Essay on How Minority Students Experience Belonging During Clinical Experiences Written Paper

88 M A R C H / A P R I L 2 0 1 4 V O L U M E 3 5 N U M B E R 2 89

"It all depends": how minority nursing students experience belonging during clinical experiences Monique Sedgwick, Tracy Oosterbroek, and Victoria Ponomar

doi: 10.5480/11-707.1

Nursing students, regardless of race or eth-

nicity, benefit from interacting with diverse

groups of peers and faculty (Wong, Seago,

Keane, & Grumbach, 2008). However,

minority students experience discrimination,

financial restraints, lack of social bonds, lack

of faculty mentorship, and lack of acknowl-

edgment and understanding on the part

of faculty and administration during their

nursing education (Ackerman-Barger, 2010).

Consequently, during clinical experiences,

they may also have difficulty developing a

sense of belonging, a universal human char-

acteristic and need and a unique and deeply

personal experience.

Because reporting minority status is

voluntary upon admission to a Canadian

nursing program, the number of nursing

students who associate themselves with a

minority group is unknown. Some students

may choose not to declare their minor-

ity status. However, because 94 percent of

the RN workforce in Canada is made up

of women (Canadian Nurses Association,

2011) and only 13 percent of the Canadian

population represent visible minorities

(Statistics Canada, 2008), it is presumed

that Caucasian women make up the pre-

dominant group of students at nursing

schools across Canada.

LIteRatuRe RevIeW

Strategies such as connecting with junior

high and high school students to increase

awareness of nursing as a career option

(Beacham, Askew, & Williams, 2009),

reserved admission seats within programs for

certain minority student groups, provision of

faculty and peer mentors, and employment

of visible and self-declared minority faculty

(Etowa, Foster, Vukic, Wittstock, & Youden,

2005) have resulted in increased enrollment

of aboriginal students in Canadian nursing

programs (Gregory, Pijl-Zieber, Barsky, &

Daniels, 2008). However, the challenge for

nursing faculty and programs is that minority

students continue to encounter barriers in

the clinical education program (Ackerman-

Barger, 2010; Smith, 2006), including inad-

equate academic preparation (Wilson,

Andrews, & Leners, 2006), perceived dis-

crimination from faculty and peers (Fischer,

2007; Giddens, 2008), lack of minority

nurse role models (Wilson et al.), financial

restraints (Giddens), alienation and ethnic

isolation (France, Fields, & Garth, 2004), and

lack of acknowledgment and understand-

ing of barriers from faculty and university

administration (Ackerman-Barger, 2010). In a

grounded theory study, 17 ethnically diverse

aIm The purpose of this study was to identify factors that influence minority nursing students’ sense of belonging during clinical experiences.

backGRound Minority nursing students encounter multiple barriers within their clinical education experiences and have a higher attrition rate than Caucasian women.

method A mixed-method approach using a survey and individual qualitative interviews was used to generate data for this study.

ResuLts Minority students’ sense of belonging is dependent on their interactions with registered nurses with whom they work, clinical nursing instructors, and student peers. Positive experiences enhance students’ sense of belonging, while negative experiences may severely impact their belongingness.

concLusIon Every interaction that minority students have with clinical nursing instructors, registered nurses, and their student peers has the potential to impact belongingness. Engaging in reflection, developing mission statements that appreciate and value diversity, and using transformative learning strategies enhance minority students’ sense of belonging.

Abstract

nursing education Perspectives

90 M A R C H / A P R I L 2 0 1 4 V O L U M E 3 5 N U M B E R 2 91

Nursing Education Perspectives

RNs interviewed indicated that intolerance

from staff and patients in the clinical setting

existed during their educational experiences.

They also indicated that even one negative

interaction, especially in front of other stu-

dents or staff, could be humiliating and

devastating (Amaro, Abriam-Yago, & Yoder,

2006). Peer support, emotional and family

support, social interactions through contact

with students and faculty, financial support,

and advocacy by faculty were factors that 18

black undergraduate nursing students attend-

ing a predominantly white nursing program

reported as having an impact on their success

in nursing school (Dapremont, 2011). Self-

declared minority students also have substan-

tially higher attrition rates in undergraduate

nursing programs than Caucasian women

(Dapremont; Moy Wood, Saylor, & Cohen,

2009; Roth, 2008).

Although these studies have added to

the literature, a gap exists in our under-

standing of these students’ experiences

within the clinical setting. Given that nurs-

ing students report clinical experiences as

the most influential factor in the develop-

ment of their nursing skills, knowledge,

and transition to the professional nurse role

(Chun-Heung & French, 1997), the pro-

fessional socialization of nursing students

is critical (Nesler, Hanner, Melburg, &

McGowan, 2001).

This study sought to identify factors that

influence the sense of belonging of minority

students from a western Canadian province

during their clinical experiences. The pur-

pose was to help nursing programs recruit

and retain a more varied nursing student

population, potentially resulting in a nursing

workforce that can better meet the health

needs of diverse people.

method

A mixed-method design was used to answer

the following research questions: a) What

factors impact the experience of belonging

among self-declared minority students? and

b) What are the consequences of positive or

negative clinical experiences of belonging for

these students?

The undergraduate nursing program

where this study was conducted is a collab-

orative program between a university and

college in western Canada. Approval was

obtained from each educational institution’s

ethics review committee. Participant rights

were verbally explained prior to completion

of the questionnaire. Return of the completed

questionnaire implied consent. Written con-

sent prior to the interview process was also

obtained. To ensure anonymity and confiden-

tiality, participant names were not required

on the questionnaire and were removed from

the interview transcripts and replaced with

pseudonyms. Only members of the research

team had access to the data. None of the

members of the research team at the time the

study was conducted were teaching clinical

courses. One member of the team identified

herself as belonging to a minority group.

Participants Minority groups may experience discrimina-

tion and subordination, possess physical and/

or cultural traits that set them apart from the

dominant group, and share a collective iden-

tity and common burdens (Feagin & Booher

Feagin, 2007). Along with having some or

all of these characteristics, minority groups

in this study included any group of students

numerically small with respect to the domi-

nant group.

All of the students in the undergradu-

ate nursing program were invited to par-

ticipate in this study; of those, 461 students

responded to the questionnaire. As part of

the questionnaire, demographic informa-

tion, including a question pertaining to

belonging to a minority group, was asked.

Forty-one questionnaires (8.8 percent) were

completed by students who self-identified as

Black American (n = 2), Latino (n = 3), First

Nations/Aboriginal (n = 9), Other (n = 11),

or Asian (n = 16). Twenty-eight students were

men; of those participants, one was Asian and

one was Black American.

All of the participants interviewed

were women. Three self-identified as

First Nations/Aboriginal. The others were

Latino, Asian, East Indian, and Black

American.

Data Collection instrument The Belongingness Scale-

Clinical Placement Experience (BES-

CPE) (Levett-Jones, Lathlean, Higgins, &

McMillan, 2009) is a 34-item questionnaire

that measures and compares the extent to

which nursing students experience a sense of

belonging during their clinical placements.

Reliability analysis revealed a Cronbach’s

alpha of 0.92. Participants selected their

responses from a five-point Likert rating

scale, with scores ranging from 1 (never true)

to 5 (always true). To enhance consistency in

response, prior to completing the question-

naire participants were instructed to reflect

on their experiences with RNs during their

most recent clinical experience.

data collection procedures Data were collected in the fall and winter of 2010-2011

over an eight-month period that coincided

with the students’ clinical experiences. At the

end of the questionnaire, students were asked

to indicate their desire to participate in an indi-

vidual, semistructured qualitative interview.

Seven students responded to the invitation.

All of the interviews were conducted in person

in the researchers’ offices and were recorded.

Data emerging from the questionnaire guided

the initial development of individual interview

questions. As a result, two questions were

asked of each participant: “What does a sense

of belonging while in a clinical experience

mean to you?” and “What positively (nega-

tively) influences your sense of belonging?”

Data generation and analysis occurred concur-

rently. Data saturation was reached after the

seventh interview since no new information

emerged (Guba & Lincoln, 1989).

Data Analysis BES-CPE data were analyzed using the

Kruskal-Wallis test, which is a nonparametric

test in which the dependent variable (belong-

ing) produces ordinal data not presumed to

be normally distributed. For this study, the

independent variable was five levels of eth-

nicity. To establish reliability and validity, all

test assumptions were met.

Qualitative data were thematically ana-

lyzed. To achieve consistency in qualitative

data analysis among the research team, one

90 M A R C H / A P R I L 2 0 1 4 V O L U M E 3 5 N U M B E R 2 91

interview was analyzed in its entirety by the

entire team. To spot persistent words and

phrases so that underlying patterns could be

identified, each transcript was read twice.

Segments and words were highlighted and

grouped into categories. Each category was

assessed for how well the data reflected

the category. Once consensus was reached

pertaining to the categories, a template was

developed for subsequent analysis. After all

of the interviews were analyzed, the research

team discussed the expansion and collapse of

the categories. The major overarching theme,

“It all depends,” was identified. Three factors

were discovered to influence minority stu-

dents’ sense of belonging: a) RNs with whom

students work, b) clinical nursing instructors,

and c) student clinical groups.

To establish trustworthiness of the quali-

tative data, both quantitative and qualitative

data were collected. Students from various

minority groups were included in the inter-

views, thereby providing comprehensive

data. The principal investigator and one of

the coinvestigators conducted the interviews

using an interview guide. All members of the

research team were involved with data analy-

sis. In addition, the processes of data collec-

tion and analysis were described to establish

auditability, and a self-declared minority

student reviewed the interpretations of the

research team to reduce any possibility of

errors and misinterpretations.

ResuLts

Quantitative Findings Although all students viewed their clinical

placements as a place to experience a sense

of belonging, participants who identified as

First Nations/Aboriginal, Asian, or Other

indicated that they felt discriminated against

on placement examinations. These students

were also more likely to feel the greatest

degree of being disliked compared to their

Caucasian counterparts. Further, they did

not perceive that they worked with RNs who

shared their professional and personal values.

Qualitative Findings The overarching theme identified was “It

all depends.” For most of the participants in

this study, the RNs with whom they worked,

clinical nursing instructors, and peer clinical

groups appeared to have the most influence

on their ability to feel like they belonged.

These factors seemed to exist on a continuum,

varied from day to day, from person to person,

and from clinical unit to clinical unit.

nurses with whom students worked All participants stated they evaluated the degree

of friendliness RNs displayed toward them. If

the RNs were perceived as being unfriendly,

then students avoided them. Conversely,

those RNs perceived as being friendly posi-

tively impacted student learning and sense of

belonging.

However, the ability of RNs to enhance

the minority students’ sense of belonging

extended beyond simply being friendly.

Nurses perceived as being judgmental and

treating minority students differently than

Caucasian students negatively impacted

learning and the sense of belonging. “Some

staff will kind of look at me like maybe I’m not

as knowledgeable or just sometimes they’re

a little bit cold. I feel like sometimes their

behavior does have to do with my minority

status. Like with my classmates a lot of the

time, they’ll be very accepting of them and

involve them in certain things or just answer

their questions. I try to not let it bother me,

but there’s a lot of prejudice.”

Indeed, many participants described

feeling invisible when they first entered the

clinical setting. As a result, they felt uncom-

fortable and distinctly unwelcomed. One

participant commented: “Every clinical

there’s always that…you come on to the unit

and it’s almost like they don’t notice you. I’m

not asking for a welcome parade, but give

me the same welcome that you extend to my

Caucasian counterparts. I’ve been in clinical

with a couple of Asian girls and it’s kind of

the same thing toward them.”

clinical nursing instructor The second factor that impacted students’ sense of

belonging was clinical nursing instructors.

Like their experience with RNs in the clinical

setting, these participants described a wide

variance in their experience of clinical nurs-

ing instructors’ influence on their ability to

feel like they belonged. Clinical nursing

instructors who spent an equal amount of

time with each student were perceived as

treating students fairly and enhanced stu-

dents’ sense of belonging.

However, clinical instructors perceived as

being biased because the student possessed

a particular characteristic, such as speaking

with an accent, did not support students’

sense of belonging and negatively impacted

their learning. One participant expressed, “I

guess when you have an accent pretty much

some instructors think that you are ignorant,

that you don’t have any education and they

treat you differently.”

Clinical instructors who used discrimina-

tory language, thereby supporting the use of

such language themselves, inhibited students’

sense of belonging. One participant recalled

a situation in which a patient had difficulty

pronouncing another minority student’s

name: “So the teacher told the [patient] to

call her ‘Asian.’ The white girls — they call

them their names, but for her the teacher and

nurses and patients just called her Asian.”

Some participants perceived feelings of

discrimination that were pervasive. To be suc-

cessful, they felt they needed to work harder

to prove to their instructor, nurses, and cli-

ents that they were capable and competent.

Although these students indicated that they

felt discriminated against by their clinical

instructors, they also had expectations that

their instructors would intervene when they

were exposed to discriminatory behaviors by

patients and staff.

student clinical group Because clini- cal group composition changed from term to

term, students were required to interact with

diverse groups of peers. To provide safe, com-

petent, and timely nursing care, students in

this study explained that it was essential that

they felt they could depend on each other.

One student noted: “When we’re on the floor,

I think we have that sense that someone has

your back and you’ve got somebody’s back.

So, if somebody looks like, ’Oh my god, I can’t

do this,’ then you’re there to help them.

Consequently, feeling connected and

part of the student clinical group was a vital

feelings of Belonging

92 M A R C H / A P R I L 2 0 1 4 V O L U M E 3 5 N U M B E R 2 93

Nursing Education Perspectives

component in the learning and socialization

process: “My student colleagues make me feel

like I belong with them. We have some kind

of connection between us. They make me feel

like, ’Okay, you’re just like us.’ Whenever I

need help, they are willing to help me.”

Some participants had a negative experi-

ence when part of a student clinical group.

These participants felt like outsiders because

they felt that they were being excluded from

interactions among their peers. “With some

of the students, some girls just didn’t talk

to me,” explained one participant. “I don’t

know if it was because of the color of my

skin.” The perception of being excluded from

interactions among peers had the potential to

impact nursing care. These students felt they

needed to work harder to gain their peers’

trust so that they might be included in the

groups’ interactions.

Because of their cultural norms with

regard to perceived acceptable behavior and

the sharing of personal information, other

participants felt that being part of a clinical

group composed predominantly of Caucasian

women made belonging difficult. One stu-

dent explained: “They talk about going

drinking and partying and I don’t really do

that, so I don’t have that common experi-

ence with them. I think maybe it’s a cultural

thing, but I don’t just start randomly talking

about what I did last night. It’s not like me

to just start off on personal information. So,

when I’m in a group where I’m the only vis-

ible minority, the information I would offer

up would be different because the base of the

conversation is also different.”

Other participants perceived blatant dis-

crimination from their student colleagues,

an experience that left them feeling hurt and

confused. “There’s sometimes in the clinical

groups where people have come up to me

… one nursing student, he’s like — I didn’t

understand why he told me but I now under-

stand because I’m a visible minority — but he

said, ’I hate to say this, but sometimes when

I see like a Chinese person and they don’t

speak English very well, I think they’re really

dumb.’ And I’m thinking, ‘Why would you

say something like that? What are you trying

to tell me?’ It’s a very difficult situation to

be in. That can really shake your sense of

belonging a lot of times.”

dIscussIon

The data that emerged revealed that visible

and self-declared minority nursing students’

experiences of belonging during clinical

experiences is varied and based on multiple

factors. Undergraduate nursing students

quickly learn that RNs, clinical nursing

instructors, and peers support the abstract

notion of cultural diversity and its inclusion

in nursing education in principle, but their

practices and behaviors often reveal a lesser

allegiance (Paterson, Osborne, & Gregory,

2004). Further, the evidence presented sug-

gested that bias and discrimination were

a systems issue at the institutional level as

well as a systemic issue, that is, biased and

discriminatory behavior is not limited to

one particular group. Minority students

experienced bias and discrimination in their

interactions with all of the groups of people

involved in their learning.

Rather than suggesting universities

increase the recruitment of minority faculty,

Paul (2003) suggested that implementing a

double-loop diversity and institutional policy

would better help faculties and students look

more closely at the challenges or obstacles

associated with discrimination and bias by

addressing the true underlying problems for

achieving cultural diversity. This self-reflec-

tive approach would encourage faculty and

students to ask, “What cultural values and

beliefs are we perpetuating that may contrib-

ute to low [First Nations/Aboriginal, Asian,

[b]lack American, Latino, Other] student

enrollment at our school?” (p. 46).

Nursing program administrators and

faculty are also encouraged to revisit their

mission statements. Mission statements that

clearly articulate a commitment to support-

ing cultural diversity are important chan-

nels through which institutional change

can occur and offer an anchor for frequent

evaluation of whether the institution is liv-

ing up to its promises (Ackerman-Barger,

2010). Further, they present to all of their

stakeholders, including registered nurses

involved in undergraduate nursing education,

statements that capture authentic apprecia-

tion and valuation — not simply tolerance —

of racial and ethnic diversity. Such statements

can only enhance minority students’ sense of

belonging.

Although the data suggest that bias and

discrimination are system-wide concerns,

individual clinical nursing instructors, RNs,

and student peers must be responsible for

their own practices. These data echo the Tilki

et al. (2007) findings and highlight minority

students’ need for support if they are to feel

valued as individuals. Seminars for faculty,

RNs, and students to address issues of racism

and help develop cultural competence and

safely raise awareness may help retain ethni-

cally diverse students (Doutrich, Wros, del

Rosario Valdez, & Ruiz, 2005; Noone, 2008).

Cultural competence in clinical nurse

education includes curriculum content as

well as pedagogic processes. As the number

of international students admitted to nursing

programs increases, faculty and students are

faced with a variety of potential challenges,

including adapting to a change in sociocul-

tural context, social integration, and differ-

ences in teaching and learning approaches.

Another significant issue is language

diversity. International students may experi-

ence difficulty in clinical settings with the

use of terminology, understanding patient

requests, or providing explanations (San

Miguel, Rogan, Kilstoff, & Brown, 2006),

as well as engaging in advocacy behaviors

that are perceived as required in complex

health environments. Tutoring and using the

“buddy system” while in the clinical setting

may assist these students in developing confi-

dence and support the development of a less

competitive environment (Noone, 2008).

Another way to facilitate cultural compe-

tence is for nursing programs and faculties to

adopt a transformative learning approach in

which the starting point is to engage in self-

examination and reflection of ethnocentric

ideas, personal prejudices, and assumptions.

This reflection will raise clinical nursing

instructors’ awareness of and sensitivity to

92 M A R C H / A P R I L 2 0 1 4 V O L U M E 3 5 N U M B E R 2 93

the alienation felt by minority students and

the potential tensions that exist between dif-

ferent clinical group members (Tilki et al.,

2007). Clinical nursing instructors should

be encouraged to confront as well as help

students and RNs with whom students work

to engage in dialogue about uncomfortable

issues and negotiate acceptable solutions to

problems. Adopting a “no-blame” culture

may empower minority students, clinical

nursing instructors, students, and RNs to

address sensitivities and challenge discrimi-

nation and racism.

limitations Data were collected from one undergradu-

ate nursing program in a western Canadian

province. Hence, generalizability of the

findings to minority students in other

undergraduate nursing programs is limited.

Further, a limited number of racial and eth-

nic groups made up the sample, and religious

and gender groups were not deliberately

represented in the sample. More research

is needed to widely represent racial, ethnic,

religious, and gender groups so that minor-

ity students’ sense of belonging might be

better understood.

concLusIon Based on the findings of this study, bias and

discrimination exist at the institutional and

individual levels, thus negatively impacting

minority students’ sense of belonging during

clinical experiences. Implementing a dou-

ble-loop diversity institutional policy, devel-

oping mission statements that appreciate and

value diversity, and engaging in transfor-

mative learning are strategies that may help

minority students develop a sense of belong-

ing during their clinical experiences. In addi-

tion, these strategies may assist nursing pro-

grams in attracting a more varied nursing stu-

dent population, thus resulting in a nursing

workforce to meet the health care needs of all

Canadians. For nursing programs to recruit

and retain an ethnically diverse nursing stu-

dent population, undergraduate nursing fac-

ulty must address the challenges and issues

within nursing education programs that may

alienate and negatively impact the sense of

belonging of ethnic minorities during clini-

cal experiences.

about the authoRs

The authors are faculty at the University

of Lethbridge Faculty of Health Sciences,

Lethbridge, Alberta, Canada. Monique

Sedgwick, PhD, RN, is an assistant professor.

Tracy Oosterbroek, MSc (Nursing), RN, is an

academic assistant. Victoria Ponomar, BN,

is a registered nurse. For more information,

contact [email protected].

keY WoRds

Minority – Nursing Students – Undergraduate

– Diversity – Belonging – Clinical Education

feelings of Belonging

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