The health outcomes of African Americans, a growing part of the US population (Humes, Jones, & Ramirez, 2011), are negatively influenced by racism, historic oppression, and consequent perceptions of mistrust of health care providers (Williams & Mohammed, 2009). Fear of medicine prevents some African Americans from seeking health care when needed (Washington, 2006). A racially integrated health care workforce within a culturally equitable and sensitive environment can lead to improved health outcomes in the African American population (National Center for Cultural Competence, 2004).
Nurses are the largest segment of the health care workforce, yet only 6.2 percent of registered nurses in 2017 identified as African American (Smiley et al., 2019); in contrast, 13.4 percent of the US population identified as African American in 2017 (US Department of Commerce, 2017). Of more significant concern, African American students do not persist to graduation- as well as European American students and other ethnic minority students (American Association of Colleges of Nursing, 2013). Despite offering important, meaningful, and economically secure work, nursing does not attract or retain an adequate number of African American students to provide an inclusive environment to meet the health care demands of the US population.
Race is a social and political construct based on the subjective identities of self and others (Perez & Hirschman, 2009). Racial identity is determined by family and community socialization with institutional and political influences (Perez & Hirschman, 2009). In the United States, the racial hierarchy is controlled and maintained by European Americans (Williams & Mohammed, 2009). In nursing education, the predominance of European American faculty minimizes the viewpoints of minorities (Hassouneh, 2008), which fails to acknowledge the structural inequalities that contribute to health disparities (Thorne, 2017). Improving the recruitment and retention of African American nurses is an important step toward open dialogue among nurses about the impact of the social influences of race and ethnicity on health and illness (Hall & Fields, 2013).
Prior research has shown that African American nursing students in predominately European American schools of nursing reported feeling isolated, awkward, uncomfortable, and othered (Payton, Howe, Timmons, & Richardson, 2013). African American students were sometimes excluded from important conversations, social groups, and cliques (Kosowski, Grams, Taylor, & Wilson, 2001); they also reported microaggressions and overt gestures of disapproval from peers, for example, eye rolling and sighing (Robinson, 2013). Some African American nursing students resolved the loneliness that they experienced by “sticking together” with other African American nursing students (Love, 2010, p. 346). Others experienced a tension between wanting to be with other African Americans and wanting to join the social groups of European American nursing students (Dapremont, 2011).
Some African American nursing students reported that faculty did not provide them with the same clinical experiences as European American students and were less willing to help them (Robinson, 2013). They reported feeling judged, believed others saw them as stupid, and felt they were “sitting on pins and needles” while in school (Love, 2010, p. 346). Discrimination and racism from faculty members were especially difficult because faculty held the power to pass or fail them (Love, 2010).
The unequal power dynamic between all students and faculty is further intensified for African American students in US society, where European Americans possess greater social and economic power (Sue, Torino, Capodilupo, Rivera, & Lin 2009). Researchers of African American students use methods that acknowledge, deconstruct, and transform power dynamics such as personal narratives or storytelling (Delgado & Stefancic, 2017); qualitative description (Im, Page, Lin, Tsai, & Cjeng, 2004; Merton, 1975); and QuantCrit, a method specific to critical race theory (Garcia, Lópex, & Vélex, 2017). Stories provide language that helps to understand the lives of others, helping to bridge the gaps that exist among those with different life experiences and worldviews (Delgado & Stefancic, 2017).
Prior research about African American students has been limited by data collected during nursing school or a focus on a specific aspect of the experience. This study sought to elicit retrospective stories from study participants to determine the experiences most meaningful to them. Retrospective stories represent an understanding of events that cannot be explained while experiencing them (Sandelowski, 1991), permitting study participants to reflect, interpret, and understand the total nursing school experience and elicit the most salient stories.
The aim of this study was to explore the experiences of African American nurses who recently graduated from a predominately European American prelicensure program. The data were collected for a doctoral study that described the experiences of standing out for African American nursing students (White, 2018). An African American research assistant (RA) during each stage of data analysis provided a new viewpoint to examine the data, leading to a secondary analysis of the data. Two research questions were asked for the secondary analysis: 1) How do recent graduates describe the experiences of being African American students in predominately European American prelicensure schools of nursing? 2) What meaning did those experiences have for recent African American prelicensure students?
Qualitative descriptive methods were used to answer the research questions. The participants provided an emic view of nursing school to immerse the research team in the African American perspective; the team assumed that participants were experts at perceiving racially motivated experiences and trusted their perceptions. White (2018) describes the sampling methods in further detail.
The sample included nurses who self-identified as African American, graduated within the last 10 years from predominately European American nursing program, and were born in the United States. Participants signed up for the study using an electronic survey, choosing a pseudonym for themselves to keep the participant and the nursing program unknown to the research team. Of 35 people who responded to the recruitment, 14 were interviewed who attended nursing school in six different states; most graduated within six years of the interview.
The study was approved and deemed exempt from the institutional review board at Indiana University. Participants read a study information sheet prior to scheduling a phone interview. One-time phone interviews were conducted for 30 to 90 minutes by the primary investigator (PI) during 2015. Semistructured interviews allowed participants to configure the interview as recommended by Lincoln and Guba (1985). The PI used open-ended questions, interview probes, and follow-up questions to elicit the stories most important to the participants. Data were determined to be saturated when they provided redundancy among the interviews (Braun & Clark, 2006). The research team focused on the prevalent stories provided by the study participants. Four planned questions were used for all interviews:
- Please describe what it was like to be a nursing student.
- What advice would you give an African American student beginning in your program in the next few weeks?
- What else is important for me to know about your nursing school experiences?
- Is there anything that I didn’t ask you that I should have?
The interviews were digitally recorded and transcribed verbatim with identifiers removed for data analysis. Data were coded after each interview to guide future interview probes and to determine data saturation as determined by the original research committee. The PI, who is European American, interviewed the participants. Two RAs assisted with data analysis: a European American nursing PhD student and an African American staff nurse. The African American RA assisted with language and cultural interpretation to minimize European American bias and assure an accurate reflection of the data as suggested by Hennink (2008).
The team read the interviews to immerse themselves in the data and coded data by hand. Codes were discussed and sorted into potential themes, identifying contrary stories. Two dichotomous themes were identified. A thematic map of the overarching themes and subthemes was created, depicting their relationships. The map, themes, and subthemes were revised multiple times until a clear pattern was formed that accurately captured the data within and across interviews. Verbatim participant quotes were chosen as exemplars of each theme and subtheme. A literature review of African American mistrust and trust in higher education was completed during thematic analysis.
Data collection and analysis were determined to be credible and dependable through reflexivity, audit and transparency, inconsistent case analysis, and member check as recommended by Lincoln and Guba (1985). An audit trail of data analysis was recorded during the research process via team meeting notes and a research journal. Study findings were confirmed when presented to African American professional nurses and faculty members. Participants were not available to validate secondary data analysis findings.
Two key paradoxical themes across the transcripts were mistrust and trust of European American faculty members. The stories of mistrust and trust captured an important element of the consequences of interacting with European American faculty. When described by participants, both themes were discussed extensively within and across interviews without prompting by the interviewer.
Mistrust was characterized as being guarded about trusting European American faculty members. Societal stereotyping and personally observed behaviors experienced during nursing school contributed to mistrust. Mistrust was validated during interactions with European American faculty members while understood in the context of US race relations. There were three components of mistrust: stereotyping, saying one thing and doing another, and the double standard.
Study participants described the prevalent negative stereotypes of African Americans in the United States as impacting their nursing school experiences. They were aware that faculty members likely held unconscious biases that led to stereotypical expectations of students. Violet explained: “People perceive you as someone who might get pregnant early on, not complete a degree, not obtain higher education, someone who is lazy or…from the ghetto.” Though stereotyping was often unspoken, participants sensed its presence in the nursing school environment. For example, Winter shared: “Sometimes people look at me and make judgments about me right off the bat…it’s like I have to do a dance to show them, ‘Look, I’m not this girl that you think that I am’…It just makes me feel sad. [One] guy was like, ‘All black people are committing the crimes’…It just hurts your feelings because you’re like, ‘I don’t commit crimes. What are you saying?’” Winter was disappointed when this stereotypical comment was made in class and no faculty member spoke up on behalf of African Americans and/or against stereotyping. Participants assumed the faculty member, when silent, lacked knowledge and insight about racial consequences and were complicit with the stereotype expressed by others.
Faculty biases fostered mistrust with African American students because they were false and European Americans were not similarly stereotyped. Vanessa described how lack of knowledge was a barrier to an otherwise trusting relationship: “There were certain things I could not talk to my white mentors about…One time, she was just like, ‘I don’t have that perspective. I wish I did but I don’t know where you’re coming from’…I accepted that…Unless you’ve lived and walked in those shoes, you just don’t get it.”
Even with this faculty member’s effort to mentor, the differences in life experiences across cultures limited understanding and fostered stereotyping. It takes extra effort and cultural learning for European American faculty to provide effective mentoring for African American students. Despite best intentions, the participants understood that European American faculty can never understand the experiences of living as an African American in the European-dominated society in the United States.
SAYING ONE THING AND DOING ANOTHER
Mistrust resulted when actions did not match the verbal message of European American faculty members. For example, Al sensed that the faculty member wasn’t pleased with her clinical paperwork, but when she asked about it, she was assured that she was passing and doing fine. Yet, Al failed the clinical rotation. The faculty member never told her why she failed or what she needed to do to improve.
Al gave another example of saying one thing and doing another: “I went through the whole appeal process. At each step of the appeal, the director of nursing basically was telling me that she agreed with me…She was the last part of the appeal and she said, ‘If it does make its way to me, I am in support of you and I would definitely pass you so that you can…graduate.’ It did end up getting to her, and when it came down to it, she never answered any of my calls…I lost the appeal. It was very, very confusing…there is nothing worse than telling me one thing and doing another.” Inconsistencies between words and actions were pivotal for study participants and interpreted as deception.
Stories about teaching or evaluating African American students differently than European American students were striking. Some participants courageously confronted faculty members when they were not getting the same attention as European American students. Mya Marie explained how she approached one clinical instructor: “One day I said, ‘I watch you in the hallway for 20, 30, 40 minutes showing other [European American] students how to look up labs, how to find, look at [X-ray] images’…I said, ‘You never do any of that with me. Is that not part of my clinical experience? Am I not going to receive that?’ Then, finally I think she was like, ‘I guess she’s right. I don’t do this with her.’” Confronting a faculty member is a challenge for any student and is magnified when the student is African American and the faculty member is European American.
Many of the participants described doubts about the evaluation of their work when they received lower grades than European American students. Some compared grades to verify the inequity. Mya Marie described: “One…instructor…would grade me very closely [to see] if anything was out of place…I would take care plans from other classmates that she had graded, pieces and parts, and we would notice the difference. When she graded theirs, they got like, ‘Well done!’ Then I would write the exact same thing, and she would say, ‘You should’ve done this, or your intervention should’ve been this.’” Participants called this a double standard. They observed, listened, and noted the different ways that some European American faculty interacted with African American students compared to European American students.
The unequal standard was unwritten and implicit. It was learned by trial and error and word of mouth, from one African American student to another. However, students rarely brought it to the attention of nursing faculty. Mya Marie advised that “sometimes you really have to pick your battles as far as you don’t want to cast yourself on the outside where people are out to get you.” Similarly, Vanessa described purposely choosing to be quiet after one unpleasant interaction with a faculty member: “I learned at that point that sometimes it’s not to your benefit to speak up. Sometimes just be quiet.”
Participants commented that they preferred the objective evaluation of didactic courses over the subjective evaluation of skill and clinical courses because of the assurance that race would not be a factor in the grade they received. Objective testing removes the potential of stereotyping influencing the evaluation of the African American student. Unfortunately, it is impossible to eliminate subjectivity entirely when evaluating students in the clinical setting.
Most participants experienced at least one faculty member who had a double standard. European American classmates and faculty members were often unaware of the double standard, so the African American students either needed to speak up or tolerate the injustice. A few faculty members using a double standard negatively influenced the overall experiences for students.
The context of stereotypes in a racialized society impacted the way nursing school was experienced by African American students. Study participants mistrusted faculty members who said one thing and did another and those who had a double standard of teaching or expectations for African American students. These experiences added challenges to the usual rigor of nursing school for African American students. Participants shared that European American faculty members were mostly unaware of how their behaviors negatively impacted their education.
As pervasive as the stories of mistrust were, there were also compelling stories of trust with European American faculty members who were positive and influential. These trusting relationships protected African American students from the harshness of nursing school, and some relationships continued beyond the nursing program. Three areas of trust were described across the interviews: seeing me as a person, taking time, and mentoring.
SEEING ME AS A PERSON
The participants shared stories of how trust formed when European American faculty recognized them as individuals. Participants trusted faculty members who went out of their way to notice them and their work. Vanessa described: “I had a professor tell me, ‘You know Vanessa, you look like you don’t give a damn but I know that you do based on the quality of your work. You need to speak up in class.’ I respected that professor for telling me that because she took notice of me and she took notice of my work…I’ve been speaking up ever since.”
This faculty member discreetly empowered Vanessa to be herself. Similarly, Bella’s advisor recognized her potential when she expressed doubt about the nursing program: “I said [to the faculty advisor], ‘I’m really kind of playing with the idea of dropping out of the nursing program and looking into a different major.’ My advisor…just encouraged me. He said, ‘It’s going to get tough, no matter what program you’re a part of…I see this caring side of you. I see that you’re strong, and you’re smart, and you’re studious, and you can get through this.’ He just really gave me the encouragement I needed to just stick with it, and to just buckle down and get the job done.”
TIME AND PRESENCE
Trust formed over time, often over the full length of the nursing program, giving faculty members and students time to show themselves as trustworthy. Vanessa commented on how it takes time to build trusting relationships: “That relationship [with a European American faculty member] took time to build. We were together for years. When I first met her, I didn’t talk to her about stuff. It took time for me to warm up to her and for her to show me that she’s somebody that was trustworthy.” Given the influence of societal stereotyping, time is needed to dismantle the assumptions that faculty members and students have about each other.
Another way to invest time with African American students was through campus and community events such as a Black Student Union and Black Lives Matter. Vanessa shared: “They [European American faculty] were active in programs that promoted diversity within the school. I saw them at those programs. I saw them working toward increasing diversity. That’s another thing that helped me to [think] this is somebody who cares about people like me. Maybe I can trust this person, and I’m going to watch them. If they continue to show me different things about who they are, then I was more apt to trust them because they showed me that they were interested in helping people like me.”
Presence was another important investment in African American students. Erica told how a faculty member “would just let me sit in there and vent to him and I appreciated that a lot. He even gave me his number and email address…He was just there. I appreciated that.”
Mentoring helped develop trusting relationships between African American students and European American faculty. Mya Marie shared: “[The faculty member said] ‘This is a safe place when you’re in my office. If you want to talk to me, you can. Other [African American] students have talked to me…I’m trying to make things better for [African American students].’ She was very aware.”
Participants described the need to be challenged by mentors. Vanessa explained: “I had a mentor who told me, ‘I want you to succeed but you’ve got to want it a lot more than I want it for you.’ That told me this woman is in my corner. [She also said], ‘You have to work harder than what you’re working. You’ve got to do more than what you’re doing.’ It was encouraging to know she was there to support me. She was an advocate when other people tried to throw me under the bus. I respect her and she was white.”
The stories of trusting relationships with European American faculty members were encouraging, hopeful, and heartening, especially compared to the stories of mistrust. Study participants wanted to be known as a person, over time, and through presence and mentoring. Trusting relationships mitigated the difficulties of school for participants as African American students in predominately European American schools of nursing.
The study findings reflect the significance of the dichotomous experiences of mistrust and trust for African American nursing students. Mistrust is predicated by racial biases present in society that are beyond the boundaries of the nursing program. African American students are keenly aware of how stereotypes influence their nursing school experiences. Race will matter in nursing programs as long as race matters in society. Stereotyping goes unchecked when European American faculty are hypocritical and have a double standard for African American students. Compelling stories of trust fostered by seeing students as individuals, time and presence, and mentoring give reason to hope that trusting relationships may mitigate the negative effects of race in nursing school.
This analysis describes how race impacts the social process of learning between students and faculty. Nursing school experiences are highly influenced by faculty. As African American students negotiate nursing school, they are sensitive to indicators that faculty members are deceptive versus trustworthy. Decisions about trustworthiness happen over time as students observe faculty who genuinely care for their success. Time is needed to undo the stereotypes that students and faculty members have about each other. For those participants who could establish a trusting relationship with faculty member(s), the relationships were meaningful, supportive, and long lasting. Participants wanted to see European American faculty members actively supporting systemic change for African American students.
The theme of mistrust is supported in the literature. Cultural mistrust describes the prevailing belief that European Americans cannot be trusted by people of color (Terrell, Taylor, Menzise, & Barrett, 2009). Historically, mistrust of European Americans helped African Americans survive the deceptive, cruel, and dangerous slave society and Jim Crow era. Cultural mistrust persists with systemic inequalities in US culture today (Terrell et al., 2009).
Cultural mistrust in education stems from historic and contemporary inferior public schools in African American neighborhoods (Ogbu, 1992). Feelings of being stereotyped are known to hinder motivation and academic achievement (Cohen & Steele, 2002). Steele (1997) describes how stereotyping is present “in the air” (p. 614), not needing to be experienced firsthand to influence student performance. For example, high levels of overall cultural mistrust have been found to correlate with lower grade point averages among African American undergraduate students (Caldwell & Obasi, 2010; Irving & Hudley, 2008).
Trust between faculty and students is integral to learning (Willie, 2000) and contributes to enrollment and graduation in higher education (Ghosh, Whipple, & Bryan, 2001). Steele (1999) found that when stereotype threat was removed from a testing situation, African American students performed better. Faculty who exhibited caring, respect, and active listening engendered trust and were viewed by minority students as most effective (Case, 2013). Yeager et al. (2016) found that trust was fostered and learning outcomes improved when faculty members provided feedback with high standards and confidence in students’ ability to succeed.
This study’s findings are also confirmed in the nursing literature where African American students describe faculty members as being unfair, showing unequal treatment, and not honoring confidences (Kosowski et al., 2001; Leroy, 2008). For example, African American students stated that faculty expectations are not always known to them (Payton et al., 2013). Others challenge the nursing profession’s Eurocentric culture (Debrew, Lewallen, & Chun, 2014) and the influences of race and racism in nursing (Beard & Julion, 2016; Hall & Fields, 2013). Our study’s findings similarly confirm that race and racism negatively impact African American students in nursing. Importantly, historical perspectives impact current situations (Bentley-Edwards, Agonafer, Edmondson, & Flannigan, 2016).
The examples of mistrust and trust with European American faculty members describe the consequences of race for African American students learning from European American faculty members. Mistrust of European American faculty is understandable when viewed from a historical context. Some faculty members mindfully turned aside societal biases and actively engaged with African American students to forge trusting and impactful relationships.
A limitation of this study is that the interviewer was European American. It is possible that candid storytelling and implied meanings were undermined due to the racial difference between the interviewer and participants. There was a risk of bias during data analysis despite the active participation of an African American RA. As participants were interviewed anonymously, the PI was unable to contact them during data analysis to ask for clarification, follow-up, or validation of study findings. Due to retrospective storytelling, the participants may not have recalled other noteworthy stories that impacted their nursing school experiences.
The sample included only students who persisted to graduation; stories from students who did not persist could differ. Consistent with qualitative approaches to inquiry, the findings do not represent all African American nursing students and/or all predominately European American schools of nursing.
Future Study and Implications
Experiences of mistrust and trust need further description and perhaps theoretical development for better understanding of how each forms and influences student success. Quantitative studies examining levels of mistrust and trust in US nursing programs and the effects on student outcomes would help prioritize the importance of this topic for future research. The data had additional evidence of participants experiencing guarded trust, which is not evident in the literature and requires further study.
It would be helpful to know which nursing school experiences promote African American student success and predictors of attrition. Since the American Association of Colleges of Nursing and the National League for Nursing do not publish attrition data by race and ethnicity, further study is needed to document the presence of disparities.
Although recruiting and mentoring African American faculty members is a priority, European American faculty members need to actively engage in understanding the impact of race in nursing. Cultural climate surveys will inform faculty how African American students perceive the nursing program. Exit interviews of all students who drop out or fail will also help reveal the cultural climate of the program. Peer review of teaching will identify areas of bias in grading and attention given to students. Faculty teaching evaluations, along with peer review, will identify faculty members needing additional education, mentoring, and practice to effectively gain the trust of African American students. Anonymous grading, an option on many electronic learning managements systems, minimizes the influences of implicit bias when evaluating written work. Providing accurate feedback, high standards, and confidence in students is known to promote trust (Yeager et al., 2016). Faculty should be encouraged to engage with African American students outside the classroom.
This study highlights how race influences the formation of trust and mistrust with faculty members in predominately European American nursing programs. Faculty members need to understand the impact of societal stereotypes and mistrustful behaviors such as not being true to their word and treating students inequitably. Helpful strategies include seeing African American students as individuals, forging relationships over time, and mentoring. Nursing faculty can do better and must do better to be informed about race and improving the nursing school environment for future African American students.
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