- Email: [email protected]
Nursing Faculty Readiness for Student Diversity
Teaching and Learning in Nursing 15 (2020) 104e108
Contents lists available at ScienceDirect
Teaching and Learning in Nursing j o u r n a l h o m e p a g e : w w w. j o u r n a l s. e l s ev i e r. c o m / teaching-and-learning-in-nursing
Educate, Excite, Engage
Nursing Faculty Readiness for Student Diversity Tim Bristol, PhD, RN, ANEF, FAAN a,*, Anne Brett, PhD, RN b, Jose Alejandro, PhD, RN, FAAN c, Jessie Colin, PhD, RN, FRE, FAAN d, Teri Murray, PhD, APHN-BC, RN, FAAN e, Virginia Wangerin, PhD, MSN, RN, CNE f, Raney Linck, DNP, RN g, Deidre Walton, JD, MSN, RN h a
School of Nursing, Walden University, Minneapolis, MN School of Nursing, College of Doctoral Studies, University of Phoenix, Phoenix, AZ Mount St. Mary’s University e Los Angeles and University of California Irvine (UCI) Health System, Los Angeles, CA d College of Nursing and Health Sciences, Barry University, Miami Shores, FL e Saint Louis University School of Nursing, St. Louis, MO f College of Human Sciences, Iowa State University, Ames, IA g School of Nursing, University of Minnesota, Minneapolis, MN h Past President, National Black Nurses Association, Washington, DC b c
a r t i c l e
i n f o
Article history: Accepted 2 September 2019 Keywords: Nursing Nursing student Participatory action research African-American Hispanic LGBTQ
a b s t r a c t Using a modified Participatory Action Research model, 531 participants attending a nurse educators' conference spent three hours doing immersive collaborative work to identify perceived barriers experienced by diverse student groups and create strategies for educators to address perceived challenges related to diversity. Initially, six diverse speakers representing minority or underrepresented populations (such as Hispanic, African-American, LGBTQ, International, and other diverse student populations) in nursing education briefly shared their stories and experiences as a student and/or nurse being from an underrepresented group. After the presentation, the participants/nurse educators participated in rotating small groups through a World Cafe model to generate (a) perceived themes around common challenges and barriers faced and (b) practical strategies to facilitate inclusion of students from various diverse populations. The goal of the work was to enhance nurse faculty's readiness for student diversity in the classroom and clinical setting. © 2019 Organization for Associate Degree Nursing. Published by Elsevier Inc. All rights reserved.
Nursing faculty continue to experience issues specific to meeting the needs of an increasingly diverse and global community of students. For two consecutive years, during an annual nurse educator conference, readiness for student diversity was explored using a format that provided an opportunity to engage over 531 World Cafe conference participants in a conversation about what diversity issues they have encountered, perceived challenges or barriers experienced by students from diverse population, and potential strategies that could be deployed. The hope was this experience would be the beginning of a conversation that could be continued at the participant's respective nursing programs.
Literature Review A review of the literature suggests that initiatives to increase the numbers of underrepresented populations in nursing are often * Corresponding author. E-mail address: [email protected] (T. Bristol).
accompanied by a myriad of challenges that could hinder a student's academic success. Students who are from underrepresented groups, disadvantaged (educationally, economically, or environmentally), and international backgrounds face unique challenges when pursuing studies in nursing education. The literature suggests challenges frequently encountered include financial issues, inadequate academic preparation before enrollment into nursing, lack of support from family, few role models or mentors, and experiences with discrimination (Loftin, Newman, Gilden, Bond, & Duman, 2013). Also students may not have the requisite preentry academic preparation such as a strong science and math background. Another predominant challenge often identified suggested that first-generation college students whose parents lack firsthand knowledge of the college experience are unable to provide the student with guidance and support needed. For example, students frequently lack sufficient financial resources to cover the expenses associated with education and living (Ferrell, DeCrane, Edwards, Folli & Tennant, 2016). An ever-increasing number of students encounter an additional challenge with language barriers because English may be an
https://doi.org/10.1016/j.teln.2019.09.001 1557-3087/© 2019 Organization for Associate Degree Nursing. Published by Elsevier Inc. All rights reserved.
T. Bristol et al. / Teaching and Learning in Nursing 15 (2020) 104e108 Table 1 Description of Participants Gender Highest degree earned
Teaching in program level
Teaching experience
Male ¼ 5% Female ¼ 95% Bachelor's degree ¼ 6% Master's degree ¼ 49% Doctoral degree ¼ 16% Other ¼ 4% Practical nursing ¼ 12% Associate degree in nursing ¼ 28% Bachelor of science in nursing ¼ 52% Graduate program ¼ 6% Other ¼ 2% 0e3 years ¼ 42% 4e6 years ¼ 44% Greater than 6 years ¼ 12%
additional language rather than the native language (Brooks Carthon, Nguyen, Pancir, & Chittams, 2015; Carter, Powell, Derouin, & Cusatis, 2015). Not surprisingly, nursing faculty, as clinicians, are often illequipped to address the challenges that accompany a student once enrolled in a nursing program. These challenges, typically referred to as the social determinants of education, serve as impediments to student success (McGill, 2016). If nursing education programs aim to increase the diversity in their student body, then it is critical that faculty are more resource-proficient to help students navigate through challenges to achieve academic success. Thus, the purpose of this article is to describe the challenges faced by students from diverse backgrounds as they pursue a nursing education and strategies faculty could use to foster success. Methodology Over 200 nurse educators gather annually for a conference focused on evidence-based teaching to promote quality learning experiences for nursing students at all levels. In 2017, a new keynote feature was added to the conference entitled “Diversity World .” The purpose of the activity was to explore the perceptions of Cafe nursing faculty who work with a diverse and at-risk student population. Six expert nurse educators and leaders shared their stories and perception of the learning environment from diverse perspectives including international students, African American students, LGBT students, Hispanic students, socioeconomically diverse students, and male students entering a predominantly female profession. The ” was repeated at the 2018 conference with a “Diversity World Cafe new audience to determine if there was consistency across groups and time. Therefore, a total of 531 nurse educators participated in the exploratory experience. Using a modified Participatory Action Research (PAR) model, the conference attendees became participants and partners in exploring the phenomena of diversity in nursing education (DeChesnay, 2014). PAR is a practical, contemporary research design that can be used effectively when the question focuses on social action and change. Results The 531 participants for this study were nurse educators registered to attend a three-day day conference held just before the start of the academic year. Consistent with the general population of nurse educators in the United States, the participants were predominately female (95%) nurse educators. The greatest percentage of the participants were master's prepared (49%) and taught in baccalaureate nursing programs (52%). Table 1 provides a description of the sample in terms of gender, years of experience as a nurse educator, type of program where the participant teaches, and the highest degree earned by the participant.
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After listening to the panel of experts, conference participants were asked to join one of six small groups, one for each diverse group represented by the expert panel. Each discussion group was asked to share their perceptions of the barriers experienced by the diverse group of students and brainstorm potential interventions or action plans to facilitate the inclusion of that group of nursing students. Discussions were limited to 15 minutes, and then the nurse educators were asked to rotate to another group to repeat the same process. Each nurse educator participated in three discussion groups addressing their perceptions related to various diverse groups of students. Color-coded worksheets were collected from each group which represented the target student nurse minority populationdinternational students, African-American students, LGBT students, Hispanic students, socioeconomically diverse students, and male students. Designated population worksheets completed in the small groups identifying the perceived barriers and potential action plans were reviewed by the diversity panel members for general themes and combined for reexamination for overarching themes. The results of participant brainstorming exercise included population-specific examples. When examined collectively, the emerging themes were consistent across all diverse populations. Four themes emerged after combining the nurse educator's perceptions of the overarching experience of diverse student populationdincreasing disparities and isolation, preparation for the pedagogical experience, limited diverse mentorship, and inadequate resources available to improve readiness. Table 2 presents each of the overarching themes and supporting data from the participants. The data were further analyzed to develop themes describing the barriers/challenges encountered by students from underrepresented students as perceived by nursing faculty. These themes included communication challenges, discrimination and isolation, and a lack of role models and diversity in academia. The second step was to generate a list of potential action plans for strategies to address each of these challenge/barrier themes. Table 3 presents a description of each challenge/barrier theme and strategies to address these themes in the classroom and clinical setting. Findings and Discussion Faculty perceptions of challenges and/or barriers experienced by an increasing diverse student population enrolled in nursing have considerable consistency whether discussing male nursing students, African-American students, LGBT students, International students with English as a second language, or the Hispanic nursing student. Four themes combining the emerged describing the nurse educator's perceptions of the overarching experience of diverse student populationdincreasing disparities and isolation, preparation for the pedagogical experience, limited diverse mentorship, and inadequate resources available to improve readiness. Increasing Disparities and Isolation Participants noted that gender influenced how certain behaviors occurred throughout the nursing programs. One revealing statement was as follows: “There is silence and invisibility, no mention of LGBT in the curriculum…” Participants noted that frequently it was difficult to place males within obstetric rotations due to societal norms. Anecdotally, participants also described situations where male students were frequently asked to provide patient lift assistance as compared to requests made of female nursing students. In the world of the male student, another noted, “A lack of men on faculty and in nursing to be role models often means there is no one to interpret ‘malenessdmale pride’ to the female faculty.” A qualitative study exploring the experience of male nurses supports this sense of disparity and
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T. Bristol et al. / Teaching and Learning in Nursing 15 (2020) 104e108
Table 2 Overall Themes From Participants Theme
Examples From Participants
Increasing disparities and isolation
Preparation for the pedagogical experience
Limited diverse mentorships
Inadequate resources to improve readiness
Culture of family (as priority) is not understood Wording and language in classroom is “foreign” when English is a second language Social normsdmale students felt it was very difficult to ask for help from an all female faculty Cultural norms not understood by faculty and other students LGBTQ struggle between visibility and vulnerability Lack of understanding of expectations Not aware of issues until they become problems Afraid to ask for help for fear of being stereotyped Examinations and other assessments were all new thereby frightening and overwhelming Reading at a higher level for English as second language students Lack of diversity of faculty Lack of diversity in clinical sites Role models are “different” and may be challenged to identify with them First-generation attending college while other family members are in jail or using drugs/alcohol Unable to navigate the financial processes for scholarships and loans. Not feeling safe to ask questions for fear of being rejected
Table 3 Challenges and Suggested Strategies Challenges
Strategies to Overcome Situation (Solutions)
Communication challenges related to cultural or gender influence on language and approaches to communication; difficulty transitioning to English language combined with the challenges of medical language and scholarly writing; and/or passive or assertive behavior congruent with culture, but not with nursing program expected outcomes.
Discrimination and isolation reported by minority students, including those with ethnic, sexual orientation, gender (male), and racial diversity.
Lack of role models/mentors and diversity in the nursing profession and the academic setting
Increased disparities (socioeconomic, social support, academic preparedness) among minority populations that create barriers to success
isolation described by participants and suggested the outcome is male nurses leaving the profession (Kronsberg, Bouret & Brett, 2018). A number of participants described how the lack of a diverse nursing workforce and nursing program faculty created feelings of being isolated from nursing peers and mentors. One participant suggested, “We need to create an atmosphere of inclusiveness.” Participants
Faculty mentoring and coaching to increase mutual understanding and merge culture or gender influence with expectations of professional nurse. Increase awareness of diversity and the related challenges to students, faculty, and related stakeholders. Pair with English-speaking students in study groups and activities, with expectation of speaking English only, proper use of grammar, and medical terminology. Provide transitional support for testing through increased time and defining or translating terminology. Create group activities that merge students learning English with those proficient in English so that all learn to communicate effectively with diverse populations. Encourage all students to learn at least one other language to enhance communications in health care. Avoid using jargon and culturally biased language in classroom and testing. Connect with role models, mentors, and support groups. Create safe places and visible signage guiding students to these places/people. Integrate learning assignments and activities that address diversity in health care providers, such as case studies, role play, and classroom discussions. Share stories of the lived experience from nurses and recipients of health care. Honor student self-identity, ask how they would describe their race, culture, or sexual identity. Facilitate environmental assessments or diversity and cultural climate. Provide education and support to faculty, staff, and students. Create social events that include family and shared foods, traditions, or stories. Examine own biases and assumptions and strive to create a supportive environment that respects all students equally. Create pathwaysdwork within the community to engage elementary, middle school, and high school students into nursing via mentorship and programming. Connect with professional organizations and support groups that enhance diversity in recruitment/retention of students, faculty, and local workforce. Connect with mentors, even if virtually. Include simulation models/manikins and scenarios inclusive of diversity. Involve students in health clinics and settings serving diverse populations. Connect student to financial resources including emergency funds. Provide support groups and role models. Create study groups and tutoring sessions that address specific disparities. Engage community resources to assist with nutrition, transportation, and childcare needs. Individualize both assessment and support strategies.
noted that often students would be matched with patients from similar ethnicities, which reduced opportunities to provide care to patients with specific clinical conditions. There were a number of examples described by the participants regarding nursing preceptors and faculty making assumptions about what would be best clinical matches based on native language of the student.
T. Bristol et al. / Teaching and Learning in Nursing 15 (2020) 104e108
With nearly 40 percent of the U.S. population identified as belonging to a different ethnic or racial group, faculty will more than likely encounter students who speak English as an additional language and not their native language (U.S. Census Bureau, 2018). Students are often challenged with language expression and comprehension, feelings of exclusion, loneliness, difficulties adjusting to the new culture, cultural practice variations, and feelings of otherness and discrimination and require assistance from the faculty in navigating the social landscape including networking and interpersonal skills (Brooks Carthon et al., 2015; Del Fabbro, Mitchell, & Shaw, 2015). When relevant colleges and universities have international offices that serve international students, nursing students should be encouraged to avail themselves of these services. One common idea offered by participants was that staff from the international office could assist faculty in learning more about the needs of international students by providing resources or professional development programs. Other minority students often expressed feelings of racial discrimination, isolation, and loneliness and indicated these feelings were impediments to their success (Coleman, 2008; Love, 2010). Nurse faculty could benefit from an improved understanding of the various minority cultures and the unique needs of students from various backgrounds including those who speak English as an additional language (Mitchell, Del Fabbro, & Shaw, 2017). It is also critical that faculty have self-awareness related to bias and how subtle messages, intentional or not, conscious or unconscious, can be detected by students. Perceived differences can have a significant impact on the student's ability to thrive in academic and social environments. Microaggressions, the subtle messages sent by body language, word choice, and behavior can be readily detected by individuals in response to difference (Sue, 2017). One tool that has been found helpful in building awareness is Harvard University's free online implicit bias test to measure one's attitude about race, gender, and sexual orientation (Project Implicit, 2011): https://implicit.harvard.edu/ implicit/takeatest.html. Faculty should strive to have a greater awareness, sensitivity, and understanding of students who are not from the predominant mainstream group, but who are from different cultural, economic, environmental, educational, and socially disadvantaged or at-risk backgrounds (Bressler, 2015). It is important to recognize that cultural and gender sensitivity is a continuous process, not a one-time event. There are many professional development or continuing education programs available to faculty which are designed to increase diversity awareness and sensitivity. The term “cultural agility” refers to the cognitive capability to see situations through different, even conflicting cultural lenses (Aoun, 2017). Cultural agility goes beyond an awareness of other cultures but teaches faculty and students to appreciate the varying understandings and values that people from different cultures bring to an institution (Bressler, 2015). Various forms of communication and language barriers were a challenge depending on the specific minority population discussion. Participants shared real-world examples where the English language was a recognized barrier for International and Hispanic students. For example, not knowing the intent of definitions and/or word context during examinations and/or clinical patient contact. The ability to understand context and intent was further complicated by the need to understand medical terminology and the requirements of scholarly writing that is native to the United States. Preparation for the Pedagogical Experience Findings from this project support the literature in that the participants' action plan recommended increasing academic enrichment opportunities such as study skills sessions, time management sessions, writing laboratories, and peer interaction groups as helpful strategies in addressing gaps in the students' academic preparedness (Murray, Pole, Ciarlo, & Holmes, 2016). Data from this project suggest
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that faculty perceived significant gaps in the preprogram preparation to help diverse students succeed in nursing programs. Gaps in preentry preparation programs are often addressed through bridge or immersion programs. Bridge or immersion programs provide students with informative sessions related to the academic, social, and financial preparation needed for college (DeWitty, Huerta, & Downing, 2016; Pritchard et al., 2016). The programs have been effective in increasing the student's academic preparation before entry, providing socialization opportunities and helping students become more aware of the expectations and diligence required for success (Gillespie, Pritchard, Bankston, Burno, & Glazer, 2017). In addition, these programs focus on activities to increase organizational and time management skills as priorities for socializing students toward success (Wros & May, 2013). In the absence of academic enrichment programs, faculty members find themselves attempting to help students compensate for inadequate preparation by providing tutoring services, study skills sessions, and teaching students test-taking strategies on an individual basis. These activities can consume a great deal of the faculty member's time to the extent that many schools have found it helpful to employ a retention coach to work with students to enhance the academic skills and direct them to additional academic support resources (Aoun, 2017; Loftin, et al., 2013). Limited Diverse Mentorships Participants emphasized what is noted in the literature, mentors can provide additional support and advocacy for students (McBride, Campbell, Woods, & Manson, 2017). A consistent perception among participants is that the lack of a diverse nursing workforce is a significant barrier for students from a diverse background. Without “seeing” someone like themselves, students struggle with envisioning that they can successfully become a nurse. Participants indicated that the diverse mentoring programs available through groups such as Hispanic or African-American nurses' organizations are helpful, and there are not adequate numbers to meet the needs of the student population. Bannister, Bowen-Brady, and Winfrey (2014) found that the mentoring process can enable nursing students to become more comfortable with the student nurse role and enhance the professional values, skills, and knowledge inherent within the role. In addition, research notes that students have an expectation that mentors have the ability to build individual relationship and teach mentee's the “tricks of the trade” (Payton, Howe, Timmons, & Richardson, 2013). Many faculty members do not understand the need for disadvantaged or minority students to have people in the academic environment who look like them and can relate to their specific experiences (Loftin, et al., 2013). Therefore, some faculty become lost when faced with the complexities associated with disadvantage. Faculty members, just as students, may need to develop a network of individuals to help them address the myriad of challenges associated with disadvantage. Limited diversity within the organizational, professional, and academic settings was a recurring theme. Participants also noted that simulation and clinical exercises were predominantly Caucasian based and lacked cultural sensitivity. Again, many misunderstandings and missed opportunities were accentuated due to a lack of cultural sensitivity due to generational and disparate mental models between students, faculty, health care professionals, patients, and the public at large. Inadequate Resources to Improve Readiness Inadequate financial resources have been identified as a constant burden for students across all sectors. Participants felt that this was
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T. Bristol et al. / Teaching and Learning in Nursing 15 (2020) 104e108
even more of a significant issue for minority, at-risk, or disadvantaged students. Oftentimes, students from diverse backgrounds are also disadvantaged economically and ill-prepared for the costs of a college education (Brooks Carthon, et al., 2015). To effectively guide and mentor students, it is important for faculty to have an awareness of the financial resources (scholarships, grants, and loans) that are available to students and encourage students to avail themselves of these resources. In addition, resources dedicated to improve nursing faculty readiness to teach a diverse and global student community continue to be problematic. Academic institutions continue to struggle in recruiting and retaining diverse faculty that is representative of the student population. In many cases, mentorship training and resources are also limited in academic institutions. Participants discussed the widening diversity divide in many clinical and pedagogical settings. A number of respondents described ineffective communication and outreach strategies that support student success. Examples included lack of resources to address social determinants of educational and professional success. It was evident that there was insufficient stakeholder outreach and engagement to understand barriers to success. Conclusion In summary, the findings from this study suggest that nursing faculty are challenged with providing structured opportunities to prepare diverse student groups for the rigor of a nursing program. Building awareness is a fundamental intervention in improving how prepared faculty are to meet the needs of students. Other strategies include learning and study strategies, time management skills, as well as mentoring and leadership development. For optimal success in the recruitment, retention, and graduation of students from diverse backgrounds, there must be a clear communication of expectations; the provision of academic, social, and financial supports; connection with administrators, faculty, and staff that includes the provision of timely feedback, involvement, and guidance (Ferrell & Decrane, 2016) References Aoun, J. E. (2017). Robot-proof: Higher education in the age of artificial intelligence. Cambridge, MA: The MIT Press. Banister, G., Bowen-Brady, H. M., & Winfrey, M. E. (2014). Using career nurse mentors to support minority nursing students and facilitate their transition to practice. Journal of Professional Nursing, 30(4), 317e325. https://doi.org/10.1016/ j.profnurs.2013.11.001. Bressler, T. (2015). The lived experience of observant Jewish nursing students: A phenomenological study (Doctoral dissertation, Molloy College). Retrieved from https://digitalcommons.molloy.edu/cgi/viewcontent.cgi? article¼1026&context¼etd. Brooks Carthon, J. M., Nguyen, T.-H., Pancir, D., & Chittams, J. (2015). Enrollment of underrepresented minorities in nursing majors: A cross sectional analysis of U.S.
nursing schools. Nurse Education Today, 35(11), 1102e1107. https://doi.org/ 10.1016/j.nedt.2015.06.007. Carter, B. M., Powell, D. L., Derouin, A. L., & Cusatis, J. (2015). Beginning with the end in mind: Cultivating minority nurse leaders. Journal of Professional Nursing, 31(2), 95e103. https://doi.org/10.1016/j.profnurs.2014.07.004. Coleman, L. D. (2008). Experiences of African American students in a predominantly white, two-year nursing program. The ABNF Journal, 19(1), 8e13. DeChesnay, M. (2014). Nursing research using participatory action research: Qualitative designs and methods in nursing. New York: Springer. Del Fabbro, L., Mitchell, C., & Shaw, J. (2015). Learning among nursing faculty: Insights from a participatory action research project about teaching international students. Journal of Nursing Education, 54(3), 153e158. https://doi.org/10.3928/0148483420150218-12. DeWitty, V. P., Huerta, C. G., & Downing, C. A. (2016). New careers in nursing: Optimizing diversity and student success for the future of nursing. Journal of Professional Nursing, 32(5), S4eS13. https://doi.org/10.1016/j.profnurs.2016.03.011. Ferrell, D., & Decrane, S. (2016). S.O.S. (Students’ Optimal Success): A model for institutional action to support minority nursing students. Journal of Cultural Diversity, 23(2), 39e45. Ferrell, D. K., DeCrane, S. K., Edwards, N., Foli, K. J., & Tennant, K. F. (2016). Minority undergraduate nursing student success. Journal of Cultural Diversity, 23(1), 3e11. Gillespie, G. L., Pritchard, T., Bankston, K., Burno, J., & Glazer, G. (2017). An evaluation of forums for discussions on inclusion in a college of nursing. Nursing Outlook, 65(1), 103e115. https://doi.org/10.1016/j.outlook.2016.08.002. Kronsberg, S., Bouret, J. R., & Brett, A. L. (2018). Lived experiences of male nurses: Dire consequences for the nursing profession. Journal of Nursing Education and Practice, 8(1), 46e53. Loftin, C., Newman, S. D., Gilden, G., Bond, M. L., & Dumas, B. P. (2013). Moving toward greater diversity: A review of interventions to increase diversity in nursing education. Journal of Transcultural Nursing, 24(4), 387e396. https://doi.org/10.1177/ 1043659613481677. Love, K. L. (2010). The lived experience of socialization among African American nursing students in a predominantly white university. Journal of Transcultural Nursing, 21(4), 342e350. https://doi.org/10.1177/ 1043659609360711. McBride, A. B., Campbell, J., Woods, N. F., & Manson, S. M. (2017). Building a mentoring network. Nursing Outlook, 65(3), 305e314. https://doi.org/10.1016/ j.outlook.2016.12.001. McGill, N. (2016). Education attainment linked to health throughout lifespan: Exploring social determinants of health. The Nation’s Health, 46(6), 1e19. Retrieved from http://thenationshealth.aphapublications.org/content/46/6/1.3. Mitchell, C., Del Fabbro, L., & Shaw, J. (2017). The acculturation, language and learning experiences of international nursing students: Implications for nursing education. Nurse Education Today, 56, 16e22. https://doi.org/10.1016/ j.nedt.2017.05.019. Murray, T., Pole, D., Ciarlo, E., & Holmes, S. (2016). A nursing workforce diversity project: Strategies for recruitment, retention, graduation, and NCLEX-RN success. Nursing Education Perspectives, 37(93), 138e143. Payton, T. D., Howe, L. A., Timmons, S. M., & Richardson, E. M. (2013). African American nursing students’ perceptions about mentoring. Nursing Education Perspectives, 34(3), 173e177. https://doi.org/10.1097/00024776-201305000-00008. Pritchard, T. J., Perazzo, J. D., Holt, J. A., Fishback, B. P., McLaughlin, M., Bankston, K. D., & Glazer, G. (2016). Evaluation of a summer bridge: Critical component of the Leadership 2.0 Program. Journal of Nursing Education, 55(4), 196e202. https://doi.org/ 10.3928/01484834-20160316-03. Project Implicit. (2011). Project Implicit bias test. Retrieved from https://implicit.harvard. edu/implicit/takeatest.html. Sue, D. W. (2017). Microaggressions and “evidence.” Perspectives on Psychological Science, 12(1), 170e172. https://doi.org/10.1177/1745691616664437. United States Census Bureau. (2018). Race. Retrieved from http://www.census.gov/ topics/population/race/about.html. Wros, P., & May, B. A. (2013). Creating and sustaining a diverse student community in a school of nursing. Hispanic Health Care International, 11(3), 131e141. https://doi.org/ 10.1891/1540-4153.11.3.131.
Contents lists available at ScienceDirect
Teaching and Learning in Nursing j o u r n a l h o m e p a g e : w w w. j o u r n a l s. e l s ev i e r. c o m / teaching-and-learning-in-nursing
Educate, Excite, Engage
Nursing Faculty Readiness for Student Diversity Tim Bristol, PhD, RN, ANEF, FAAN a,*, Anne Brett, PhD, RN b, Jose Alejandro, PhD, RN, FAAN c, Jessie Colin, PhD, RN, FRE, FAAN d, Teri Murray, PhD, APHN-BC, RN, FAAN e, Virginia Wangerin, PhD, MSN, RN, CNE f, Raney Linck, DNP, RN g, Deidre Walton, JD, MSN, RN h a
School of Nursing, Walden University, Minneapolis, MN School of Nursing, College of Doctoral Studies, University of Phoenix, Phoenix, AZ Mount St. Mary’s University e Los Angeles and University of California Irvine (UCI) Health System, Los Angeles, CA d College of Nursing and Health Sciences, Barry University, Miami Shores, FL e Saint Louis University School of Nursing, St. Louis, MO f College of Human Sciences, Iowa State University, Ames, IA g School of Nursing, University of Minnesota, Minneapolis, MN h Past President, National Black Nurses Association, Washington, DC b c
a r t i c l e
i n f o
Article history: Accepted 2 September 2019 Keywords: Nursing Nursing student Participatory action research African-American Hispanic LGBTQ
a b s t r a c t Using a modified Participatory Action Research model, 531 participants attending a nurse educators' conference spent three hours doing immersive collaborative work to identify perceived barriers experienced by diverse student groups and create strategies for educators to address perceived challenges related to diversity. Initially, six diverse speakers representing minority or underrepresented populations (such as Hispanic, African-American, LGBTQ, International, and other diverse student populations) in nursing education briefly shared their stories and experiences as a student and/or nurse being from an underrepresented group. After the presentation, the participants/nurse educators participated in rotating small groups through a World Cafe model to generate (a) perceived themes around common challenges and barriers faced and (b) practical strategies to facilitate inclusion of students from various diverse populations. The goal of the work was to enhance nurse faculty's readiness for student diversity in the classroom and clinical setting. © 2019 Organization for Associate Degree Nursing. Published by Elsevier Inc. All rights reserved.
Nursing faculty continue to experience issues specific to meeting the needs of an increasingly diverse and global community of students. For two consecutive years, during an annual nurse educator conference, readiness for student diversity was explored using a format that provided an opportunity to engage over 531 World Cafe conference participants in a conversation about what diversity issues they have encountered, perceived challenges or barriers experienced by students from diverse population, and potential strategies that could be deployed. The hope was this experience would be the beginning of a conversation that could be continued at the participant's respective nursing programs.
Literature Review A review of the literature suggests that initiatives to increase the numbers of underrepresented populations in nursing are often * Corresponding author. E-mail address: [email protected] (T. Bristol).
accompanied by a myriad of challenges that could hinder a student's academic success. Students who are from underrepresented groups, disadvantaged (educationally, economically, or environmentally), and international backgrounds face unique challenges when pursuing studies in nursing education. The literature suggests challenges frequently encountered include financial issues, inadequate academic preparation before enrollment into nursing, lack of support from family, few role models or mentors, and experiences with discrimination (Loftin, Newman, Gilden, Bond, & Duman, 2013). Also students may not have the requisite preentry academic preparation such as a strong science and math background. Another predominant challenge often identified suggested that first-generation college students whose parents lack firsthand knowledge of the college experience are unable to provide the student with guidance and support needed. For example, students frequently lack sufficient financial resources to cover the expenses associated with education and living (Ferrell, DeCrane, Edwards, Folli & Tennant, 2016). An ever-increasing number of students encounter an additional challenge with language barriers because English may be an
https://doi.org/10.1016/j.teln.2019.09.001 1557-3087/© 2019 Organization for Associate Degree Nursing. Published by Elsevier Inc. All rights reserved.
T. Bristol et al. / Teaching and Learning in Nursing 15 (2020) 104e108 Table 1 Description of Participants Gender Highest degree earned
Teaching in program level
Teaching experience
Male ¼ 5% Female ¼ 95% Bachelor's degree ¼ 6% Master's degree ¼ 49% Doctoral degree ¼ 16% Other ¼ 4% Practical nursing ¼ 12% Associate degree in nursing ¼ 28% Bachelor of science in nursing ¼ 52% Graduate program ¼ 6% Other ¼ 2% 0e3 years ¼ 42% 4e6 years ¼ 44% Greater than 6 years ¼ 12%
additional language rather than the native language (Brooks Carthon, Nguyen, Pancir, & Chittams, 2015; Carter, Powell, Derouin, & Cusatis, 2015). Not surprisingly, nursing faculty, as clinicians, are often illequipped to address the challenges that accompany a student once enrolled in a nursing program. These challenges, typically referred to as the social determinants of education, serve as impediments to student success (McGill, 2016). If nursing education programs aim to increase the diversity in their student body, then it is critical that faculty are more resource-proficient to help students navigate through challenges to achieve academic success. Thus, the purpose of this article is to describe the challenges faced by students from diverse backgrounds as they pursue a nursing education and strategies faculty could use to foster success. Methodology Over 200 nurse educators gather annually for a conference focused on evidence-based teaching to promote quality learning experiences for nursing students at all levels. In 2017, a new keynote feature was added to the conference entitled “Diversity World .” The purpose of the activity was to explore the perceptions of Cafe nursing faculty who work with a diverse and at-risk student population. Six expert nurse educators and leaders shared their stories and perception of the learning environment from diverse perspectives including international students, African American students, LGBT students, Hispanic students, socioeconomically diverse students, and male students entering a predominantly female profession. The ” was repeated at the 2018 conference with a “Diversity World Cafe new audience to determine if there was consistency across groups and time. Therefore, a total of 531 nurse educators participated in the exploratory experience. Using a modified Participatory Action Research (PAR) model, the conference attendees became participants and partners in exploring the phenomena of diversity in nursing education (DeChesnay, 2014). PAR is a practical, contemporary research design that can be used effectively when the question focuses on social action and change. Results The 531 participants for this study were nurse educators registered to attend a three-day day conference held just before the start of the academic year. Consistent with the general population of nurse educators in the United States, the participants were predominately female (95%) nurse educators. The greatest percentage of the participants were master's prepared (49%) and taught in baccalaureate nursing programs (52%). Table 1 provides a description of the sample in terms of gender, years of experience as a nurse educator, type of program where the participant teaches, and the highest degree earned by the participant.
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After listening to the panel of experts, conference participants were asked to join one of six small groups, one for each diverse group represented by the expert panel. Each discussion group was asked to share their perceptions of the barriers experienced by the diverse group of students and brainstorm potential interventions or action plans to facilitate the inclusion of that group of nursing students. Discussions were limited to 15 minutes, and then the nurse educators were asked to rotate to another group to repeat the same process. Each nurse educator participated in three discussion groups addressing their perceptions related to various diverse groups of students. Color-coded worksheets were collected from each group which represented the target student nurse minority populationdinternational students, African-American students, LGBT students, Hispanic students, socioeconomically diverse students, and male students. Designated population worksheets completed in the small groups identifying the perceived barriers and potential action plans were reviewed by the diversity panel members for general themes and combined for reexamination for overarching themes. The results of participant brainstorming exercise included population-specific examples. When examined collectively, the emerging themes were consistent across all diverse populations. Four themes emerged after combining the nurse educator's perceptions of the overarching experience of diverse student populationdincreasing disparities and isolation, preparation for the pedagogical experience, limited diverse mentorship, and inadequate resources available to improve readiness. Table 2 presents each of the overarching themes and supporting data from the participants. The data were further analyzed to develop themes describing the barriers/challenges encountered by students from underrepresented students as perceived by nursing faculty. These themes included communication challenges, discrimination and isolation, and a lack of role models and diversity in academia. The second step was to generate a list of potential action plans for strategies to address each of these challenge/barrier themes. Table 3 presents a description of each challenge/barrier theme and strategies to address these themes in the classroom and clinical setting. Findings and Discussion Faculty perceptions of challenges and/or barriers experienced by an increasing diverse student population enrolled in nursing have considerable consistency whether discussing male nursing students, African-American students, LGBT students, International students with English as a second language, or the Hispanic nursing student. Four themes combining the emerged describing the nurse educator's perceptions of the overarching experience of diverse student populationdincreasing disparities and isolation, preparation for the pedagogical experience, limited diverse mentorship, and inadequate resources available to improve readiness. Increasing Disparities and Isolation Participants noted that gender influenced how certain behaviors occurred throughout the nursing programs. One revealing statement was as follows: “There is silence and invisibility, no mention of LGBT in the curriculum…” Participants noted that frequently it was difficult to place males within obstetric rotations due to societal norms. Anecdotally, participants also described situations where male students were frequently asked to provide patient lift assistance as compared to requests made of female nursing students. In the world of the male student, another noted, “A lack of men on faculty and in nursing to be role models often means there is no one to interpret ‘malenessdmale pride’ to the female faculty.” A qualitative study exploring the experience of male nurses supports this sense of disparity and
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Table 2 Overall Themes From Participants Theme
Examples From Participants
Increasing disparities and isolation
Preparation for the pedagogical experience
Limited diverse mentorships
Inadequate resources to improve readiness
Culture of family (as priority) is not understood Wording and language in classroom is “foreign” when English is a second language Social normsdmale students felt it was very difficult to ask for help from an all female faculty Cultural norms not understood by faculty and other students LGBTQ struggle between visibility and vulnerability Lack of understanding of expectations Not aware of issues until they become problems Afraid to ask for help for fear of being stereotyped Examinations and other assessments were all new thereby frightening and overwhelming Reading at a higher level for English as second language students Lack of diversity of faculty Lack of diversity in clinical sites Role models are “different” and may be challenged to identify with them First-generation attending college while other family members are in jail or using drugs/alcohol Unable to navigate the financial processes for scholarships and loans. Not feeling safe to ask questions for fear of being rejected
Table 3 Challenges and Suggested Strategies Challenges
Strategies to Overcome Situation (Solutions)
Communication challenges related to cultural or gender influence on language and approaches to communication; difficulty transitioning to English language combined with the challenges of medical language and scholarly writing; and/or passive or assertive behavior congruent with culture, but not with nursing program expected outcomes.
Discrimination and isolation reported by minority students, including those with ethnic, sexual orientation, gender (male), and racial diversity.
Lack of role models/mentors and diversity in the nursing profession and the academic setting
Increased disparities (socioeconomic, social support, academic preparedness) among minority populations that create barriers to success
isolation described by participants and suggested the outcome is male nurses leaving the profession (Kronsberg, Bouret & Brett, 2018). A number of participants described how the lack of a diverse nursing workforce and nursing program faculty created feelings of being isolated from nursing peers and mentors. One participant suggested, “We need to create an atmosphere of inclusiveness.” Participants
Faculty mentoring and coaching to increase mutual understanding and merge culture or gender influence with expectations of professional nurse. Increase awareness of diversity and the related challenges to students, faculty, and related stakeholders. Pair with English-speaking students in study groups and activities, with expectation of speaking English only, proper use of grammar, and medical terminology. Provide transitional support for testing through increased time and defining or translating terminology. Create group activities that merge students learning English with those proficient in English so that all learn to communicate effectively with diverse populations. Encourage all students to learn at least one other language to enhance communications in health care. Avoid using jargon and culturally biased language in classroom and testing. Connect with role models, mentors, and support groups. Create safe places and visible signage guiding students to these places/people. Integrate learning assignments and activities that address diversity in health care providers, such as case studies, role play, and classroom discussions. Share stories of the lived experience from nurses and recipients of health care. Honor student self-identity, ask how they would describe their race, culture, or sexual identity. Facilitate environmental assessments or diversity and cultural climate. Provide education and support to faculty, staff, and students. Create social events that include family and shared foods, traditions, or stories. Examine own biases and assumptions and strive to create a supportive environment that respects all students equally. Create pathwaysdwork within the community to engage elementary, middle school, and high school students into nursing via mentorship and programming. Connect with professional organizations and support groups that enhance diversity in recruitment/retention of students, faculty, and local workforce. Connect with mentors, even if virtually. Include simulation models/manikins and scenarios inclusive of diversity. Involve students in health clinics and settings serving diverse populations. Connect student to financial resources including emergency funds. Provide support groups and role models. Create study groups and tutoring sessions that address specific disparities. Engage community resources to assist with nutrition, transportation, and childcare needs. Individualize both assessment and support strategies.
noted that often students would be matched with patients from similar ethnicities, which reduced opportunities to provide care to patients with specific clinical conditions. There were a number of examples described by the participants regarding nursing preceptors and faculty making assumptions about what would be best clinical matches based on native language of the student.
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With nearly 40 percent of the U.S. population identified as belonging to a different ethnic or racial group, faculty will more than likely encounter students who speak English as an additional language and not their native language (U.S. Census Bureau, 2018). Students are often challenged with language expression and comprehension, feelings of exclusion, loneliness, difficulties adjusting to the new culture, cultural practice variations, and feelings of otherness and discrimination and require assistance from the faculty in navigating the social landscape including networking and interpersonal skills (Brooks Carthon et al., 2015; Del Fabbro, Mitchell, & Shaw, 2015). When relevant colleges and universities have international offices that serve international students, nursing students should be encouraged to avail themselves of these services. One common idea offered by participants was that staff from the international office could assist faculty in learning more about the needs of international students by providing resources or professional development programs. Other minority students often expressed feelings of racial discrimination, isolation, and loneliness and indicated these feelings were impediments to their success (Coleman, 2008; Love, 2010). Nurse faculty could benefit from an improved understanding of the various minority cultures and the unique needs of students from various backgrounds including those who speak English as an additional language (Mitchell, Del Fabbro, & Shaw, 2017). It is also critical that faculty have self-awareness related to bias and how subtle messages, intentional or not, conscious or unconscious, can be detected by students. Perceived differences can have a significant impact on the student's ability to thrive in academic and social environments. Microaggressions, the subtle messages sent by body language, word choice, and behavior can be readily detected by individuals in response to difference (Sue, 2017). One tool that has been found helpful in building awareness is Harvard University's free online implicit bias test to measure one's attitude about race, gender, and sexual orientation (Project Implicit, 2011): https://implicit.harvard.edu/ implicit/takeatest.html. Faculty should strive to have a greater awareness, sensitivity, and understanding of students who are not from the predominant mainstream group, but who are from different cultural, economic, environmental, educational, and socially disadvantaged or at-risk backgrounds (Bressler, 2015). It is important to recognize that cultural and gender sensitivity is a continuous process, not a one-time event. There are many professional development or continuing education programs available to faculty which are designed to increase diversity awareness and sensitivity. The term “cultural agility” refers to the cognitive capability to see situations through different, even conflicting cultural lenses (Aoun, 2017). Cultural agility goes beyond an awareness of other cultures but teaches faculty and students to appreciate the varying understandings and values that people from different cultures bring to an institution (Bressler, 2015). Various forms of communication and language barriers were a challenge depending on the specific minority population discussion. Participants shared real-world examples where the English language was a recognized barrier for International and Hispanic students. For example, not knowing the intent of definitions and/or word context during examinations and/or clinical patient contact. The ability to understand context and intent was further complicated by the need to understand medical terminology and the requirements of scholarly writing that is native to the United States. Preparation for the Pedagogical Experience Findings from this project support the literature in that the participants' action plan recommended increasing academic enrichment opportunities such as study skills sessions, time management sessions, writing laboratories, and peer interaction groups as helpful strategies in addressing gaps in the students' academic preparedness (Murray, Pole, Ciarlo, & Holmes, 2016). Data from this project suggest
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that faculty perceived significant gaps in the preprogram preparation to help diverse students succeed in nursing programs. Gaps in preentry preparation programs are often addressed through bridge or immersion programs. Bridge or immersion programs provide students with informative sessions related to the academic, social, and financial preparation needed for college (DeWitty, Huerta, & Downing, 2016; Pritchard et al., 2016). The programs have been effective in increasing the student's academic preparation before entry, providing socialization opportunities and helping students become more aware of the expectations and diligence required for success (Gillespie, Pritchard, Bankston, Burno, & Glazer, 2017). In addition, these programs focus on activities to increase organizational and time management skills as priorities for socializing students toward success (Wros & May, 2013). In the absence of academic enrichment programs, faculty members find themselves attempting to help students compensate for inadequate preparation by providing tutoring services, study skills sessions, and teaching students test-taking strategies on an individual basis. These activities can consume a great deal of the faculty member's time to the extent that many schools have found it helpful to employ a retention coach to work with students to enhance the academic skills and direct them to additional academic support resources (Aoun, 2017; Loftin, et al., 2013). Limited Diverse Mentorships Participants emphasized what is noted in the literature, mentors can provide additional support and advocacy for students (McBride, Campbell, Woods, & Manson, 2017). A consistent perception among participants is that the lack of a diverse nursing workforce is a significant barrier for students from a diverse background. Without “seeing” someone like themselves, students struggle with envisioning that they can successfully become a nurse. Participants indicated that the diverse mentoring programs available through groups such as Hispanic or African-American nurses' organizations are helpful, and there are not adequate numbers to meet the needs of the student population. Bannister, Bowen-Brady, and Winfrey (2014) found that the mentoring process can enable nursing students to become more comfortable with the student nurse role and enhance the professional values, skills, and knowledge inherent within the role. In addition, research notes that students have an expectation that mentors have the ability to build individual relationship and teach mentee's the “tricks of the trade” (Payton, Howe, Timmons, & Richardson, 2013). Many faculty members do not understand the need for disadvantaged or minority students to have people in the academic environment who look like them and can relate to their specific experiences (Loftin, et al., 2013). Therefore, some faculty become lost when faced with the complexities associated with disadvantage. Faculty members, just as students, may need to develop a network of individuals to help them address the myriad of challenges associated with disadvantage. Limited diversity within the organizational, professional, and academic settings was a recurring theme. Participants also noted that simulation and clinical exercises were predominantly Caucasian based and lacked cultural sensitivity. Again, many misunderstandings and missed opportunities were accentuated due to a lack of cultural sensitivity due to generational and disparate mental models between students, faculty, health care professionals, patients, and the public at large. Inadequate Resources to Improve Readiness Inadequate financial resources have been identified as a constant burden for students across all sectors. Participants felt that this was
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even more of a significant issue for minority, at-risk, or disadvantaged students. Oftentimes, students from diverse backgrounds are also disadvantaged economically and ill-prepared for the costs of a college education (Brooks Carthon, et al., 2015). To effectively guide and mentor students, it is important for faculty to have an awareness of the financial resources (scholarships, grants, and loans) that are available to students and encourage students to avail themselves of these resources. In addition, resources dedicated to improve nursing faculty readiness to teach a diverse and global student community continue to be problematic. Academic institutions continue to struggle in recruiting and retaining diverse faculty that is representative of the student population. In many cases, mentorship training and resources are also limited in academic institutions. Participants discussed the widening diversity divide in many clinical and pedagogical settings. A number of respondents described ineffective communication and outreach strategies that support student success. Examples included lack of resources to address social determinants of educational and professional success. It was evident that there was insufficient stakeholder outreach and engagement to understand barriers to success. Conclusion In summary, the findings from this study suggest that nursing faculty are challenged with providing structured opportunities to prepare diverse student groups for the rigor of a nursing program. Building awareness is a fundamental intervention in improving how prepared faculty are to meet the needs of students. Other strategies include learning and study strategies, time management skills, as well as mentoring and leadership development. For optimal success in the recruitment, retention, and graduation of students from diverse backgrounds, there must be a clear communication of expectations; the provision of academic, social, and financial supports; connection with administrators, faculty, and staff that includes the provision of timely feedback, involvement, and guidance (Ferrell & Decrane, 2016) References Aoun, J. E. (2017). Robot-proof: Higher education in the age of artificial intelligence. Cambridge, MA: The MIT Press. Banister, G., Bowen-Brady, H. M., & Winfrey, M. E. (2014). Using career nurse mentors to support minority nursing students and facilitate their transition to practice. Journal of Professional Nursing, 30(4), 317e325. https://doi.org/10.1016/ j.profnurs.2013.11.001. Bressler, T. (2015). The lived experience of observant Jewish nursing students: A phenomenological study (Doctoral dissertation, Molloy College). Retrieved from https://digitalcommons.molloy.edu/cgi/viewcontent.cgi? article¼1026&context¼etd. Brooks Carthon, J. M., Nguyen, T.-H., Pancir, D., & Chittams, J. (2015). Enrollment of underrepresented minorities in nursing majors: A cross sectional analysis of U.S.
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