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Acculturation Into Nursing for Hispanic/Latino Prelicensure Nursing Students and New Graduates

Integrative Review of Literature

Woodley, Lisa K. PhD, RN, CNE, CHPN; Lewallen, Lynne P. PhD, RN, CNE, ANEF

doi: 10.1097/NNE.0000000000000610
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Background Increasing recruitment and retention of Hispanic/Latino nursing students is urgently needed to increase the diversity of the nursing profession and address persisting health disparities.

Purpose This integrative review describes current knowledge of Hispanic/Latino prelicensure nursing student and new graduate experiences.

Methods A comprehensive literature review was performed using several online databases.

Results The Theory of Cultural Marginality provides structure for organizing and synthesizing the literature. Several concepts from the theory are prominent in the literature, including marginal living and across-culture conflict, easing cultural tension and adjustment responses, and contextual, independent, and personal influences.

Conclusions The process that Hispanic/Latino prelicensure nursing students and new graduates experience as they acculturate into the profession of nursing is complex. Understanding this process is paramount for nurse educators and should be the foundation on which to design, measure, and evaluate educational strategies aimed at fostering student success.

Author Affiliations: Assistant Professor (Dr Woodley), School of Nursing, University of North Carolina at Chapel Hill; and Professor and Associate Dean for Academic Affairs (Dr Lewallen), School of Nursing, University of North Carolina at Greensboro, Greensboro.

The authors declare no conflicts of interest.

Correspondence: Dr Woodley, School of Nursing, Office 529, Carrington Hall, The University of North Carolina School of Nursing, Chapel Hill, NC, 27599-7460 (lwoodley@email.unc.edu).

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (www.nurseeducatoronline.com).

Accepted for publication: September 1, 2018

Published ahead of print: November 1, 2018

Online date: November 2, 2018

The US population is rapidly growing in diversity, and by 2043, those who are from underrepresented minority (URM) groups are projected to become the majority.1 The Hispanic/Latino population represents the fastest growing URM population within the United States. In 2016, 1 in 6 people living in the United States was Hispanic/Latino; by 2060, this ratio is predicted to be 1 in 3.1 In contrast, the nursing profession remains predominantly female and white, and although its diversity is slowly increasing, it is not doing so at the national pace.2 Recent reports indicate that only 3% of practicing nurses within the US self-identify as Hispanic/Latino,3 the second smallest ethnic group of nurses nationally next to American Indian and Alaskan Natives.4

An abundance of literature ties the persistence of health disparities with the shortage of minority groups within health care professions.5-8 The lack of Hispanic/Latino nurses is particularly problematic, not only because of the rising numbers of Hispanic/Latino people in the United States, but also because this group is highly impacted by health disparities. Challenges arise when nurses attempt to address health disparities and provide culturally responsive care, because most nurses are not intimately familiar with their patients' cultures.2,6,7 National initiatives aimed at increasing the diversity of the nursing workforce in order to lessen health disparities are being put in place, including efforts to recruit and retain more students from underrepresented groups.6

According to the American Association of Colleges of Nursing,9 Hispanic/Latino students accounted for 6.8%, 7.7%, 8.4%, and 11% of entry-level baccalaureate nursing students across the United States in 2010, 2012, 2014, and 2017, respectively. Although the trends look encouraging, more work needs to be done. These numbers do not come close to approximating the US population; moreover, admitted student numbers do not equate to those who graduate. Students who represent minorities in gender, race, and ethnicity continue to experience overall higher attrition rates than white females.2,6 It is unknown exactly why Hispanic/Latino nursing students tend to experience less success in prelicensure nursing programs than the majority group of white females. This integrative literature review examines the experiences of Hispanic/Latino nursing students.

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Purpose

Increasing the recruitment and retention of URM nursing students is urgently needed to increase the diversity of the nursing profession. The aim of this article is to describe current knowledge reflecting the complex process that Hispanic/Latino prelicensure nursing students and new graduates experience as they acculturate into the profession of nursing.

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Theoretical Framework

Choi's10 Theory of Cultural Marginality guided this review, providing a nursing-specific framework for addressing the multidimensional factors that influence Hispanic/Latino prelicensure nursing students and context for organizing and conceptualizing the existing literature. The theory provides context for understanding the complexity of the acculturation process for these students entering the culture of nursing and offers nurse educators direction in understanding and identifying how students may respond. The theory illustrates how the context of the nursing education environment acts as an important influence for students, as well as how individual and personal influences impact the student's acculturation into nursing. Because the theory recognizes these influences, it encourages nurse educators to develop learner-centered, culturally responsive educational strategies designed to facilitate URM nursing student success.

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Methods

This integrative review follows the methodology proposed by Whittemore and Knafl,11 including problem identification, literature search, data evaluation, data analysis, and presentation. A comprehensive literature search was performed using online databases of Cumulative Index of Nursing and Allied Health Literature, PubMed, Education Full Text, and ProQuest Dissertations and Theses Global. Consultation with a reference librarian aided in the development and refinement of search terms in the databases, ensuring a thorough and comprehensive search. Search terms used and results yielded are described in the accompanying Table 1, Supplemental Digital Content, http://links.lww.com/NE/A552. In addition, reference lists of studies included in this integrative review were appraised for the inclusion of additional relevant literature. A PRISMA12 flow diagram reflecting the search process is found in the Figure, Supplemental Digital Content, http://links.lww.com/NE/A554.

For inclusion in this review, literature had to report research conducted within the United States since 2007, be published in English, and focus on Hispanic/Latino prelicensure nursing student or new graduate experiences or outcomes. Research was excluded from this review if it was published before 2007, conducted outside the United States, and/or focused on other types of students such as graduate nursing students. Nonresearch references, such as commentaries, letters, expert opinion, and review articles, were also excluded, as was research about URM nursing students in general but not specifically Hispanic/Latino students. Titles and abstracts were reviewed for relevance, eliminating many references, and a full-text review of the remaining references further narrowed the literature. In total, 18 research articles and dissertations met the selection criteria and were included in this review. A matrix was used to organize studies according to their purpose, theoretical framework if used, design, sample, and findings and is found in Table 2, Supplemental Digital Content, http://links.lww.com/NE/A553.

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Results

Studies in this review included a variety of designs reflecting qualitative and quantitative research. Of the 18 studies that met inclusion criteria, 13 were qualitative, 4 were quantitative, and 1 was a mixed-methods design. Qualitative designs included descriptive qualitative, phenomenology with and without bracketing, and grounded theory. Quantitative designs included cross-sectional descriptive and exploratory studies, as well as 1 secondary data analysis. The mixed-methods study used a convergent mixed-methods design with descriptive qualitative interviews and electronic surveys. Thirteen of the studies were published, and the remaining studies were unpublished dissertations. More than a third of the studies (n = 7) were conducted in Texas; the rest represented other locations within the United States.

Samples varied among the studies. Three studies were conducted exclusively with newer practicing nurses who were Hispanic/Latino, and another 2 used a mixed sample of prelicensure nursing students and new practicing nurses. One study examined staff, faculty, and administrator perceptions of resources available for Hispanic/Latino nursing students but did not include students in their sample; another used data shared from administrators of prelicensure nursing programs in Texas to compare resources offered with graduation rates of Hispanic students. One study compared Hispanic/Latino nursing students' and administrators' perceptions of barriers and supports, whereas another compared Hispanic/Latino and American Indian students' perceptions of barriers in nursing school with the views of white students.

Many of the studies focused on a specific component of the Hispanic/Latino nursing student experience, such as recruitment and retention, resources offered, academic performance in a course, barriers to program completion, completion of programs after an academic failure, or support for student retention. Of the 9 studies that kept their sample specific to Hispanic/Latino prelicensure nursing students, 6 were single-site studies, limiting applicability to other locations. No studies were retrieved that addressed the entirety of the experience for Hispanic/Latino prelicensure nursing students acculturating into nursing.

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Discussion

The subheadings that follow correspond to aspects of the acculturation process experienced by Hispanic/Latino nursing students according to the Theory of Cultural Marginality.10 These have been used to organize and synthesize the literature and frame the discussion within the broader context of the theory. Table 2, Supplemental Digital Content, http://links.lww.com/NE/A553, is a matrix with details of all the included studies.

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Marginal Living and Across-Culture Conflict

Choi10 describes marginal living as the tension that is experienced when individuals find themselves between their culture of origin and a new culture. This tension has a push/pull quality and results in across-culture conflict, which can have positive or negative effects. Experiences consistent with marginal living were described in 9 of the studies reflecting Hispanic/Latino prelicensure nursing student perspectives. Bond and colleagues13 described the tension that participants experienced between having to fulfill family values and expectations and the commitment necessary to succeed in nursing school. This was further compounded for 1 participant on the basis of his gender, who indicated that when his family member heard he wanted to be a nurse, he was instead encouraged to become a doctor.13 Some female participants did not feel that family wanted them to succeed, because being an independent nurse directly contrasted to cultural expectations of Hispanic females staying at home and “meeting your family load.”13(p140) Participants in other studies described an almost verbatim experience. In some cases, participants felt that the sense of pressure from their culture of origin was overpowering at times because their performance in nursing school not only reflected on them as individuals but on their families as well.14-16

Participants in Rivera-Goba and Nieto's17(p44) study identified experiences consistent with marginalization, described as living “between 2 worlds.” These participants described feeling isolated within their nursing programs on the basis of their Hispanic ethnicity, as well as having to juggle their school demands around other responsibilities. They were often advised to work less by faculty who did not understand the financial and family commitments that these students held; participants felt misunderstood and further isolated by this “advice.”17

Moceri's18(p5) participants described similar experiences, such as the “cultural obstacles related to participants' heavy primary family responsibilities that conflicted with the demands of nursing education.” In addition, these participants experienced cultural dissonance when the academic culture of competitiveness clashed with their cultural values of working cooperatively. Participants in Evan's19(p214) study went as far as to say they were “attached at the umbilicus” to their families. Dolan et al14 noted similar feelings of tension experienced by Hispanic/Latino nursing students who described family members being proud of them for attending college, yet teasing them about reducing participation in family activities. These students felt their families did not always support them in their student role and instead expected fulfillment of traditional roles, creating stress and feelings of self-doubt. Diaz20(p133) reported that for those who are Hispanic/Latino, “family takes precedence… family is an institution.” Despite the pressures faced engaging in the new culture of nursing while maintaining relationships in their culture of origin, family was also seen as a major support and source of strength for Hispanic/Latino participants across many studies. The importance of family and community as a support was described either explicitly or implicitly in the discussion of themes in qualitative studies.14-22

According to the Theory of Cultural Marginality, the new culture itself may display contradictions, such as appearing to be welcoming but demonstrating discrimination toward the individual; the theory posits that this contradiction can create anxiety, uncertainty, and feelings of alienation when the individual attempts to negotiate the acculturation process.10 This phenomenon was observed across numerous studies. For example, participants described feeling different and standing out because there were few Hispanic role models in nursing academia or clinical settings.17,21,23,24 Some reported incidences of racism or discrimination from peers and faculty.16-18 One participant stated “It's very hard to connect with most of the people that go here… they have this notion that you are really different.”23(p161) One person said, “When you're pretty and white, you have it made and are accepted because stuff doesn't happen to you. You don't have to go in a store and have people look at you like you are going to steal or can't afford it.”16(p1854) This sense of being different did not always go away after graduation; practicing nurses noted, “I'm the only Hispanic nurse” and voiced feelings of loneliness.24(p1296)

The Theory of Cultural Marginality asserts that cross-cultural tension may impact individuals in a positive manner, through the development of resilience and hope,10 which can be seen in the literature included in this review. Many qualitative studies emphasized the importance of personal resilience or determination,13,16,18,21,22 whereas others noted the prominence of hope and goal orientation.18,20 Students in Sheils'22 study described doing whatever it took to achieve their goal, whereas participants in Moceri's18(p9) inquiry identified “being cabezona” or stubborn in their ability to overcome obstacles and reach their goals.

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Easing Cultural Tension and Adjustment Responses

According to the Theory of Cultural Marginality, individuals respond to cross-cultural conflict in a number of ways to ease cultural tension.10 Many students across multiple studies described experiences consistent with poise or being on the periphery of both cultures. These students identified feelings of isolation, loneliness, not fitting in, feeling different, and/or being anxious.16-18,21,23,24 Several authors noted that Hispanic/Latino nursing students often must commute, instead of living on or near campus, which adds physical and psychological distance between the student and the nursing school and further exacerbates feelings of isolation.16,19,23 Most authors noted that attrition rates, reflective of reconstructed return in the theory, are higher for Hispanic/Latino prelicensure nursing students than the majority group, but could not identify a reason. Other researchers tried to identify specific predictors to lower attrition, but none of these predictors took into account the complexity of the acculturation process or the prominent role that the culture of origin plays for these students.14,25-27

One researcher approached attrition from a different stance, studying ways to promote Hispanic/Latino nursing student success after academic failure. Ninan28 used a phenomenological approach to discover how Hispanic nursing students successfully completed their nursing program after academic failure. She described these students going through a state of intense despair after academic failure, but then engaging in self-reflection, changing their strategies, and achieving success through graduating and passing state licensing examinations.

The Theory of Cultural Marginality describes another response called integration, occurring when individuals create a third culture by blending the culture of origin and the new culture.10 In the literature reviewed here, evidence suggests that integration is achieved by some Hispanic/Latino nursing students and is a goal for many. Participants describe not only the empowerment they feel when working with Spanish-speaking patients,14,24 but also being highly sought after by employers because of their cultural awareness and multilingualism.24 Some participants planned to work in community settings with underserved populations because of their unique ability to integrate their Hispanic culture with the world of nursing.22

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Contextual, Independent, and Personal Influences

According to Choi's10 theory, contextual factors are important contributors to the acculturation process and may include characteristics of the dominant group such as how welcoming and supportive it is, resources available to the newcomer, and group composition. Nine studies sought to describe contextual barriers and supports to success, but no consistent designs or instruments were used. Instead, studies reflected a variety of research designs including descriptive qualitative approach with focus groups or private interviews, ethnography, cross-sectional quantitative designs with online surveys, program self-assessment tools, secondary data analyses, and a convergent mixed-methods design.13,15,18,20,22,26,27,29,30 No instrument was used in more than 1 study; psychometric qualities of the tools were inconsistently reported, limiting generalizability of results. Sample selection also varied; some studies included nursing students and new graduates, whereas others focused on administrators, staff, and faculty. Consequently, drawing comparisons or inferences across studies is challenging at best.

Independent influences can also impact the acculturation process10 and may include factors such as age of joining the new culture, length of stay, language proficiency, ethnic identity, socioeconomic status, and immigration experiences. Research is limited on the independent influences that impact Hispanic/Latino prelicensure students as they acculturate into the profession of nursing. Of the studies reviewed, only 1 included English language acculturation as a variable that might impact academic outcomes, and this was mediated by the addition of another variable—how much the student interacted with academic networks.27

As previously described, personal influences of Hispanic/Latino prelicensure nursing students, such as resilience and study habits, have been explored by several researchers, all through qualitative study designs.13,14,16,18,20,21 The overarching finding from these studies is the importance of tenacity or resilience in helping these students achieve their goals.

The findings of this integrative review highlight the following facts about the published work in this area. The 18 studies meeting inclusion criteria differed widely in terms of study design, methodology, sample, setting, purpose, and location, making inferences across studies difficult. Certain areas of the United States have been more heavily studied, such as Texas, whereas other areas of the United States are completing or lacking in research about this phenomenon, even though Hispanic/Latino people live and attend nursing school in all 50 states. The Theory of Cultural Marginality10 was a useful lens through which to view these studies. Aspects of the theory appeared across many studies, including the phenomena of marginal living, across-culture conflict recognition, and adjustment responses to ease cultural tension. Some literature reflecting study of contextual influences was found, but research describing personal and individual influences on the acculturation process for Hispanic/Latino nursing students into nursing is scarce.

Most of the research focused on a particular aspect of the process but did not seek to understand the complexity or wholeness of the process that Hispanic/Latino students experience as they acculturate into nursing. Finally, studies that focused on particular student outcomes, such as passing a specific nursing course or graduating from the program, did not take into account how individual characteristics (such as gender, language fluency, country of birth, and first-generation college student status) and specific ethnicities within the Hispanic culture impact students. Instead, research considered Hispanic or Latino as 1 group only.

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Limitations and Recommendation for Future Research

Because contextual, individual, and personal influences contribute to the acculturation experience into the nursing profession for Hispanic/Latino students, it is essential to study these influences, particularly how they might promote student success. Several studies have aimed to measure the effectiveness of contextual influences, such as mentoring programs, the impact of financial aid and scholarships, and academic advising and technical support.13,18,26,29,30 Lacking, however, is evidence of how individual influences, such as English and Spanish language fluency, whether the student was born in the United States, if the student is a first-generation college student, or if the student belongs to more than 1 underrepresented population (eg, being Hispanic/Latino and male), impact the acculturation process into nursing. Also missing are studies examining personal influences that affect the acculturation process into nursing, such as previous success in another career, time spent in the nursing program, coping strategies, openness to ideas, resilience, and/or personality characteristics. If these influences were better understood, evidence-based educational recommendations could be made.

The Theory of Cultural Marginality informs potential interventions. For example, helpful resources such as forming groups fostering cohesion of these students across their nursing programs, facilitating Hispanic student to Hispanic student mentorship programs, and making concerted efforts to hire more Hispanic/Latino faculty as role models might be studied. Further study about the impact of contextual, individual, and personal influences individually and cumulatively on the acculturation process of Hispanic/Latino students in prelicensure nursing programs is also needed.

A gap exists in the literature on the relationship of teaching methods and styles and the experience of acculturation for Hispanic/Latino nursing students. DeBrew et al31 noted that faculty should incorporate diversity into nursing education, emphasizing the importance of individualizing education to meet the individual needs of students, rather than taking the approach that in order to be fair one must treat each student in the same way. Bond et al13 remarked that ways in which Hispanic/Latino nursing students are incorporated into class discussions may increase student anxiety and make them uncomfortable when they are asked to provide perspectives reflecting all Hispanic people. On the other hand, Sheils22 noted that personal relationships with others including faculty were powerful in fostering Hispanic/Latino nursing student success. More studies regarding the specific impact that faculty teaching approaches have on the acculturation experience of these students are needed. Similarly, providing continuing education for faculty in ways to provide a more culture-inclusive presentation of the profession of nursing when teaching students and considering how to better understand the Hispanic/Latino nursing student experience are also educational priorities. Consistent and sustained efforts are required, moving beyond a simple approach to one that reflects the complexity of the process for URM students acculturating into the profession of nursing.

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References

1. US Census Bureau. US Census Bureau Projections Show a Slower Growing, Older, More Diverse Nation a Half Century From Now. Available at https://www.census.gov/newsroom/releases/archives/population/cb12-243.html. Accessed May 21, 2018.
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Keywords:

acculturation; Hispanic/Latino; integrative review; minority students; nursing students

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