offered a 3-year degree and then eventually in 1956, it offered its first BSN degree.
Hammond and Davis (2005) highlighted the implementation of the first PhD nursing program at an HBCU. In 1976, Hampton University offered its first master's degree in nursing and in 1999, they admitted their first class of four PhD nursing students. Today, Hampton's PhD in nursing is a 4-year, full-time program that specializes in graduating students that conduct research designed to provide quality health care to families. Students gain knowledge about family nursing through the completion of an independent research project, courses on family nursing, and field work. The PhD in nursing at Hampton aims to prepare students, specifically minority students, to provide health care education for vulnerable populations through culturally competent care. The process of creating a PhD program at an HBCU nursing school requires the school to show that the program would meet a need and that the school has the finances and qualified faculty to teach it. Because most HBCUs lack financial resources, building PhD programs in nursing has been challenging, even though there is a need for Black nursing faculty. As of 2013, HBCU nursing schools have only a dozen master's programs and two PhD programs (Noonan, Lindong, & Jaitley, 2013).
Collaborations between HBCUS and non-HBCUS
With a similar mission of increasing the number of minorities in the health profession, HBCUs have partnered with non-HBCUs. Through these collaborations, both types of institutions share their resources and benefit in various ways. In 1978, Bethune Cookman College (an HBCU) and University of Florida (a non-HBCU) came together around a nursing initiative that featured a feeder program to University of Florida's graduate programs in nursing (Louis et al., 2015). Considering the difficulty of making the transition from a small HBCU to a large non-HBCU, the administration from both schools met often to ensure successful retention rates of students from Bethune Cookman College. In a similar attempt to maintain retention, students from both institutions were encouraged to have open conversations about issues related to minority groups. This approach allowed the students to work with people from diverse cultural backgrounds and recognized everyone's unique contributions to the field. Administration also worked together to increase funding for scholarships that would help cover tuition, books, and other educational expenses for nursing students. Additionally, the initiative offered GRE Preparation classes and graduate school applications workshops to encourage graduate school applications. Mentors at both institutions were proactive with helping students stay on track by working one-to-one with students (McWhirter, Courage, & Yearwood-Dixon, 2003).
During the inception of Hampton University's PhD in nursing program (mentioned earlier) in 1999, the institution established a partnership with the University of Pennsylvania (a non-HBCU). The collaboration ensured that Hampton University would receive consultation advice and research opportunities and that the University of Pennsylvania would diversify their faculty and student body. For example, Hampton faculty members were invited to audit research courses and attend research symposiums (Hutchinson et al., 2007).
In 2001, the National Institutes of Health funded a partnership between the University of North Carolina-Chapel Hill and North Carolina Central University (an HBCU). The year-long Research Enrichment and Apprenticeship Program was created to increase the number of African American nursing researchers in an effort to encourage graduate careers in nursing. Through this collaboration, a total of nine students (five from North Carolina Central University and four from University of North Carolina-Chapel Hill) benefitted immensely. According to program evaluation data, each student partnered with a faculty mentor to complete a research project, enhanced their writing skills, and bolstered their critical thinking skills. Some of the projects included risk assessment in preterm infants and HIV/AIDS prevention within a community of Mexican immigrants (Leeman, Goeppinger, Funk, & Roland, 2003).
Vanderbilt University (a non-HBCU) and Fisk University (an HBCU) collaborated in 2004. Vanderbilt University aimed to boost the ranks of minority graduate students and partnered with Fisk University to implement an undergraduate nursing program. Only 2 miles away, Fisk University used the classrooms at Vanderbilt University for its nursing students involved in the program. This relationship was beneficial to both institutions in that Fisk has fewer financial resources in comparison to Vanderbilt, whereas Vanderbilt was hard pressed to attract a significant percentage of Black students (Fisk University, 2017).
Although partnerships between HBCUs and non-HBCUs can be fruitful for both parties, it is essential that these partnerships be constructed in fair and equitable ways that bring benefits to all parties. There have been instances of non-HBCUs that included HBCUs in grant proposals for projects merely to meet grant requirements. Further, some non-HBCUs have benefited greatly from a pipeline program for graduate school but have given little to the HBCUs supplying students—students who add greatly to the diversity in graduate programs at non-HBCUs.
HBCU Nursing Programs: by the Numbers
The contribution of HBCUs to the overall education of nurses from 2013 to 2017 has been relatively limited. Of the approximately 4,500 postsecondary institutions accredited to confer bachelor's degrees in the United States, 2,333 (53%) of them offered bachelor's in nursing fields in 2017. This accounts for an increase of 16% over 5 years, as over 300 new universities conferred nursing degrees in 2017 than in 2013. The number of HBCUs conferring nursing degrees has remained constant. Sixty-six percent of all HBCUs have conferred nursing degrees. Taken together, HBCUs represented less than 3% of all institutions conferring degrees in nursing fields in 2017 (Table 1).
No. of Institutions Conferring Bachelor's in Nursing Degrees by Type (2013–2017)
The drop in the number of nursing students graduating from HBCUs parallels the relatively small increase in the number graduating from non-HBCUs. In 2017, there were 289,342 bachelor's degrees conferred in nursing fields, accounting for an increase of 38% over five years. At non-HBCUs, the growth has also been comparable, with degree conferrals increasing by 39% over 5 years. HBCUs have seen a decrease in bachelor's degrees conferred in nursing fields. Between 2013 and 2017, degrees in nursing fields decreased by 19%.
For students of color, the shifts in degree conferrals have been more drastic. Fifty percent more students of color received a bachelor's in nursing fields between 2013 and 2017, growing from 58,306 to 88,000. Although the total number of degrees conferred to students of color has increased dramatically over the past 5 years, it represents a modest growth in the proportional representation of students of color receiving bachelor's in nursing fields. In 2013, students of color accounted for 28% of all degrees in nursing. Five years later, in 2017, they represented 30% of all bachelor's in nursing fields, thus achieving a 2% increase. Black/African American students accounted for 10% of all bachelor's conferred in nursing fields in 2013. At non-HBCUs, they represented 9% of all degree recipients, while representing 61% of all degree recipients at HBCUs. Notably, the proportion of degrees conferred to Black/African American students has decreased in the past 5 years. In 2017, only 8.7% (−0.2%) of degrees at non-HBCUs were conferred to Black/African Americans. At HBCUs, Black/African Americans decreased in representation to 51% of all degree conferrals (–9%) (Table 2).
Bachelor's in Nursing Degrees Conferred by Ethnoracial Group and Institutional Type (2013–2017)
Although Table 2 details how Black/African Americans have decreased in their proportional representation of all bachelor's in nursing fields, it does not mean that the total number of degrees conferred to Black/African Americans has decreased. In fact, 26,860 degrees in nursing fields were conferred to Black/African Americans, representing a 28% increase from the 20,956 degrees granted 5 years prior.
Table 3 shows that the growth is attributable to an increase in nursing field degrees conferred to Black/African Americans by non-HBCUs. In 5 years, non-HBCUs increased the number of degrees conferred to Black/African Americans by 35%. HBCUs, however, decreased conferrals to Black/African Americans by 32%, from 2,622 to 1,786.
Bachelor's in Nursing Degrees Conferred to Black/African Americans by Institutional Type (2013–2017)
Importantly, nursing fields include a variety of specializations and not all that receive a degree in nursing necessarily enter the nursing profession as RNs. Table 4 focuses on institutions that have reported conferring bachelor's in Registered Nursing (subcategorized with the 31.3801 Classification of Instructional Program code). A smaller proportion of institutions reported conferring degrees in Registered Nursing. In 2017, 1,053 institutions across the United States reported conferring degrees in Registered Nursing, of which 33 (3%) were HBCUs. Thus, less than half (45%) of institutions conferring bachelor's in nursing fields (as noted in Table 1) report conferring Registered Nursing bachelors.
Bachelor's Degrees Conferred in Registered Nursing (2013–2017)
In 2017, HBCUs represent 3% of all institutions conferring bachelor's in Registered Nursing, yet confer 7% of all Registered Nursing bachelor's degrees for Black/African Americans in the nation. The disproportionate role that HBCUs play in conferring bachelor's degrees to Black/African American is particularly notable given that only 2.5% of degrees conferred to all students of color in Registered Nursing hail from HBCUs. Indeed, HBCUs only confer slightly over 1% of all bachelor's in Registered Nursing. Thus, the fact that double the rate of Black/African Americans in the nation receive their Registered Nursing bachelor's degree from an HBCU suggests that these 35 institutions play a critical role in advancing an increased representation of Black/African Americans in nursing (Table 4).
Recruitment and Retention of HBCU Nursing Students
HBCUs recruit and retain nursing students by creating an environment that acknowledges and addresses the implicit and explicit racial biases faced by students of color. HBCUs have implemented an array of recruitment and retention strategies to increase minority representation in the nursing profession. Baccalaureate Enrollment and Success Tactics for RNs (BESTRN) a program offered at Norfolk State University increased student enrollment by 20% and retention by 25%, as well as the first-attempt pass rate for the National Council Li-censure Examination-Registered Nurses (NCLEX-RN®) by 14%. The NCLEX-RN is administered by the National Council of State Boards of Nursing to measure nursing knowledge for prospective nurses. Norfolk State University does this by providing minority nursing students with scholarship opportunities, academic and personal mentoring, financial advisement, support for special learning needs, and more. As a result of the BESTRN program's accomplishments, an Intro to Nursing course was developed for prospective nursing students. Additionally, UNV 101, a freshman orientation course, was modified to inform incoming freshmen about the nursing program's “expectations” and “core values.” Community partnerships increased enrollment capacity for 60 RN-to-BSN clinical placements, as students had the option to intern for various health education initiatives. The nursing department also hired a student advisor/recruiter to support student retention for the RN-to-BSN program by connecting students to financial and academic resources (Norfolk State University, 2017).
Talley et al. (2016) found that HBCUs provide students support in their remediation courses, preparation for the NCLEXRN, and insight on successful testing strategies from faculty members. Using focus groups with 16 graduate and undergraduate nursing students, their findings demonstrate that nursing support systems contributed to the integration of nursing students, as nursing faculty and advisors created a familial community for students to connect.
HBCUs also work with high school students to prepare the next generation of nursing students. Some HBCUs have collaborated with high schools to reduce the number of years in nursing school. North Carolina Central University has collaborated with public high schools in Durham to implement the Early College High School Program. This program identifies promising high school students, assists them in preparing for college, and allows them to complete their bachelor's degree in just 2 years after completing high school through the use of dual enrollment courses (Minority Nurse, 2013). These examples demonstrate the commitment of HBCUs to uplifting Black students in nursing education.
Although little research has been conducted on HBCU nursing programs, there has been ample research produced over the past three decades that details both quantitatively and qualitatively on the strengths of HBCUs in terms of providing a rich and nurturing environment for learning and growth (Gasman, 2008; Conrad & Gasman, 2017; Drewry & Doermann, 2001; Flores & Park, 2015; Kim & Conrad, 2006). This area of research is also important in understanding the unique contributions of HBCUs. One of the most important research studies was conducted by Kim and Conrad (2006) and determined that even with students with lower SAT scores and GPAs, as well as fewer institutional resources, HBCUs are able to meet the degree attainment outcomes boasted by non-HBCUs. Flores and Park (2015) also found that students attending HBCUs are retained and graduate at the same rates as non-HBCUs, when controlling for income, and do so with fewer family and institutional resources. Gasman (2008) found that African American students at HBCUs gain substantial social capital through faculty and peer relationships that they benefit from well after graduation. Likewise, Shorette and Palmer (2015) found that HBCUs are important contributors to noncognitive skills, including peer-to-peer support and increased self-esteem, that support student academic and social success in college.
Challenges of Nursing Programs at HBCUS
Although HBCUs have contributed a vast amount to both students and communities, the institutions, faculty, and students continue to face many challenges. Since the passing of the Higher Education Act of 1965, colleges and universities that strive to diversify the health care profession have received extra funding to recruit students of color. Although enrollment rates of minorities in nursing programs increased, retention and graduation rates decreased during this time (Goeppinger et al., 2009). In response to this paradoxical relationship, the National Advisory Committee on Black Higher Education and Black Colleges and Universities was assigned to propose solutions to the low retention rates. It was found that main causes of high dropout rates were a sense of alienation, academic unpreparedness, a competitive culture, intentional or unintentional discrimination, and financial difficulties. Childs, Jones, Nugent, and Cook (2004) proposed several solutions to overcome the issues of retention. These include ensuring faculty sensitivity to student needs, implementing formal advisement for all students, and rethinking curricula so that it is focused on student learning.
Many studies on cultural perception have been conducted at colleges and universities, including HBCUs. Warren (2015) defined perception as “the process of making meaning about others based on one's own subjective social and cultural perspectives” (p. 156). In Warren's study, 16 undergraduate and graduate prenursing and nursing students of color were recruited via snowball sampling method and were asked to complete a demographic questionnaire, as well as participate in semistructured focus groups. Based on the research, the researchers uncovered the following themes: open communication is essential to learnings, lack of resources is detrimental to the success of students, and support system and professional socialization are important to the success of nursing students at HBCUs.
Similar to Warren (2015), Murray (2015) answered the question of why such a low percentage of Black students enrolled in nursing programs successfully graduate from their program in comparison to their White counterparts. For example, in 2014, there was a 10% enrollment rate of African American students in nursing education, with a graduation rate of only 8.9%. Murray's data show that the students faced many adversities at non-HBCU nursing programs, including difficulty being themselves, inability to reach out to faculty for help, or feeling ostracized. Despite not facing these particular challenges at HBCUs, students continue to struggle with retention and graduation. Researchers point to lack of preparation for college and family income as key factors as both of these relate positively with retention and graduation (Conrad & Gasman, 2017).
Talley et al. (2016) found that support from role models and mentors led to positive academic and professional outcomes for undergraduate and graduate nursing students. They also found that students expressed interest and motivation in mentoring underrepresented minority students, as they, too, greatly benefited from the guidance, support, and motivation their role models and mentors provided them. Findings by Talley et al. (2016) demonstrate the barriers HBCU nursing students face during nursing education and provide insight as to how HBCU nursing students overcome these barriers.
HBCU students will often struggle academically. Tolson (2013) discussed the academic challenges of HBCU students. More specifically, students struggle to meet the NCLEX-RN requirements. HBCU students often experience low pass rates on the NCLEX-RN. In addition, NCLEX-RN pass rates have an impact on nursing shortages, program accreditation and reputation, and the surrounding community, as minority nurses are hindered from practicing. Tolson (2013) found that NCLEXRN tutoring, decreased work hours, and individualized strategies for approaching the examination positively influenced participants' first-attempt pass rate.
Hill, Del Favero, and Ropers-Huilman (2005) explained that after becoming a nurse, African American nurses do not have many leadership positions. A lot of this has to do with the small pool of same-race mentors. Additionally, the study finds that faculty at non-HBCUs have higher salaries and more tenured positions. However, faculty at HBCUs are more satisfied with the environment and the culture. Productivity, quantified by the number of faculty publications and grant amounts received, was higher at non-HBCUS than at HCBUs. A higher percentage of HBCU faculty held positions on campus in academic leadership, compared to faculty at non-HBCUs. The survey showed that faculty members are happier with the environment and mission at HBCUs and feel supported in their pursuit of leadership positions.
Conclusion and Recommendations
Although there are efforts to increase the number of under-represented students in the nursing profession, minority students are continuously hindered by institutional and structural barriers. All colleges and universities must work to identify these barriers and create pathways to success for students; sometimes breaking down barriers means changing policies, traditions, and practices that have been in place for decades.
HBCUs continue to address issues of access and success and have greatly contributed to the mobility of minority nursing students. We offer the following recommendations for HBCUs nursing programs and nursing programs more generally. First, the implementation of culturally relevant and community-based curricula will serve as a source of pride and motivation for African American students, changing their educational experiences. It is vital that students see examples in the curriculum that speak to their experiences. Second, it is imperative to provide ample opportunities to practice and prepare for licensing examinations in order to demystify the examination process and reduce stereotype threat (Tolson, 2013). Third, program administrators should ensure that students have proper funding so they do not have to be distracted from their studies by financial pressures. Advocating for need-based aid for nursing programs will help the most vulnerable students. Fourth, programs will have increased success if they offer developmental classes that bring students, who may have been failed by the primary and secondary system in the United States, up to speed. Finally, educational programs should provide opportunities for peer mentoring for students (Gasman, 2008; Shorette & Palmer, 2015). Often, peers are highly skilled at understanding the unique challenges students have and can relate more closely than faculty and staff to these challenges, offering first-hand advice.
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No. of Institutions Conferring Bachelor's in Nursing Degreesa by Type (2013–2017)
Bachelor's in Nursing Degreesa Conferred by Ethnoracial Group and Institutional Type (2013–2017)
|Students of colorb||55,370||2,936||58,306|
|Black or Hispanic||36,866||2,724||39,590|
|Students of colorb||65,216||2,616||67,832|
|Black or Hispanic||43,626||2,442||46,068|
|Students of colorb||72,442||2,388||74,830|
|Black or Hispanic||48,940||2,146||51,086|
|Students of colorb||78,676||2,292||80,968|
|Black or Hispanic||54,074||2,088||56,162|
|Students of colorb||85,870||2,130||88,000|
|Black or Hispanic||59,768||1,930||61,698|
Bachelor's in Nursing Degreesa Conferred to Black/African Americans by Institutional Type (2013–2017)
Bachelor's Degrees Conferred in Registered Nursinga (2013–2017)
|Year||Institutions||All Ethnoracial Groups||Students of Color||Black/African American|