The Institute of Medicine (2010) made reducing health disparities a national research priority, and health leadership groups have identified a need for an increased number of culturally competent nurses (Amaro et al., 2006; Graham et al., 2016). As the demographics of patients in the United States change to include higher numbers of minorities, it is important to increase the diversity of the nurses caring for them (Ferrell & DeCrane, 2016). Previous research shows that providers who identify as a minority are more likely to practice in underserved areas with minority populations, which leads to more effective, culturally competent care for those areas (Davis & Davis, 2010; Ferrell et al., 2016).
Despite efforts to increase the number of minority students graduating from nursing programs, the number of minority nurses remains far below the percentage of minorities in the general population (Ferrell & DeCrane, 2016; Graham et al., 2016). Of concern here is the lack of Latinx nurses in the United States. According to the U.S. Census Bureau, (n.d.), 18.5% of the United States population in 2019 identified as Latino or Hispanic, yet only 7.2% of RNs in this country identified as Latino or Hispanic (U.S. Bureau of Labor Statistics, 2020). The National League for Nursing (n.d.) reported an increase of Hispanic students enrolled in basic nursing programs from 8.1% in 2016 to 9.8% in 2018. Although this increase in enrollment is an improvement, it still does not match the nation's Hispanic/Latino population.
The experiences of Latinx students in higher education have been explored by researchers. Although the number of Latinx students who are enrolling in higher education is increasing, they are less likely to complete their education and earn a degree than White students (Barnard et al., 2018; Flink, 2017; Murphy & Murphy, 2017). Most college students experience some sort of stress during their education, but Latinx students are faced with unique stressors, such as discrimination, stereotyping, and being first-generation college students (Flink, 2017). Nursing education is considered one of the most stressful fields of study in higher education (Bartlett et al., 2016; Labrague et al., 2017) and nursing students report negative effects of stress on their health and well-being, such as anxiety and migraines (Bartlett et al., 2016), depression (Hamaideh et al., 2017), insomnia (Labrague et al., 2017), and other stress-related illnesses. Students experiencing excessively high levels of stress are also at risk for noncompletion of the nursing program (Ferrell & DeCrane, 2016; Hamaideh et al., 2017; Labrague et al., 2017). The added stress from an academically challenging field of study can contribute to the already lower college completion rates of Latinx students.
Although there is a growing body of literature addressing stress in nursing students in general (Hamaideh et al., 2017; Labrague et al., 2017; Sheu et al., 2002), little qualitative research has been reported that focuses on the unique experiences of stress in Latinx nursing students. Gaining insight into the specific stressors that contribute to attrition will help nursing faculty and administrators understand how to best support and retain minority students (Harris et al., 2014), specifically Latinx students, as they are the fastest growing minority group in the United States (Anderson & Shapiro, 2011). This is significant because the low number of culturally diverse students in nursing programs contributes to a population of RNs that does not reflect the cultural diversity of the country. Therefore, the purpose of this qualitative phenomenological study was to explore the factors contributing to acute psychological stress and reported efficacy of coping methods used by adult Latinx students enrolled in prelicensure nursing programs.
The theoretical framework for this study is the Transactional Model of Stress and Coping (Lazarus & Folkman, 1987). Central to this theory are the concepts of cognitive appraisal and coping. Lazarus and Folkman described two types of appraisal: primary and secondary. With primary appraisal, the individual determines the relevance of what is happening and whether it will affect their well-being. The extent to which an individual feels an emotional, stressful response will depend on how much is at stake. Secondary appraisal involves a cognitive process in which the individual determines if anything can be done to prevent harm or improve the situation, as well as evaluates different coping strategies that can be used (Folkman et al., 1986). The authors further described two functions of coping: managing the problem (problem-focused coping), and regulating emotion or how one thinks about the situation (emotion-focused coping). Viewing the lived experience of stress in Latinx nursing students through this lens is a way that nurse educators can understand Latinx nursing students' appraisal of stressors and the coping strategies they use.
Data Collection Method
The majority of studies on cultural diversity in schools of nursing is quantitative; thus, researchers saw a need to examine the issue from a richer, qualitative perspective. To gain a true understanding of unique experiences of the stressors prelicensure Latinx nursing students experience during their nursing education, the researchers thought it was important to hear directly from them. Using a phenomenological approach for the inquiry, semistructured focus group interviews were conducted to gather the participants' stories. Phenomenology allows researchers to describe “the common meaning for several individuals of their lived experiences of a concept or phenomenon” (Creswell & Poth, 2018, p. 75) and is an appropriate approach to understand the lived experience of stress in Latinx nursing students. The focus group format offers a level of comfort and support for participants that one-to-one interviews do not and affords deeper insight into their experiences. Additionally, phenomenological focus groups have the advantage of enriching the data “as a result of participants reflecting on and sharing their experiences” (Bradbury-Jones et al., 2009, p. 667).
Participants and Setting
The study took place at three different schools of nursing in the Pacific Northwest and used a purposive sampling approach. Two sites each had five participants agree to be part of the focus group, and the other site had two. All participants were over 18 years old and self-identified as Latinx. Each participant was recruited via email or flyer sent out through their school's email system. All participants were currently enrolled in an undergraduate nursing program. Seven participants were from community colleges offering an associate degree, whereas five participants were from a university offering a bachelor's degree. Eleven of the participants identified as female, and the twelfth identified as male.
Prior to data collection, institutional review board approval was obtained from each of the three research sites. Participants then were recruited, and focus groups were scheduled on each campus to make attendance more convenient for the participants. Private rooms were reserved to increase comfort and ease the interview process, and each room was arranged as invitingly as possible to facilitate rich, open discussion. Each of the three authors moderated one focus group interview, and only the researcher and the participants were present during the interview. The authors are nurse educators and conducted the interview at the school where they teach. The use of three focus groups, each one from different school of nursing, allowed “for the possibility of confirming or replicating findings” (Remler & Van Ryzin, 2015, p. 70).
At the beginning of the interviews, basic demographics were collected, including age, year in the program, and gender. The purpose of the interview then was explained, and each participant signed a consent form agreeing to participate and was asked to choose a pseudonym. Participants were asked to refer to each other by this name for the duration of the audio-recorded interview to ensure confidentiality. Over the course of the interviews, participants were asked a series of common questions developed by the researchers about their experiences in nursing school, with specific attention paid to types of stressors and use of coping methods (Table 1), given that the goal of this phenomenological study was to explore the lived experience of stress. The discussion was facilitated to encourage participants to share their experiences with each other, and the moderator guided the interview to ensure all the questions were addressed. A total of three focus groups were conducted, one for each location, and each lasted approximately 60 minutes.
Focus Group Questions
Each researcher independently transcribed the audio recordings of the interviews, then analyzed the data using the method of phenomenological analysis recommended by Creswell and Poth (2018). Accuracy was ensured by listening to the recordings and reviewing the transcripts. Then, each researcher reviewed the transcripts from all the interviews and created a list of significant words or phrases that emerged from the stories of the participants. After the researchers independently analyzed the transcripts, they shared their thoughts and reanalyzed the data. They extracted significant statements from the data and organized them into categories of nonoverlapping, thematic elements (Creswell & Poth, 2018). Each category was explored in detail to identify themes of emerging patterns and connections. After these themes were developed and it was apparent that no new patterns were emerging, the researchers crafted the textural experiences of the “what” of the experience, and the structural descriptions providing context for the “how” of the experience (Creswell & Poth, 2018). These themes were aggregated into a rich, thick, composite narrative portraying the essence of the experiences of participants as they navigate through an undergraduate nursing program.
For research studies to have an effect on either practice or the theory of a field, they need to be rigorously conducted and offer conclusions that ring true to the readers (Merriam & Tisdell, 2016). The researchers used several techniques to enhance the credibility and consistency (i.e., trustworthiness) of the research and analysis. The first technique, triangulation, is defined as how evidence from multiple sources converge on a finding (Remler & Van Ryzin, 2015) and can be accomplished through the use of multiple methods, multiple sources of data, multiple investigators, or multiple theories (Merriam & Tisdell, 2016). Triangulation in this study was accomplished via the use of multiple sources of data (i.e., three separate interview groups from three different schools of nursing) and multiple investigators. The investigators independently analyzed all the data, which allowed for comparison and cross-checking of findings.
The researchers also enhanced trustworthiness using the strategy of reflexivity. Reflexivity provides an explanation of how researchers affect and are affected by the research process and includes an explanation of biases, dispositions, and assumptions (Merriam & Tisdell, 2016). Practicing reflexivity allowed the researchers to examine how personal experiences and biases might shape the interpretation of data (Creswell & Creswell, 2018).
Researchers attempted to use highly descriptive, detailed language to present the participants and included examples of their interactions to provide evidence for findings. These rich, thick descriptions allow readers to assess ability to transfer the findings to different settings, enhances the credibility of the study, and details the essence of the experiences of participants.
Five main themes emerged from this study: Stress of Course-work, School–Life Balance, Navigating Uncharted Territory, Feeling Unsupported, and Staying the Course. Two of these themes were evidenced in currently available literature and likely affect all nursing students (i.e., stress of coursework and school–life balance). However, Navigating Uncharted Territory, Feeling Unsupported, and Staying the Course are themes that may be unique to Latinx students.
Stress of Coursework
Compared with other fields of study, nursing education is considered to be one of the most stressful and emotionally demanding (Bartlett et al., 2016; Jimenez et al., 2010; Labrague et al., 2017). Within nursing programs, students identify high academic workload (Hamaideh et al., 2017; Lekan et al., 2018; Lo, 2002) and lack of time or difficulty with time management (He et al., 2018; Shipton, 2002; Wolf et al., 2015) as the main causes of stress. These same results were evident in the current study findings, as the heavy workload was perceived by some students as the most difficult part of nursing school. One participant said, “Even though I try really hard, sometimes our workload can be a little overwhelming.”
Shipton (2002) found that students felt they had lack of time to finish all the academic work, and coupled with the high intensity of the program, ultimately felt as if their lives were in chaos. Study participants echoed this idea, as expressed by this participant: “It is a lot of work and you definitely have to like manage your time.”
Additionally, some participants described stress resulting from inconsistency in instruction, such as different teaching styles and expectations from instructors in cotaught courses. One participant stated, “They each have a different way of teaching…and expectations and testing…. I find that what's more difficult for me is kind of trying to get the hang of the instructors and the way they teach…and the stuff they want you to learn.”
The clinical component of the coursework was also perceived as stressful by some of the participants. Common clinical stressors in the literature include pressure from instructors (Hamaideh et al., 2017; Shipton, 2002), negative interactions with nursing staff (Hamaideh et al., 2017), clinical evaluations (Shipton, 2002), competition among classmates (Shipton, 2002), and fears of failure or incompetence (Wolf et al., 2015). One participant stated, “My first clinical experience was crazy. I cried the first day. I was like, maybe this is not for me.”
Some participants felt like they were thrown into the clinical setting without adequate preparation, felt they did not know what they were doing, and reported having bad experiences with staff nurses. A participant said, “Clinical is a little more challenging for me…. I just felt like I was going and I didn't even know what it actually looked like before…. You're just thrown out there and I don't really know how this is supposed to go. It's like, just like trying to figure it out and that part is hard.”
In previous studies, students reported feelings of stress related to the teaching and learning environment, as well as the course structure. Lack of timely feedback (Gibbons et al., 2008), high course workload demands (Hamaideh et al., 2017; Lo, 2002), and fears of failing coursework or failure to graduate (Wolf et al., 2015) were common stressors. Some participants spoke of test anxiety as a specific perceived stressor and identified two causes: the need to maintain a certain grade in order to pass the course, and the amount of content students are expected to master. A participant said, “Because I get test anxiety, that's been the hardest for me…feeling like oh my God, there's so much information to retain.” Another stated, “Sometimes where I have a test…my stress levels just skyrocket and you know, I have a difficult time concentrating and like reading a question and I'll find myself re-reading the question like two or three times and it still doesn't make sense.”
Maintaining balance between school, family, and work was another perceived stress for the participants. Difficulty balancing outside life and school led students to learn to say no and refrain from participating in social functions. One participant commented, “Basically, fourth quarter I was very ‘study, study, study’ all the time…. I didn't hang out with friends and do anything. I would say no to everything.”
Amaro et al. (2006) found that families actually could be the source of much stress for minority students, as many had to work to provide financial resources and shoulder most of the daily care of the family and consequently had decreased time for studying. Several participants described the need to work, both during the prerequisite courses and during the nursing program to pay for school and support themselves and their families. This not only caused a delay for some of the students in applying to nursing school, but it also created stress because they had less time for studying. Participants said:
- [My daughter] is turning eight and the other one's turning 6 and I'm currently pregnant…. I decided to come back to school in 2012…. I did some of my [prerequisite courses] but um, at that time my husband, he was in jail. So, I needed to go back to work because I couldn't you know, I couldn't do it by myself…. It took me awhile…. I was on and off [in school].
- It's hard to work…. I've been working twelves for two and a half years and it wasn't a problem until I started school and I can't, I can't study, I can't do anything when I get home from work because I'm just exhausted.
- For part of the program, I was working full time on the neuro unit as a [certified nursing assistant] and then also going to school full time. So, it was really difficult, and you know my grades kind of reflect it.
Navigating Uncharted Territory
Some of the participants were first generation college students, did not know how to enroll in college, and did not know what to expect from nursing school. A participant said, “My parents didn't get degrees and didn't even really go to school…. It's kind of challenging because, it's not that they don't understand but they don't really know. I mean, they didn't go through it.”
Being in uncharted territory required students to learn to navigate college without having guidance from family. They had to learn to ask for help from outside sources. This is supported by the report by Barnard et al. (2018) that 75% of Latinx students are first-generation and are unable to navigate the college environment without the help of their parents. According to one participant:
A lot of it is just kind of figuring out your own way. It's like uncharted territory. If you have financial questions or any questions, you kind of don't have those resources. You typically would talk to someone and say “Hey, what do I do about this?” You have to find other people outside of the family at like the university or other places to kind of meet those needs. That's more stressful than going up to mom and being like, “Hey, how do I do this?” or “Help me do this.”
Participants described feeling unsupported as a stressor. Some described how guidance counselors were not encouraging or supportive of their aspirations:
I started applying for nursing school in 2015. And so it took me until now to get in and that was really discouraging…. I also had an advisor…. She gave me some really bad advice and was like, “If your application score isn't above this level, you shouldn't even be applying,” and she like basically turned me away.
Minority students differ from the general population in that they are more likely to feel isolated and marginalized on campus (Veal et al., 2012). According to one participant:
You know, it's funny. When I was a kid, I didn't really understand what a minority was. I mean, I knew I was a minority, but I always thought that meant, like, I was lesser than the other people around me. I thought somehow, I was not as good or whatever because I was a minority.
Despite reporting a high desire to be involved with peers, faculty, and staff (Ferrell & DeCrane, 2016), minority students may have difficulty functioning within institutions with little diversity and may even avoid campus when possible because they feel uncomfortable when faced with a predominantly White student population (Young-Brice et al., 2018). This lack of diversity in nursing resulted in participants feeling unsupported. One participant said, “We don't see ourselves as being nurses because none of the nurses we see look like us.”
Staying the Course
Despite the various challenges and stressors, participants described overcoming the challenges and staying the course. Some of the participants repeated prerequisite courses to earn a higher grade that would make them more competitive. Others applied to nursing programs multiple times and persevered until they were admitted. Participant comments included:
- You feel really proud of yourself and it's really satisfying knowing that you got that far.
- So, for me it's like, okay, like I can do this. I beat the odds and they told me I couldn't get in and I got in so for me, it's really personally satisfying. Made me realize that it's possible to do something.
Common among the students was that family, friends, and the nursing program cohort were a great source of support: “I think my cohort is the true reason why I'm successful because we're all very supportive of one another.”
Participants discussed other techniques that helped them to stay the course, such as positive self-talk, going to the gym, being active, lowering high expectations of self, eating, going to movies, and getting rest: “When I switched my mentality, like I don't have to get a 99 or a 100, you know, an 89 is fine, my stress went way down.”
Many of the participants also described a sense of pride and accomplishment of being a nursing student: “You feel a great sense of pride for being able to make it this far, especially if it's like you know not something that anyone else in your family has done. You're kind of a trailblazer, so that kind of gives you a sense of pride.”
The primary limitation of this study was the small sample size, particularly the small focus group that consisted of two participants. Attempts to recruit additional participants at the one setting with two participants were unsuccessful. Given that all participants were from the Pacific Northwest, they may not represent Latinx nursing students throughout the country. An additional limitation is the lack of male representation within the focus groups. Male Latinx nursing students may have unique experiences that were not captured in the discussions, as only one male participated. Although careful and verbatim transcription of the interviews was conducted, the authors did not member check the emerging findings from the interviews. This could be an additional limitation.
A potential additional limitation is that the researchers are White nurse educators at the institutions where the study was conducted. This raises the issue of power between researchers and participants (Creswell & Creswell, 2018), so it is possible that participants felt uncomfortable disclosing their feelings about their experiences in the nursing program. Additionally, the researchers acknowledge the possibility that, as educators and current doctoral students, they may have developed subconscious biases or assumptions of the stressors of nursing education that could have affected thematic analysis. These risks were mitigated by the researchers bracketing, or examining, how their own positions affect and are affected by the research process. They understood that personal experiences and biases inform research and made every attempt to clarify assumptions, worldviews, and theoretical orientations as they relate to the current study (Merriam & Tisdell, 2016).
Implications and Conclusion
Latinx students are less likely to complete degrees compared with White students; therefore, it is important to understand the stressors that Latinx nursing students experience in the challenging environment of nursing education. Few published studies specifically focus on the experiences of stress in Latinx nursing students and how these stressors influence recruitment and retention. The findings of this study add to this limited body of knowledge and help paint a picture of the experiences of stress in Latinx students, as well as coping strategies that add to their persistence and success in obtaining an education in nursing. Although some of the themes that emerged in this study are likely applicable to the general nursing population (i.e., stress of coursework and difficulty finding school–life balance), several of the themes may be more specific to the Latinx population. With this in mind, nurse educators should work to foster cohesiveness among the students within each cohort, as these are the groups of students that will be working closely together for the duration of the program.
Although most general population students found family to be a positive source of support, families can be the source of much stress for minority students (Amaro et al., 2006). Many need to work to provide financial resources while shouldering most of the daily care of the family, and consequently have decreased time for studying or socializing (Veal et al., 2012). Participants spoke of the stress of working full or part time, in addition to being of being full-time students. Generally, working while in nursing school is discouraged and class schedules are often rigid. However, it is important to understand that some Latinx students do not have a choice regarding whether to work because their families depend on their incomes. Knowing this, nurse educators should make an effort to help the students to arrange their schedules to accommodate both school and work.
Aside from balancing work and school, minority students differ from the general population in that they are more likely to feel isolated and marginalized on campus (Ferrell & DeCrane, 2016; Veal et al., 2012; Young-Brice et al., 2018). Several participants mentioned this sense of otherness. At one school, all the Latinx students sit together in class and have noted that there is a glaring lack of diversity among their cohort. Others mentioned that they are constantly reminded of their minority status, which they feel carries a negative connotation. It is important that nurse educators be sensitive to the fact that Latinx students feel isolated and should help identify Latinx colleagues who can serve as mentors. Additionally, nurse educators should be sensitive regarding the terminology they use to refer to ethnically diverse groups of students and should specifically ask the students how they prefer to be addressed. As White instructors, the researchers were not aware that students find the term minority to be demeaning because it is such a widely used term. However, armed with that knowledge, they will now work with students to find more acceptable terminology.
Many of the participants mentioned that they are first-generation college students and had difficulty navigating the college environment. From not knowing how to enroll in classes to being discouraged by counselors to apply to the nursing programs, students felt unsupported every step of the way. The participants stated that it would have been helpful if actual nursing instructors (or people who are familiar with the programs) would have been available to answer their questions as they tried to navigate this uncharted territory. With this in mind, nursing programs should designate a specific outreach faculty member who is both visible and available to answer prospective student questions.
Finally, multiple participants spoke of feeling unsupported in their efforts to gain admission to the nursing program. They were discouraged by high school teachers, essentially turned away by college guidance counselors, and some had to apply multiple times before being accepted into the nursing program. Recruitment efforts should be enhanced for Latinx students who express an interest in nursing. Latinx students need encouragement and support rather than discouragement at multiple touch points in their academic counseling. There was some discussion of the competitive admission process being a specific barrier, as it does not take into account the unique background of culturally diverse students. As nursing programs work to increase diversity, they would be well served to review and possibly revise their admission policies to include consideration of students' cultural diversity.
This study has offered insight into the experiences of stress in Latinx nursing students, specifically some of the barriers and difficulties that they face. Because the overall goal is to increase diversity in nursing programs, studies such as this one that focus on the unique experiences of minority nursing students are essential. Nurse educators need to continue to gain insight into the specific issues that serve to keep diverse students out of nursing programs, as well as continue to address issues that contribute to attrition. By investigating and understanding these issues from the viewpoints of students, educators can learn how best to support and retain them. This is significant because the lack of cultural diversity of students in nursing programs compared with the diversity of the country leads to a population of nurses that does not match the cultural diversity of the population of the United States.
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Focus Group Questions
|Why did you decide to become a nurse?|
|In general, how would you say the nursing program is going for you?|
|What are you finding to be the easiest aspect? The most difficult?|
|One thing nursing students sometimes struggle with is time management. How are you doing balancing everything in your life?|
|Do you find yourselves feeling overwhelmed at times, given how rigorous nursing education is?|
|What do you do when you are feeling overwhelmed or stressed?|
|Do those things help you to feel better? Is there one thing that works better than another?|
|Are there any stressors in your life that you believe are unique? Ones that you do not think other students have to deal with?|
|If there was one thing you could change about the nursing, what would it be?|
|What does it mean to you to be in the nursing program?|