To address the lack of evidence-based strategies, a longitudinal mixed-methods study was conducted with a group of fourth-year baccalaureate nursing students at a large mid-Atlantic university. The results, reported elsewhere (Metzger & Taggart, in press), indicated that underrepresented minority students and majority students value inclusivity and associate it with positive outcomes, such as sense of belongingness in the classroom and clinical environments, satisfaction and confidence with learning, and self-efficacy in the clinical setting. Students also identified the pedagogical strategies (i.e., learning names, storytelling, sitting in clinical groups, and time together outside of class) they believed were most strongly linked to inclusivity. In general, underrepresented minority students reported lower levels of belongingness, satisfaction, and confidence than did majority students at all time points.
In this study, focus groups were conducted to enhance our understanding of the survey data, obtain students' perspectives on specific pedagogical strategies, and clarify any differences between majority and underrepresented minority students' survey responses. As expected, this was achieved. However, during our examination of the focus group transcripts, we realized the focus group participants provided information that far exceeded the scope of the original study and addressed an educational priority in nursing education. Participants had generously shared their perspectives on inclusivity, and identified facilitators and barriers to inclusivity, as well as actual and predicted outcomes of inclusive (and noninclusive) learning experiences. Participants also shared personal stories and recommended various ways in which clinicians, educators, and students can promote compassion and resilience in our current and future nursing workforce. We were inspired to conduct a secondary qualitative descriptive study. This article highlights the findings from the four focus groups, conducted with underrepresented minority students and majority students, at two different time points during the academic year. If faculty have a deeper understanding of students' experiences and perspectives, they may be better equipped to include pedagogical strategies that promote inclusion.
Design and Sample
This study was a secondary qualitative descriptive study using focus group data from a larger mixed-methods study (Metzger & Taggart, in press). Convenience sampling was used to recruit fourth-year students enrolled in a traditional baccalaureate nursing program at a large mid-Atlantic university. As part of the larger study, all fourth-year students (n = 81) were invited, on the first day of class, to complete a sociodemographic profile sheet, indicating sex, age and racial/ethnic identity. Students also completed several online questionnaires measuring belongingness, self-confidence and satisfaction with learning, self-efficacy in the clinical setting, and knowledge and attitudes about inclusive learning environments at three time points during the academic year. Purposeful sampling was then used to recruit two subgroups for focus groups: one group who self-identified on the sociodemographic survey as under-represented minority students in nursing (men, older than age 25 years, or racial or ethnic minority), and a second group who self-identified as majority students in nursing (White women between the ages of 20 and 25 years). Overall, 27% of the 81 members of the class self-identified as belonging to an under-represented minority group in nursing.
A total of 13 students participated in the focus groups in the fall. The majority students group included seven White female students (mean age = 21.43 years [SD, 0.53 years]; range, 21 to 22 years). The underrepresented minority group included six students who self-identified as male or Black or Hispanic (all 21 years old). To respect the confidentiality of the participants in the underrepresented minority focus groups, sex was not linked to race or ethnicity; we merely reported that the participants self-identified as a member of an underrepresented minority group. One student from each group did not attend the second focus group in the spring due to other commitments.
Human Subjects Protection
The University of Virginia Institutional Review Board approved the study protocol before any data were collected. All fourth-year students in residence (n = 81) were invited to participate in the study. Written informed consent was obtained from all of the focus group participants. Only the two non-nursing faculty research team members, trained in research methods and focus group facilitation, were involved in participant recruitment and retention, and data collection. One researcher was a doctoral candidate in psychology currently working for the university's Center for Teaching Excellence, and the second researcher was a master's-prepared senior administrative member of the school's Inclusion, Diversity, and Excellence Achievement initiative. Data were not released to the faculty principal investigator until after final course grades had been submitted. To protect participant confidentiality, characteristics of the focus group participants and associated frequency counts are not displayed in any public presentation of findings. For example, because there were so few men from underrepresented racial and ethnic groups, it would be easy for members of the larger university community to identify participants if we linked gender with race or ethnicity when describing the study sample.
A total of four focus groups, each lasting between 44 and 66 minutes, were completed at two timepoints during the academic year: once at the end of the fall semester and once midway through the spring semester before students began clinical practicum. Two focus groups, one with majority students and one with underrepresented minority students, were completed at each timepoint. The rationale for separate focus groups for underrepresented minority students was to increase the likelihood that participants would feel comfortable sharing their perspectives on topics such as inclusion and belongingness (Evans, 2004). Second focus groups conducted with the same participants permitted within-group (i.e., change over time) as well as between-group comparisons.
Focus groups were conducted in small, private conference rooms, by two facilitators: one served as the interviewer and the second served as the note-taker. The two main facilitators (J.T., E.A.) were nonfaculty research team members with prior experience in conducting focus groups. Focus group interview guides were designed to capture participants' perspectives on the specific inclusive pedagogical strategies incorporated into their fourth-year clinical course and included questions such as: “What does the term inclusive classroom mean to you?” “How, if at all, did the following strategies influence the sense of belongingness or inclusivity in the classroom?” “What, if any, are the outcomes of an inclusive classroom?” Focus group notes served as secondary sources of data and included information such as seating arrangements, nonverbal communication, group dynamics, environmental factors, and facilitators' thoughts and impressions.
Data Management and Analysis
Focus groups were audiorecorded and transcribed verbatim by professional transcriptionists. Transcripts were deidentified and checked for accuracy against the original recordings. Qualitative content analysis (Kearney, 2001; Miles et al., 2020; Sandelowski, 2000) was used to extract pertinent themes from the data. This involved first getting a sense of the whole by reading and re-reading the transcripts while listening to the recorded focus group discussions. This was followed with line-by-line coding using a start list of codes derived from the interview guide questions and the extant literature on inclusion and belongingness. Codes then were collapsed into larger conceptual categories.
Matrices, one for each of the conceptual categories (Averill, 2002; Miles et al., 2020; Saldaña, 2016), were created to examine patterns and trends in the data, thereby facilitating within-group and between-group comparisons. Themes, each representing a unique aspect of the participants' experiences, were identified. Several strategies to enhance methodological rigor were incorporated into the research process. These included extensive notetaking and memo writing; peer debriefing, which involved parallel coding and review by the research team of all data analysis notes; member checking using free text responses on surveys and course evaluations; and using trained focus group facilitators.
The results were organized into three themes that together represented the students' collective experience. Each thematic statement will be discussed separately with excerpts from the focus group transcripts to illustrate how participants' words informed theme development.
The first theme that emerged was, “Just because you are allowed in does not mean you belong; underrepresented minority and majority students describe inclusive learning environments differently.”
During the first focus group, participants were asked to describe or define an inclusive learning environment. Both underrepresented minority and majority students described an inclusive classroom as one in which they felt comfortable and respected, and experienced a sense of belonging. However, there were notable differences between the groups. Underrepresented minority students also discussed feeling safe, feeling free from hostility, and being able to show up as themselves and not as a representative of a group as key to inclusivity. Students' comments included:
- I feel like creating a safe space to bring up difficult topics. . . or asking the question that you perceive is dumb. You have to feel safe in order to do that because you don't want to be ridiculed or anything.
- Before I was like, “Okay, I understand that I'm Hispanic… but I should not be the only one that answers [questions about Hispanic patients].” In the past, I've felt like I have had to be the ambassador.
Underrepresented minority students also included gender, race, religion, backgrounds, and political beliefs when discussing inclusivity, whereas the majority students generally did not. For instance, during the first focus group, only one majority student included respect for everyone regardless of background, race, gender, or religion in her definition of an inclusive classroom. In the second focus group, this same participant mentioned diversity as essential for an inclusive and healthy work environment. She stated, “I think having those different representations, whether it's cultural or gender or sex or anything like that, would be helpful in making other people feel included on the unit.” On both occasions, no one else in the majority students' group commented on or echoed what had been said, which was unusual within the group dynamics.
In addition, during the fall focus groups, both majority students and underrepresented minority students occasionally used a communication technique referred to as “compare and contrast,” meaning they provided examples of situations in which they felt excluded, devalued, or disrespected to illustrate how their current inclusive classroom experience differed. The term “breach in inclusivity” was used to signify words and behaviors that disrupted the sense of belongingness of any community member. There was little difference between the groups regarding how they compared noninclusive classroom experiences to their current inclusive classroom experience during the first focus group. One underrepresented minority student said:
In [the course], it felt like the teachers didn't really care about teaching us…and that really affected how we felt…. We didn't seem to matter…but she felt like our class mattered.
One majority student said:
You just feel like they don't care about the class, so why would you care about the class, and you don't feel like you can go to them with your questions.… Dr. [the professor] is open and would want to work through conflicts.
During the second focus group in the spring, however, underrepresented minority students compared and contrasted more frequently than majority students, sharing stories of times they felt unwelcomed or excluded. One underrepresented minority student said:
When I first got to [the school], nobody looked like me. Nobody dressed like me, and I was really scared of making friends and feeling included. [The participant became tearful.] Like, I don't know why I am getting emotional. Okay, never mind, you know what I'm saying, it's a sad thing…. When I first came, I was scared, but felt really included. Because I feel like people were just nice to each other and that was something that was really nice. But then I feel like as it went on…people felt more comfortable and people kind of said mean things. So then you kind of just got to feeling not as included.
Other group members nodded in agreement as the participant shared her experience, and some of the participants also became emotional. This was followed by more than 10 minutes of other group members recounting instances in which they felt excluded. Underrepresented minority students' comments were:
- There is no one who looks or understands my perspective, you know? And I think even going through clinical experiences, it was really hard, too. Because I felt like people were surprised to see me in that space. I felt welcomed, but I didn't feel included.
- I feel a lot of times when [a breach in inclusivity] happens, though, I don't really react to it. Because I'm like, “Wait, did that really just happen? Did you really just say that?” [But I don't want] to offend someone, because I feel like [if you speak up] sometimes people just feel like you're attacking them and you're attacking their beliefs. I'm not trying to—I'm just trying to talk about how I feel and what systemically happens in society.
Facilitator notes and researcher memos indicated the focus group leaders and other research team members also experienced feelings of empathy for the students and sadness that these experiences continued to be a part of underrepresented minority students' educational journey.
The second theme identified was, “We may be in this together, but inclusivity requires a top-down approach; every aspect of the learning community affects inclusivity, but teachers as leaders are especially influential.”
Both underrepresented minority and majority students across time agreed that although all aspects of the learning environment affected their sense of belonging, teachers exerted the greatest influence. Because of the aims of the larger study, discussions during the first focus groups centered on the students' classroom experience. Therefore, their use of the term teacher referred mostly to the professor teaching the large clinical course.
Results from the larger study indicated that students associated certain faculty characteristics (e.g., being approachable, relatable, invested, and a strong leader) and behaviors (e.g., learning names, connecting with students outside of class, storytelling, and organizing and promoting group activities) with inclusivity (Metzger & Taggart, in press). A more in-depth qualitative analysis revealed how and why this was so.
If the instructor exhibited certain behaviors, such as learning students' names, connecting with students outside of class, or sharing stories or “lessons learned” from clinical practice, students determined that the teacher genuinely cared about them and was invested in their success, and that the classroom was inclusive. One majority student said, “That sense of belonging. That feeling that you matter.… You're valued like a real person. It's a respect thing. Her knowing our names and stuff is a good picture of all that.” Another majority student noted, “[The professor] genuinely cared…. She was on our team and we weren't just left by ourselves. She was in it with us to succeed and to learn.” Another underrepresented minority student said:
With the stories, [professor] is showing us that on that road you will not be the ideal nurse at first, but you will get there and that is very encouraging for students…because, you know, we're accepted for where we're at…. We belong here.
Once a caring and inclusive atmosphere had been established, this became the “lens” through which other behaviors and classroom policies were viewed. Participants commented on the professor's policies regarding late assignments and attendance. One of the majority students said, “[Professor] thinks highly of you. . . if there's ever a question about an assignment or any issue, I just know that she would give us the benefit of the doubt.” Another majority student said:
[The professor] notices if you're there or not…. If someone's absent [the professor asks] the clinical group, “Do you know if they're okay?” and not in a “I'm gonna get them in trouble for attendance way,” but just in like, a truly caring way and just inclusive way.
On the other hand, if the teacher did not demonstrate those inclusive behaviors and characteristics, the classroom experience was characterized as noninclusive and students reported adverse outcomes. One majority student described the negative cycle that resulted from that experience:
[It] leads us to not respect them and not respect the class, and we don't…it's just this whole cycle that perpetuates into we don't feel respected. We don't respect them. We don't respect the class. They don't respect the class. It's just like it goes into everything and then you just get this attitude of negativity and stress as you walk into the classroom and you're like, “I do not want to go to this class.” It perpetuates and it spreads and it affects your entire life.
During the spring focus groups, participants expanded the term teacher to include clinical instructors, preceptors, experienced clinicians, clinical leaders, and managers. Again, participants from both groups expressed the importance of the teacher or leader setting the tone on the unit. One underrepresented minority student said:
It starts at the top.… It's a top-down approach. A good example is [name of two different units]. One is amazing and I really enjoy working on, and the other just sucks and you don't want to be in [it].
Both majority students and underrepresented minority students shared examples of breaches in inclusivity in the clinical setting. However, underrepresented minority students shared many more examples, and nearly all of the examples were of breaches that were either perpetrated by or unaddressed by their teachers. The following comments were made by two different underrepresented minority students:
- In my clinical for Labor and Delivery…my instructor said a lot of stereotypes about different groups of people, how they give birth and stuff like that. Her preferences for certain races that she prefers to have as patients.
- During rounds, the team talked really negatively about the patients and said racially bad things. I told my instructor about it, and she was like, “Yeah, I agree with you. That's not how they should act, but I'm not going to say anything because I don't want them to treat you differently.” In the moment, I was like, “Oh yeah, I don't want them to treat us differently,” but [really] she wasn't standing up for us. She didn't really consider how that felt.
Students were asked to recommend additional strategies to improve inclusivity at their school. Participants in both groups agreed that the current strategies they deemed inclusive in the classroom should be more broadly adopted. In addition, students in both groups discussed the important role that they have in promoting a sense of belonging. The majority students discussed this in terms of how they treat patients. For example, one of the majority students commented:
So [sense of belonging] is something I would definitely look for in where I work, but also something I want to contribute…. It can be small things and that's perhaps the biggest thing, is like, you can do small steps to really make a statement that you respect and care about somebody.
The underrepresented minority students also made recommendations and saw themselves as part of the solution. However, in addition, they emphasized the importance of changing institutional culture to promote a greater sense of belongingness. They recommended greater transparency and being more intentional about their goals to have a more inclusive culture: “Own it, this is our teaching philosophy. This is what we believe.”
Some suggestions centered around promoting interactions among people, especially diverse groups, both in the academic and clinical setting. The following comments made by under-represented minority students illustrate this:
- I don't feel like there's a huge opportunity to get to know everyone else in other classes. I feel like it's really hard to relate to people that you don't know, and there are so many more people here…. I feel like it would just be cool to have us all intermingle more…because then you meet more people who are different and then you start understanding like each person out there is different and you're more open and inclusive.
- Because I feel like [the university], in and of itself, has structures that divide us…. And I don't want to decrease the number of white [people] at this school, I just want more people who I can relate to, and I think it's important, too, when you're building a generation of nurses for the future.
- I oftentimes feel like when we talk about cultural diversity and inclusivity and stuff, school of nursing…. I don't know if this is just me and maybe I've seen it wrong, but I feel like we've been bullying individuals who come from culturally diverse backgrounds and like we've been having a conversation, but I don't know, are students who maybe aren't of different races having these conversations?… But I think we need to kind of push ourselves to be more vulnerable and actually talk about these things.
Other underrepresented minority students advocated for peer mentoring and support:
I think it would be kind of cool to have the fourth years and first years meet up and talk about inclusivity, because I feel like as a first year, if you'd asked, “Oh, what can we do?” I would have not really given much thought to it, because we haven't been critically thinking about inclusivity. But as a fourth year, I feel like I could have really fruitful conversations with some of the younger students here.
Still other students wanted to change how cultural competence or humility was approached in coursework:
- There needs to be more of an honest openness and talk about culture [within the United States], because I think a lot of times we see culture as something outside of this country. But there are different cultures within here and I've heard different negative things about the cultures we serve in Appalachia and stuff like that and not enough understanding of…just an openness to the variety of human experiences…being open to the idea that I can be different than what you expect and so can our patients. That's what needs to be taught.
- If there is any cultural competencies that are taught in the nursing school, I wish it would be taught by someone who might belong to those groups, you know?
The third theme identified was, “The experience may be local, but the impact is global; the outcomes of an inclusive learning environment extend beyond the classroom.”
During both focus groups, the participants shared their perspectives for the short-term and predicted future impact of inclusive learning experiences. When students characterized the classroom and teacher as inclusive, they responded by becoming more engaged, which they then believed encouraged the faculty to respond in kind. One of the majority students said:
I was so engaged; I was ready to learn. Never really checked my phone or social media because she was just as engaged, and she was so passionate about what she was teaching about. All I wanted to do was sit there and listen and learn from it.
One of the underrepresented minority students, said “It creates an air of respect. [The instructor] respects us, but we also respect her by doing the work…. You want to go to class and you want to learn the material.” The classroom atmosphere was characterized by optimism and energy, which then carried over to the clinical setting. Participants assumed that their teachers were using a learner-centered approach in the classroom, simulation, and clinical environments to reinforce the principles of holistic patient-centered care. One underrepresented minority student noted, “The stories emphasized the importance of what we are learning…through the stories, she showed how to provide holistic care.” Another underrepresented minority student said, “I'm more attentive to things that I wouldn't necessarily think about before…paying attention to the whole patient.”
Similarly, students maintained that an inclusive classroom exemplified a healthy work environment. Participants spoke at length about how their academic experience has influenced their job searches and future career aspirations. Comments made by the majority students included, “She incorporated what a healthy work environment should be…in our class, and now that we've seen it in action, we know what to look for” and “Down the road I would really enjoy being a clinical instructor or preceptor…knowing how [the professor] made us feel…. I can think back to her and why she made such a difference and embody that.” One of the underrepresented minority students said, “Her classroom in general showed what I would say is one of the healthiest work environment…. I've learned how you can add to a healthy work environment and how your presence affects environments.”
The only discernible difference between the underrepresented minority and majority student groups related to this theme was that underrepresented minority students tended to share more instances of breaches in inclusivity in the clinical setting and concerns about finding an inclusive workplace. For example, during the discussion of the importance of an inclusive work environment, one underrepresented minority student reported being bullied by a former preceptor. In that same discussion, another participant made the following comment, “One of the things I'm most nervous about for practicum and my future job is getting bullied…because that happens a lot in nursing.” Participants continued their discussion moving back and forth between the importance of an inclusive workplace and instances when they observed or experienced lack of inclusivity in the clinical setting. One underrepresented minority student shared how a sense of belongingness affected his job search:
[Belonging] affected me a lot more than I expected it to. I just rejected an offer from a unit, mostly because I felt like I didn't belong there. It was a very diverse workplace, but I still didn't belong because of how they approached inclusivity, which is they didn't approach it at all.
All students benefit from being in an inclusive learning environment. Despite some differences in how underrepresented minority students and majority students discussed inclusivity, there were remarkable similarities in the evidence students used to determine whether a teacher or learning experience was inclusive. Once inclusivity was established (or not), that became the lens through which all other behaviors, policies, and activities were viewed. For example, because students determined that their classroom was inclusive, they characterized the attendance policy as caring, not punitive. Furthermore, students related a learner-centered classroom to patient-centered care and an inclusive classroom to a healthy work environment. In other words, the classroom became an exemplar of what can and should be in clinical practice.
The breaches in inclusivity—ranging from relatively innocuous and unintended to overt and intended—and the associated adverse outcomes experienced by underrepresented minority students in nursing reported in this study have been well documented by other research teams (Ackerman-Barger & Hummel, 2015; Love, 2010; Sanner & Wilson, 2008; Sedgwick & Kellett, 2015), as have the positive outcomes associated with inclusive learning experiences (Metzger & Taggart, in press; Miller et al., 2019; Rainey et al., 2019; Sedgwick et al., 2014).
What has been less well-documented is empirically derived evidence on which to base the development, implementation, and testing of pedagogical strategies to enhance inclusion. Because this study conducted focus groups over time with both underrepresented minority students and majority students, we were able to compare groups and examine how their perspectives changed over time. By presenting the findings as themes, supported by the participants' words, nurse educators gain a deeper understanding of the students' experiences related to inclusion. This in turn may reassure educators that all students benefit from an inclusive learning environment and that relatively low-resource strategies can yield results.
These results highlight three important steps moving forward. First, they highlight the need for culture change. In the absence of inclusivity, diversity in baccalaureate nursing education likely will be insufficient in meaningfully increasing the size, diversity, and preparedness of the nursing workforce. Instead, all hands are needed “on-deck” to create inclusive learning environments—those in which all students feel a sense of belongingness. Students recognize what constitutes an inclusive environment, and they understand its value from experience. Their classrooms become a proxy for work environments, and student-centered classrooms become a proxy for patient-centered care. Students were never explicitly told this connection; they made it for themselves.
Second, these results highlight the need to include students in the quest for inclusive learning environments. Students are willing to take part, and they have many different recommendations for creating these environments. Their recommendations were thoughtful, and many were not resource intensive. Students do not expect faculty and institutions to do all the work, although they do believe the efforts must be top-down. They are eager to participate in bringing about change. Furthermore, when students are on board, their enthusiasm is infectious and inspires faculty and other leaders to continue their efforts and celebrate their successes.
Third, these results highlight the need to intervene during breaches in inclusivity. Although inclusivity is important to all students, underrepresented minority students experience many more breaches. Academic and clinical leaders have a crucial role to play in addressing these breaches; addressing the breaches, even without resolution, may combat feelings of exclusivity and thereby mitigate the damage of discrimination.
Findings from the qualitative analysis of the focus group interviews have implications for nursing education, practice, and research. First, despite being highly engaged in the focus groups, underrepresented minority students shared stories—many of which had been previously untold—only after establishing a strong rapport with the facilitators. This suggests that students are willing to discuss difficult issues but require trusted leaders to facilitate the discussions. Without opportunities to respectfully engage in honest dialogue, majority students may assume all is well, and underrepresented minority students may assume no one cares.
In addition, faculty in both classroom and clinical settings may wish to invest time before and at the beginning of a course to lay the foundation for an inclusive learning experience. They are leaders and role models, and as such, they should consider all interactions to be opportunities to demonstrate compassionate and professional behavior. Many schools have readily available resources to assist faculty in the incorporation of inclusive pedagogical strategies. For faculty working at institutions without on-site resources, there are online resources. Furthermore, many of the recommendations made by these focus group participants are not resource intensive.
Similarly, clinicians, clinical leaders, and managers should discuss as a unit what type of example they are setting for students. If they want to attract and retain a diverse workforce, they should model inclusive behavior and healthy work environments. Many students pay close attention to whether they experience a sense of belonging during clinical learning experiences and use this to guide their job searches.
The descriptive information from this and other studies may inform intervention development and empirical testing. The participants in this study were highly engaged in the research process and willing to share their perspectives. In fact, many thought that being included in research indicated that the faculty cared about them, reinforcing their perceptions that the classroom was inclusive. Collecting data on pedagogical strategies can facilitate relatively quick change at the institutional level and, when more widely disseminated, can broaden the evidence base for all faculty across settings.