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LaDonia D. Patterson, EdD, RN, CNE

African American Males as Registered Nursing Students: A Scoping Review

Abstract: The purpose o f this scoping review was to assess the nursing education literature regarding African American male pre-licensure nursing students. There is a lack o f diversity among registered nurses, with African American males being one o f the most underrepresented groups in the profession. As such, understanding factors that hinder and facilitate their entry into the profession is imperative. The author searched the electronic databases CINAHL, ProQuest, and ERIC using the search terms that included African American, Black, male, nursing, and student. The search generated two thousand eight hundred seventy- eight titles. Seven studies were included in the scoping review. Results from the scoping review revealed themes that may influence retention and successful completion o f pre-licensure nursing programs fo r African American male students.

Key Words: African American, Black, male, nursing student, retention

T he lack of diversity among registered nurses has garnered national attention, with clinicians, educators, and scholars working to identify

ways to address this issue (American Association of Colleges of Nursing [AACN], 2015,2017; Institute of Medicine [IOM] ,2011; National Advising Council on Nurse Education, 2013; National League for Nursing [NLN], 2016). Increasing diversity within the healthcare workforce has been identified as one part of a multifaceted approach to combatting the disparities that lead to poor health outcomes among minority patients in the U.S. (Kelly, 2015; Villarruel, Washington, Lecher,

& Carver, 2015; Williams et al., 2014). Although diversity among nursing students (AACN, 2017) and graduates from pre-licensure nursing programs (Campaign for Action, 2019) has marginally improved, the racial, ethnic, and gender composition of the registered nurse population still does not reflect that of the patient populations it serves. Lor example, although racial and ethnic minority groups comprise 39% of the U.S. population (U.S. Census Bureau, 2018), only 19% of registered nurses (RNs) in the U.S. represent racial and ethnic minority groups (Smiley et al., 2018). Similarly, men make up almost half of the U.S. population (Bureau of Labor Statistics [BLS], 2018; U.S. Census Bureau, 2018), yet men comprise less than ten percent of the registered nurse population (Smiley et al., 2018). African American men belong to one of the most underrepresented groups in the nursing profession (Smiley et al., 2018).

Scholars recognize that retaining students from minority backgrounds in pre-licensure registered nursing programs is essential to increasing diversity in the registered nurse population (Bond, Cason, & Baxley, 2015; Dapremont, 2014; Kelly, 2015). As such, promoting retention of African American male students in pre- licensure registered nursing programs is one strategy that can be used to positively affect the number of African American male nurse graduates. To accomplish this, however, nurse educators must be aware of the circumstances that influence the retention of African American male pre-licensure nursing students. The purpose of this scoping review was to assess the nursing education literature to determine what is known about African American male pre-licensure nursing students.

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Table 1. Inclusion and exclusion criteria f o r literature search

Inclusion Criteria Exclusion Criteria

Primary qualitative or quantitative research studies, including doctoral dissertations

A research study conducted in the U.S.

Written and published in English

Published in a peer-reviewed academic journal

The study sample includes African American male baccalaureate degree or associate degree nursing students

Results specific to African American male nursing students reported in study findings

Abstract available

Review articles; non-research studies

A research study conducted outside of the U.S.

Written and published in a language other than English

Not peer-reviewed or published in an academic journal

Research study sample only includes primary, secondary education students or students in vocational/practical or graduate/doctoral nursing education programs No study findings specific to African American males reported

No available abstract

METHODOLOGY The author performed a scoping review of the

literature in order to determine the state of knowledge about African American male pre-licensure nursing students. A scoping review, also called a scoping study, is an approach to knowledge synthesis that is used to identify and map essential concepts related to a specific phenomenon (Arksey & O ’Malley, 2005; Whittemore, Chao, Jang, Minges & Park, 2014). The focus of a scoping review is to gather many primary evidence sources to increase the breadth of knowledge related to the phenomenon (Arksey & O ’Malley, 2005). For example, scoping reviews differ from systematic reviews in that scoping reviews include primary sources that represent a variety of research designs. This enhances what is known about the phenomenon by providing insight into the types of methodologies that are being used to research the phenomenon (Colquhoun et al.. 2014). The scoping review was an appropriate approach to knowledge synthesis for this particular inquiry because it appeared that the body of literature related to African American male nursing students would be limited. Thus, reviewing a diverse body of research studies allowed the author to glean as much insight as possible from the literature available.

Search method A literature search using the electronic reference

databases Cumulative Index to Nursing and Allied Health Literature (CINAHL®), ProQuest Nursing and Allied Health, Educational Resources Information Center (ERIC), ProQuest Education, and Education Full Text databases was conducted to ensure a comprehensive review that included sources indexed in nursing, allied health, and education databases. The search terms used to identify relevant studies were: Black, African American, minority, male, men, nursing student, and retention. Abstracts with relevant titles were reviewed. Studies that met the inclusion criteria for the scoping review were retained (see Table 1).

The searches of the electronic databases yielded a total of 3,990 titles that were reviewed: CINAHL® (« = 989), ProQuest Nursing and Allied Health {n = 1,889), ERIC (n = 297), ProQuest Education (n = 813), and Education Full-Text (n = 2). Thirty-two abstracts were reviewed for research studies with titles that met the inclusion criteria. Ultimately, only six studies from these searches were retained for the scoping review. An ancestry search using the reference lists of these six research articles was conducted. No additional studies were identified using this approach. Prior to conducting the search for the scoping review, one study had already been identified

The ABNF Journal 20 Winter 2020

through a traditional search of the higher education literature. That study was also included in the scoping review for a total of seven articles included in the review. None of these 3,990 titles generated from the searches were research studies that focused specifically on African American male pre-licensure nursing students.

Study selection To be selected for inclusion in the scoping review,

a research study had to meet the inclusion criteria. Research studies included in the review were published

between 2010 and 2017, conducted in the U.S., written and published in English in a peer-reviewed academic journal or were doctoral dissertations, and had an abstract available. Research studies were not limited to a specific research design; however, the study had to include as participants African American male students who were either enrolled in a pre-licensure associate degree or baccalaureate registered nurse program or had graduated from an associate degree or baccalaureate degree pre- licensure nursing program in the United States. Research studies also needed to report study findings specific to the

Figure 1. Study selection process

• Databases searched: CINAHL®, ProQuest Nursing and Allied Health, Educational Resources Information Center, ProQuest Education, Education Full-Text

• Search terms: (black OR African American OR minority) AND (male OR men) AND (nursing student) AND (retention)

• Articles published 2010-2017 n=3,990 titles for review

____________________________________±________________________________________ 1. 3, 990 titles reviewed 2. 18 duplicate titles excluded 3. 3,940 titles did not pertain to the topic of interest or meet inclusion criteria. The studies:

• had no results reported for African American/Black American male nursing students.

• were conducted outside of the U.S. • did not include nursing students in sample. • focused on practical nursing students. • were not primary research articles. • focused on cultural competence, clinical practice, or minority nursing faculty.

4. 32 abstracts reviewed 5. 26 studies were excluded based on abstract - did not meet inclusion criteria 6. six full-text articles/dissertations retained and included in the review 7. one article identified through a previously conducted review of the literature was

included

Studies that met inclusion criteria and included in scoping review n= 7

T h e A B N F Journal 21 Winter 2020

African American male study participants to be included in the review. Studies that were excluded focused on clinical nursing practice, African American males as patients, practical nursing programs, or African American males who were in fields other than nursing, such as counseling, education, and STEM (see Figure 1).

Charting data and summarizing results Charting data from research studies is required to

summarize and report results from studies included in a scoping review (Arksey & O ’Malley, 2005). For this scoping review, only research findings specific to African American males were charted. These data are charted in Table 2. Results for the scoping review are reported using the subthemes created using thematic analysis.

FINDINGS AND DISCUSSION Seven primary studies were included in this review,

three of which were doctoral dissertations. The primary focus of these research studies was on identifying what influenced minority student success in completing pre-licensure nursing programs. Promoting minority student success could play a critical role in increasing diversity in the nursing profession. Students who belong to underrepresented groups in nursing face barriers, such as academic difficulty, bias, social isolation, and lack of mentoring that can adversely affect their success in nursing education programs (Hodges et al., 2017; Murray, 2015a; Murray, 2015b; Sedgwick & Kellett, 2015; Smith & Smyer, 2015; White & Fulton, 2015). To ensure that a diverse group of nurse graduates are eligible to enter the nursing workforce, students who belong to underrepresented groups must be able to achieve success in attaining nursing degrees. As such, nurse educators need to identify strategies that can be employed to mitigate barriers to successful program completion.

Research design This scoping review failed to yield any quantitative

studies that met inclusion criteria. Thus, all of the research studies included in the review employed a qualitative research design, with six of the seven studies using a descriptive qualitative approach. African American male nursing students made up a relatively small number (n = 12) of the total number of participants (n = 50) included in the research studies for this review. Thus, researchers who are interested in examining African American males as nursing students might have difficulty recruiting a large enough sample to conduct a study using a quantitative research design.

Institution and program type There was diversity in program and institution type

between the seven research studies, with participants being enrolled in or having graduated from either an associate degree or a baccalaureate degree program at a Historically Black College/University or a Predominantly White Institution. However, none of the African American male participants were enrolled in or had graduated from an entry-level accelerated m aster’s degree program in nursing, a proprietary (for-profit) institution, or an online nursing program. Harris and Wood (2013) suggested that attending for-profit institutions of higher education could have adverse effects on success for men of color. Additionally, Palacios and Wood (2016) found that Black male students in community college achieved greater success when taking face-to-face courses. Many proprietary institutions offer online education programs (Sturgis, 2012) that are appealing to students from diverse backgrounds (Ke & Kwak, 2013; Sturgis, 2012). Therefore, future research should explore factors that influence success for African American male students enrolled in online pre-licensure nursing programs to determine if online education facilitates or further hinders success in program completion.

Demographic information The purpose of this scoping review was to identify

research studies that would provide insight into the experiences and attributes of African American male pre-licensure registered nursing students. Demographic information (ie age, marital status, employment status, etc.) for the African American male nursing students was not described in all of the research studies (see Table 2). However, three studies listed participants’ ages (Boruff, 2012; Goings, 2016; Sweet, 2012). These ages ranged from 27 to 50 years old, indicating that at least four of the African American male nursing students were older than traditional college-aged students (Jeffreys, 2015). Several of these students had children and family obligations outside of school (Barren, 2013; Boruff, 2012) . The African American male nursing students in the studies were described as high achieving, motivated, and confident (Barren, 2013; Goings, 2016).

Another participant was pursuing an associate degree in nursing as a second degree (Boruff, 2012). Having males enter nursing as a second career is beneficial to the profession because these men bring with them knowledge and insight from other disciplines and can offer innovative perspectives for addressing nursing issues (Christensen & Knight, 2014; Marks & Bevan, 2013) . Many of the African American males discussed being employed part-time while enrolled in an associate degree nursing program (Barren, 2013; Boruff, 2012).

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The ABNF Journal 25 Winter 2020

Thematic analysis During a thematic analysis of the results from the

research studies included in the scoping review, four themes emerged that provided insight into the perceptions and experiences of African American male pre-licensure

registered nursing students. These themes were: (a) deciding to pursue nursing, (b) being socially integrated, (c) being the only one, and (d) achieving success (see Table 3). Each theme is discussed in the following sections.

Table 3. What is known about African American male registered nursing students? Assignments and projects

______________Theme_________________________________ Associated Factors___________________

Deciding to pursue nursing as a • Nurses as family members (Barren, 2013; Boruff, career 2012)

• Observed nurses care for ill family members (Boruff, 2012)

Being socially integrated

Being the only one

Achieving success

Barriers to being socially integrated • Lack o f culturally responsive campus events (Sweet,

2012) • Being excluded (Barren, 2013; Dapremont, 2014) • Experiencing racism (Barren, 2013; Dapremont, 2014) • Feelings of inferiority (Sweet, 2012)

Facilitators to being socially integrated • Belonging to the Student Nurses Association (Boruff,

2012) • Feeling accepted/wanted (Barren, 2013; Boruff, 2012) • Interacting with peers (Barren, 2013; Dapremont,

2011; Sweet, 2012)

• Being the only African American/Black male in class (Boruff, 2012)

• No African American/Black males in the clinical setting (Boruff, 2012)

• Few/No African American/Black faculty (Sweet, 2012)

• Few/No African American/Black role models/mentors (Talley et al., 2016)

• Working as LPN provided preparation (Boruff, 2012) • Flaving determination (Boruff, 2012) • Being motivated (Barren, 2013; Going, 2016) • Maintaining support systems (ie family, friends, peers)

(Barren, 2013; Boruff, 2012; Dapremont, 2011; Goings, 2016; Sweet, 2012)

• Caring faculty - especially African American/Black faculty (Barren, 2013; Boruff, 2012; Sweet, 2012)

o Caring faculty can also positively influence social integration (Barren, 2013; Boruff, 2012)

• Positive institutional environment (Goings, 2016) • Overcoming academic barriers (Boruff, 2012) • Managing financial difficulty (Barren, 2013; Boruff,

2012)__________________

The ABNF Journal 26 W inter 2020

Deciding to pursue a nursing career Despite the need to increase diversity in the nursing

profession, minority students may not be interested in pursuing a career in nursing. Melillo, Dowling, Abdallah, Findeisen, and Knight (2013) found that only 45% of middle and high school students from diverse backgrounds expressed interest in a career in nursing. Additionally, Olichwier (2014) found that African American college students exhibited little interest in pursuing nursing as a career. Males may be diverted away from a career in nursing because of the profession’s image as being work for females. Thus, to increase gender diversity in nursing, it is imperative to understand what prompts men to enter the profession.

Having nurses as family members and observing nurses care for ill family members were identified as having positively influenced the decisions of African American males to pursue nursing as a career (Barren, 2013; Boruff, 2012). Although nursing is a female-dominated profession, men in nursing tend to earn more money annually than their female counterparts (Potera, 2015). Thus, nursing can offer stable employment and financial opportunities for African American males, a group that has historically been socioeconomically depressed (Xanthos, Treadwell, & Holden, 2010).

Being socially integrated Social integration, as it pertains to student retention

in higher education, refers to students’ feelings of being included in the social structure of an academic institution (Chang, Lerer, & Talley, 2010). Social integration can facilitate student success by improving persistence and retention (Tinto, 1975). Interactions with faculty and peers outside of the classroom can positively influence social integration (Chang, Lerer, & Talley, 2010; Wood & Harris, 2014). Each of the African American male nursing student participants discussed conditions that either positively or negatively influenced their interactions with peers and faculty members.

Tinto (1975) acknowledged the positive relationship between social integration and student persistence, suggesting that students who exhibit higher levels of social integration are less likely to drop out of college. Naturally, a student who is less likely to drop out has a greater chance of being retained in institutions of higher education. Additionally, Harris and Wood (2013) recognized the positive connection between social integration and student success for men of color in four-year institutions of higher education. Developing friendships with peers, participating in study groups, and belonging to student organizations promote social integration (Harris & Wood, 2013). African American males who participated in these seven research studies

perceived that faculty interactions and peer support contributed to their success in nursing school (Barren, 2013; Boruff, 2012; Dapremont, 2011, Goings, 2016; Sweet, 2012).

However, factors that hinder social integration also emerged during analysis. For example, the African American males shared their experiences with racism, being excluded, and feelings of inferiority (Barren, 2013; Dapremont, 2014; Sweet, 2012). Conditions such as these can adversely affect social interactions with peers and faculty members and weaken the social ties that African American males may have to the social structure of the college, adversely affecting social integration and potentially student retention. Being African American (Colville, Cottom, Robinette, Wald, & Waters, 2015; Herrera, 2013) and being male (Herrera, 2013) have been linked to a lower chance of being retained in a pre-licensure nursing program. Thus, examining and understanding the impact that social integration could have retention for African American male nursing students may be central to promoting their success in nursing programs.

Being the only one Some participants shared that they were the only

African American males in their class (Boruff, 2012). They noted that there were no African American males where they completed clinical rotations and few African American faculty members to serve as mentors and role models (Boruff, 2012; Sweet, 2012; Talley, Talley, & Collins-McNeil, 2016). The lack of African American male nurses and nursing students has implications for recruitment and African American male nursing student success. Concerning recruitment, the lack of African American males in nursing may prevent other African American males from pursuing nursing as a career, as students are more inclined to pursue careers that include individuals with backgrounds similar to theirs (Talley et al., 2016).

Feeling isolated, lonely, or alienated is not uncommon for African American and male nursing students; these feelings have been identified in the nursing education literature as being barriers to student success (Hodges et al., 2017; Murray, 2015a; Murray, 2015b; White & Fulton, 2015). Thus, being the only African American male in class may heighten feelings of isolation, loneliness, and alienation, which in turn, can decrease their sense of belonging (Sedgwick & Kellet, 2015; Sedgwick, Oosterbroek, & Ponomar, 2014). Sense of belonging has been associated with persistence and program success for African American male collegians (Harris & Wood, 2013).

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Achieving success Most of the research studies included in this review

focused on what facilitated success for minority nursing students in pre-licensure programs. African American males enrolled in these studies identified many circumstances that promoted their success in nursing school, such as having determination (Boruff, 2012), being motivated (Goings, 2016), and having support from family and friends (Boruff, 2012; Dapremont, 2011; Goings, 2016; Sweet, 2012). These men also suggested that caring faculty members (Boruff, 2012) and a positive institutional climate (Goings, 2016) also facilitated their success. One participant credited his success in an ADN program, in part, to working as a licensed practice nurse (LPN) before enrolling and while enrolled in the program (Boruff, 2012). While academic difficulty has been cited as a barrier to success for minority students, only one of the African American male nursing students reported academic difficulty (Boruff, 2012), while another was described by the researcher as being high achieving (Goings, 2016).

LIMITATIONS The primary limitation of this scoping review was the

small number of research studies included. Had a larger number of research studies been included in the scoping review, additional themes could have been identified, providing even more insight into African American males as pre-licensure nursing students. The limited number of research studies that convey the perspectives of African American male nursing students indicates a need for additional research focused on this population of nursing students.

Additional limitations are that the scoping review included only qualitative research studies that reflected the perspectives of only twelve men. It is probable that other African American male nursing students would not hold these perspectives. Descriptive quantitative data could be useful in determining how frequently the themes identified in this review reflect the perspectives of other African American male nursing students.

Results of this scoping review were also limited because studies published before 2010 were excluded. This criterion excluded the only available research study that focused on African American male baccalaureate nursing students (Dorsey, 2005). In this quantitative research study, nursing education administrators reported their perceptions of effective strategies for recruiting and retaining African American male students in baccalaureate degree nursing programs (Dorsey, 2005). These administrators perceived that financial aid was the most effective strategy for recruiting and retaining African American male nursing students (Dorsey, 2005).

Lack of adequate financial resources can hinder nursing program completion for minority nursing students (Bond et al., 2015). However, the issue of financial difficulty was referenced just twice in the findings from this review (Barren, 2013; Boruff, 2012). Far more prevalent in the findings for this scoping review were the factors that affected social integration.

IMPLICATIONS FOR NURSE EDUCATORS No studies about African American male nursing

students were generated by the search strategies employed in the scoping review. While results of this review have provided valuable insight into what is known about African American male pre-licensure students, these findings only represent perspectives of a few African American males. Therefore, this is an area that requires further scientific inquiry.

First, it is essential to identify which identified themes are most salient to the experience and success of African American male pre-licensure nursing students. For example, items related to social integration were discussed more frequently than those associated with academic or financial struggles. However, academic and financial struggles are two frequently cited barriers to minority nursing student success. Is it possible that experiencing racism, exclusion, and other factors that pose barriers to social integration are more of a threat to African American male nursing student success than the potential for poor academic performance and financial constraints? Or, is it possible that academic and financial issues did not pose as much of a barrier for African American men in these studies because they were older than the traditional age student and were able to balance work obligations with academic obligations? For example, Jeffreys (2012) noted that older students might be able to manage their time better and possess study skills that facilitate their success. Could this have been true for the African American men included in the research studies for this review? To answer these questions, research designs other than descriptive qualitative need to be employed in future studies.

Another question that arose during the thematic analysis was related to experiences with discrimination. African American nursing students and male nursing students often encounter discrimination and bias. Pham’s (2011) study of minority male nursing students, none of whom identified as African American, revealed that this group encounters bias related to both their race and their gender. These study participants reported encountering more bias related to their gender than their race/ethnicity (Pham, 2011). Conversely, Black male teachers perceived that they encountered more bias regarding race than their gender, as these teachers believed that being male still

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afforded them some privilege in a female-dominated profession (Brockenbrough, 2012).

Studies included in the scoping review focused on student success, which supports the need for shifting attention away from examining factors that pose barriers to minority student success to exploring factors that describe how minority pre-licensure nursing students overcome barriers to achieve success. Further inquiry into African American male nursing students should also explore how program type (ie online or accelerated master’s entry) and institution type (eg proprietary) influence student success.

CONCLUSIONS Retaining African American male students in pre-

licensure nursing programs can address issues related to the lack of diversity in the nursing workforce. Unfortunately, nursing education literature offers little evidence on this topic. Further exploration can guide nurse educators in implementing initiatives that can increase the representation of African American males in the nursing profession.

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LaDonia D. Patterson, EdD, RN, CNE, practices as a Registered Professional Nurse fo r the Wellness Center at Agnes Scott College in Decatur, GA. Dr. Patterson may be reached at: 141 E. College Ave., Decatur, GA 30030 or at: [email protected].

Acknowledgments This manuscript is a component o f a doctoral dissertation entitled “Achieving Success in Pre-licensure Registered Nursing Programs: An Explanatory Case Study o f African American M ales.” The author would like to acknowledge Drs. Christy Berding, Cynthia Brown, Cynthia Epps, and Tammy McClenny fo r their support and insight during the writing and editing process. The author would also like to acknowledge the African American male students she has had the pleasure o f teaching throughout her career as a nurse educator. Thank you fo r allowing me to be a part o f your journey.

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