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Baccalaureate minority nursing students perceived barriers and facilitators to clinical education practices: an integrative review.

Abstract

AIM This integrative review synthesized baccalaureate minority nursing students' perceptions of their clinical experiences.

BACKGROUND The diversity of the nursing workforce does not mirror the United States population. Attrition rates of minority nursing students remain higher than rates for White students. Literature examining facilitators and barriers to minority student success predominantly focuses on academic factors, excluding those relevant to clinical education.

METHOD An integrative review using literature from nursing and education.

FINDINGS Three common perceived barriers were identified: discrimination from faculty, peers, nursing staff, and patients; bias in faculty grading practices; and isolation.

CONCLUSION Although little is known about the relationship between clinical failures and overall attrition, this review provides evidence that minority students encounter significant barriers in clinical education. To increase the diversity of the nursing workforce, faculty must address these issues and make modifications to ensure an equal opportunity at a quality education for all students.

KEY WORDS Minority Nursing Student--Diversity--Nursing Education--Clinical Nursing

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The diversity of the current nursing workforce does not mirror that of the United States population (Melillo, Dowling, Abdallah, Findeisen, & Knight, 2013). Minority nurses are underrepresented, comprising only 16.8 percent of the nursing population, whereas the total US population is 22.3 percent minority (US Census Bureau, 2013; US Department of Health and Human Services, 2010). A recent census report projected that, by 2043, racial and ethnic minorities will make up over half of the population (America.gov, 2010).

A culturally diverse nursing workforce is necessary to meet the health care needs of this increasingly diverse population. Improvements in nursing workforce diversity and cultural competence education for health care providers are among the most potentially effective interventions needed to reverse the numerous differences found in the quality of health care provided to racial and ethnic minorities (Pacquaio, 2007). National organizations, including the National League for Nursing (NLN), the American Association of Colleges of Nursing (AACN), the Institute of Medicine (IOM), and the American Nurses Association (ANA), agree that increasing the racial and ethnic diversity of students in nursing programs is a high priority (AACN, 2009; American Nurses Association, 2011; Institute of Medicine, 2011; Loftin, Newman, Dumas, Gilden, & Bond, 2012; NLN, 2010). Therefore, it is important to identify and address both facilitators and perceived barriers to the success of minority nursing students in all aspects of their nursing education.

Barriers to successful completion of a nursing program for minority nursing students include financial and work issues (Amaro, Abriam-Yago, & Yoder, 2006), inadequate academic preparation and study skills (Amaro et al., 2006), lack of support from family, role models, or mentoring (Amaro et al., 2006; Taxis, 2006; Villarruel, Canales, & Torres, 2001), and experiences with discrimination and isolation in the clinical setting (Sedgwick, Oosterbroek, & Ponomar, 2014). These barriers have contributed to a disparity in the nursing profession and resulted in attrition rates as high as 85 percent in minority student populations (Gardner, 2005; Giddens, 2008; Taxis, 2006).

Efforts to admit, retain, and graduate minority nursing students have resulted in increases in the number of minority students graduating from BSN programs overall, from 24.6 percent in 2009 to 28.4 percent in 2013 (AACN, 2009-2013). Despite these efforts, attrition rates continue to be a concern as the number of Black and Hispanic nursing students graduating from BSN programs continues to fluctuate (AACN, 2009-2013; Coleman, 2008; Jeffreys, 2012; Taxis, 2006). Although the number of minority nursing students enrolled in both associate degree (ADN) and BSN programs have only slightly decreased, from 29 percent in 2009 to 28 percent in 2014, there have been significant decreases in Black and Hispanic student enrollment in ADN programs. Hispanic student enrollment in ADN programs has fluctuated, from 7.6 percent in 2009 to 6 percent in 2012, with Black student enrollment decreasing from 13.9 percent in 2009 to 9 percent in 2012 (NLN, 2009-2013).

The literature is replete with studies identifying facilitators and barriers to successful completion of nursing programs by minority students; however, these studies and interventions focus on academic factors in the classroom and fail to incorporate clinical education experiences. This lack of attention to clinical education is significant, as nursing students report clinical experiences to be the most influential factor in the development of their nursing skills, knowledge, and transition into the professional nurse role (Chun-Heung & French, 1997; Sedgwick et al., 2014).

Minority students continue to encounter significant barriers in the clinical component of their education programs (Ackerman-Barger, 2010). Because there is sparse literature addressing issues concerning nursing student clinical failure (McGregor, 2007), it is unclear if a relationship exists between attrition rates and the perceived clinical barriers reported by minority nursing students. The purpose of this integrative review is to identify how undergraduate minority nursing students' perceptions, including facilitators and barriers, of their clinical education experiences is reported in the published literature.

THEORETICAL FRAMEWORK

Jeffreys' Nontraditional Undergraduate Retention and Success (NURS) model guided this review. This ecological model provides a discipline-specific framework that addresses the multidimensional factors affecting retention of nursing students in order to identify at-risk students, develop prescriptive strategies for success, guide Innovations in educational research, and evaluate intervention effectiveness (Jeffreys, 2012). The model posits that the retention and overall success of nontraditional nursing students is based on the interaction of student characteristics, including race and ethnicity, with academic factors, professional integration factors, environmental factors, outside surrounding factors, and psychological factors.

Academic factors in the NURS model include personal study skills, study hours, attendance, class schedule, and general academic services (Jeffreys, 2012). Environmental factors are presumed more important for nontraditional nursing students than academic factors and include those factors external to the academic process such as financial status, family emotional support, living arrangements, and transportation. Outside surrounding factors are those factors existing outside the academic setting such as the health care system and nursing professional issues. Finally, professional integration factors include those factors that enhance students' interaction with the social system of the college environment such as memberships in professional organizations, encouragement by friends, peer mentoring, and enrichment programs.

Nontraditional in the Jeffreys (2012) model refers to a nursing student who is enrolled in an entry-level undergraduate nursing program and who meets one or more of the following criteria: a) 25 years or older, b) commuter, c) enrolled part-time, d) male, e) member of an ethnic and/or racial minority, f) speaks English as a second (other) language, g) has dependent children, h) has a general equivalency diploma, and I) is required to take remedial classes. This integrative review focuses on nontraditional students who are members of an ethnic and/or racial minority. The facilitators and barriers reported in this review were organized using concepts of the NURS model.

METHOD

This integrative review follows the five steps as identified by Whlttemore and Knafl (2005). These steps include problem identification, literature search, data evaluation and analysis, and presentation. Using a two-step strategy, a literature search was conducted to find relevant and related studies published between 1985 and 2015. Consultation with a reference librarian aided in the refinement of search terms in the databases.

In the first step of the search, the key words minority, diversity, education clinical, nursing, and baccalaureate were used in various combinations with the Boolean "and" in the Academic Search Complete, Cumulative Index to Nursing and Allied Health Literature, Educational Resources Information Center, Education Full Text (H.W. Wilson), Ovid/MEDLINE, Scopus, and PubMed databases to ascertain articles relevant to the concept of interest. In the second step of the search, the reference lists of all articles meeting inclusion criteria were searched for additional manuscripts. This strategy initially yielded 634 articles.

For Inclusion in this review, peer-reviewed articles were required to report on a sample of minority nursing students who were currently enrolled in or previously graduated from an ADN or BSN degree nursing program. Studies that focused on all other types of nursing programs were excluded from this study. Articles were excluded if published prior to 1985; a review of the literature revealed that there had been no studies dealing directly or indirectly with minority students' feelings about their education experiences prior to this year. Articles were also excluded if they reported on studies conducted outside the United States and Canada.

Titles and abstracts were reviewed for relevance, eliminating many articles from the review. In total, 14 articles met the selection criteria and were included in this review.

RESULTS

Of the 14 studies included in this review, 10 are qualitative, 1 is a mixed-methods study, and 3 are descriptive. The majority are at least 10 years old; 2 are less than five years old. Minority students represented in the review include Blacks, Hispanics, Asian/Pacific Islander, Portuguese, Filipino, First Nation/Aboriginal, American Indian, and other. Four studies were conducted with samples composed of a combination of White and minority students (Anfinson, 1999; Evans, 2008; Mahat, 1998; Sedgwick et al., 2014).

The subheadings in this section consist of the factors that influence retention of nontraditional nursing students according to the NURS model. The reviewed studies are presented in Table 1 and rated using the Melnyk and Fineout-Overholt (2011) system for determining hierarchy of evidence.

Academic Factors

Of the 14 studies in this review, five identified academic factors from the NURS model as perceived barriers to clinical education practices that may affect retention of minority nursing students (Anfinson, 1996; Evans, 2008; Jordan, 1996; Langston-Moss, 1997; Tucker-Alien, 1991). Two studies (Langston-Moss, 1997; Tucker-Alien, 1991) described Black students' feelings that both clinical assignments and grading were generally unfair in comparison to assignments and grading for their White peers. Hispanic and Asian/Pacific Islander students in these studies viewed the grading practices of clinical faculty as being much fairer than the grading practices of faculty in classroom settings.

In contrast, 18 White students in the Evans (2008) study were asked how school was going, and only one student identified fear of failure in the clinical setting. Evans, Jordan (1996), and Langston-Moss (1997) described the students' clinical experiences and practices In the assessment lab as being void of culturally appropriate practice, with textbook material focused only on White patients. Black students in the Jordan study further expressed concern that the exclusion of culturally appropriate nursing care was a systems issue and was overall unfair to all nursing students, as they would be unprepared as RNs to care for diverse patient populations. Anfinson (1999) described the students' perceptions of clinical faculty's negative assumptions regarding their level of competence in the clinical setting and how this may alter the students' learning experience and academic outcomes.

Outside Surrounding Factors

Two studies in this review identified outside factors that exist as perceived barriers for undergraduate students. Langston-Moss (1997) and Amaro et al. (2006) concluded that minority students experience discrimination from nursing directors, staff, and patients in their clinical education practices. Students told of encounters in which they experienced offensive comments from nursing directors and patients regarding their English as a second language.

Professional integration Factors

Minority students in 11 studies perceived professional integration factors as barriers to clinical education practices. These studies identified negative interactions between minority students and clinical faculty, peers, and nurses to whom they were assigned during clinical rotations. In contrast, Villarruel et al. (2001) identified no perceived barriers to clinical education practices of Hispanic students. Villarruel et al. (2001) and Tucker-Alien (1991) identified experiences promoting professional integration with Hispanic students. Students reported that their clinical experiences in Hispanic communities were beneficial. Patients and clinical faculty valued their bilingual skills, and experiences were organized to ensure success.

Four studies in this review identified interactions with peers in the clinical setting as barriers for Black and Asian/Pacific Islander students. Students reported being the last chosen by their peers in the laboratory, which created a sense of being other (Aiken, Cervero, & Johnson-Bailey, 2001; Dapremont, 2011; France, Fields, & Garth, 2004; Sedgwick et al., 2014). Hispanic students in the study by Evans (2008) reported that being the only Hispanic students in the lab led to repeated absences.

Some Black, Hispanic, and American Indian students perceived that covert racism and racial profiling were present and relayed by both faculty and peers (Aiken et al., 2001; Evans, 2008; Langston-Moss, 1997). These students provided specific encounters of racially offensive comments from both White students and faculty in the clinical area. Langston-Moss (1997), Mills-Wisneski (2005), and Anfinson (1999) reported that the absence of minority faculty in the clinical setting was a perceived barrier fa minority nursing students.

Two studies (Gapper, 2006; Sedgwick et al., 2014) reported students' feeling that nurses in the clinical setting did not share their professional and personal values. These differences impacted their behavior and communication.

One study (Mahat, 1998) identified no significant correlations between stressors (e.g., initial experiences, interpersonal relationships, heavy workload, feelings of helplessness) and the ability to perform roles among Filipino and Hispanic students. However, it identified positive correlations between interpersonal relationships and seeking social support coping strategies from Black and White students. The small sample size (15 African American students) precluded meaningful analysis.

Additional Findings

No studies in this review collected individual-level measures to identify minority nursing students' satisfaction with the clinical component of their educational experience. In addition, no study focused on both academic and nonacademic outcomes in minority nursing students. The NURS model posits that psychological outcomes such as satisfaction mediate performance and persistence outcomes (Jeffreys, 2012). No studies focused on facilitators to minority student success in clinical education practices. Only four studies focused on the clinical experiences of diverse groups of nursing students (Anfinson, 1999; Evans, 2008; Mahat, 1998; Sedgwick et al., 2014).

DISCUSSION

Perhaps the most noteworthy finding of this integrative review is that, despite the congruence in perceived barriers to clinical education practices as reported by minority students in nursing programs throughout the US, no high level of evidence or intervention studies exist in this area. The barriers reported add to the barriers to success for minority nursing students identified in an integrative review by Loftin, Newman, Gilden, Bond, and Dumas (2013). Results support the need for nursing programs to adopt a multidimensional approach for the overall success of minority students in clinical education practices by selecting and adapting strategies that best fit the students' needs and resources.

Results of this review highlight the need for the nursing profession to focus its endeavors on the Sullivan Commission's (2004) recommendation to increase the diversity of the nursing workforce by first acknowledging the exclusive Eurocentric culture of nursing education (DeBrew, Lewallen, & Chun, 2014). Efforts must be implemented to change the environment to one that ensures diverse groups of learners are successful in all aspects of their nursing programs.

The evidence presented suggests that bias and discrimination are both an issue at the nursing program level as well as a systemic issue as students in these studies experience bias and discrimination with all groups of people in their clinical education practices. DeBrew and colleagues (DeBrew et al., 2014; DeBrew & Lewallen, 2014) conducted a qualitative study to describe faculty decision-making regarding clinical evaluation; 88 percent of participants were White women. Faculty struggled with whether to pass or fail students who are often viewed as outsiders in nursing education.

Findings from this review confirm that prejudicial and discriminatory practices of clinical faculty have a negative effect on the clinical experiences of minority nursing students. Because nurse faculty in the US are primarily White women, it is imperative that unbiased and culturally competent pedagogical efforts are taken to ensure that race does not play a role in the instruction and evaluation of minority students (AACN, 2011a, 2011b; Hassouneh, 2006; Puzan, 2003). Students who may harbor this suspicion must be disabused of the notion that bias exists from clinical faculty (Anfinson, 1993). The clinical evaluation process requires analysis and restructuring to ensure an objective, inclusive process in which faculty avoid unintentionally holding students to their own cultural norms.

The participants in the reviewed studies most commonly described clinical experiences affecting professional integration and socialization. These findings are alarming because professional integration factors are at the center of the NURS model and are considered the crossroads of a nontraditional nursing student's decision to persist, drop out, or stop out (Jeffreys, 2012). Opportunities for professional socialization in clinical experiences can become facilitators of success and achievement for diverse students (Jeffreys, 2012; Loftin et al., 2012). However, nursing programs have failed to identify best practices or develop enrichment programs for minority students in their clinical education practices.

Multiple nursing remediation programs focus on academic factors, with increased retention the primary intervention outcome. Very few clinical remediation programs exist for nursing students overall, with even fewer programs implementing and evaluating the effectiveness of interventions aimed at facilitating minority student success in the clinical setting (Gallant, McDonald, & Smith Higuchi, 2006; Loftin et al., 2013). The development and testing of enrichment programs focusing on both clinical and emotional support during the key transitional phase from nursing student to professional nurse is vital and will provide minority students safe avenues to be successful in their nursing careers.

The findings from this review have implications for nurse faculty, program administrators, and clinical education practice partners. Commitment to the retention and program success of minority nursing students can significantly reduce, if not eliminate, many of the barriers they face and increase the retention of minority nursing students.

This review includes only students currently enrolled or recently graduated from a nursing program. It is not clear if minority students who are not able to persist through to program completion have similar or additional barriers to success that are not identified by those who are successful in their nursing programs.

CONCLUSION

To achieve a nursing workforce that is able to meet the health care needs of all patient populations, advances to promote diversity in nursing education must begin with changing its exclusive, traditional culture to one that ensures that all learners are provided an equal opportunity to a quality nursing education. The first step is to address the challenges and issues within nursing education programs that may negatively impact the clinical experiences of minority nursing students. This integrative review provides evidence of the significant barriers minority nursing students encounter in their clinical education experiences that may affect attrition.

Crystal L. Graham, MSN-Ed, RN, CHSE, Is a PhD candidate and simulation lab coordinator/instructor, Francis Marion University Department of Nursing, Florence, South Carolina. Shannon M. Phillips, PhD, RN, CCRN, is assistant professor, Medical University of South Carotina College of Nursing. Susan D. Newman, PhD, RN, CRRN, is associate professor, Medical University of South Carolina College of Nursing. Teresa W. Atz, PhD, RN, CHSE, is assistant professor, Medical University of South Carolina College of Nursing. For information, write to cgraham@fmarion.edu.

doi:10.1097/01.NEP.0000000000000003

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Table 1: Presentation of Studies

Author,       Study Purpose               Theoretical Framework
Date

Tucker-       Ascertain minority          None stated
Alien,        nursing students'
1991          feelings about
              educational
              experiences in large,
              urban, multiuniversity
              setting.

Jordan,       Examine lived               Critical
1996          experience of African       hermeneutic
              American students           inquiry
              enrolled in
              predominantly White
              BSN programs.

Langston-     Explore experiences         None stated
Moss,         of Black American
1997          female students in
              predominantly White
              ADN/BSN programs.

Mahat,        Identify junior BSN         Theory of
1998          nursing students from       cognitive
              different ethnic            appraisal of stress
              backgrounds
              perceived stressors/
              coping strategies
              during clinical
              component of their
              nursing education.

Anfinson,     Twofold, to explore         None stated
1999          nursing students'
              perceptions regarding
              differences in clinical
              experience that relate
              to minority-racial
              status/to suggest
              processes that
              facilitate knowledge
              application in
              clinical setting.

Aiken et      Explain factors that        Black feminist
al., 2001     encouraged/
              discouraged the
              participation of Black
              women in RN
              completion programs.

Villarruel    Identify barriers and       None stated
et al.,       bridges to
2001          educational mobility as
              experienced by
              Hispanic nurses who
              advanced from an
              ADN degree to a BSN
              degree.

France et     Explore lived               Watson's Theory
al., 2004     experience of Black         of Human
              nursing students in         Science and
              predominantly White         Human Care
              university in rural
              Southeastern community
              to develop interventions
              for retention.

Mills-        Examine African             None stated
Wisneski,     American BSN
2005          students' perceptions
              of the absence of
              minority nursing
              faculty in their
              program.

Amaro et      Determine ethnically        Grounded theory
al., 2006     diverse nursing
              students' perceptions
              of educational barrias.

Gapper,       Explore past and            VanManen's
2006          present expaiences          lifeworld
              of first-genaation          conceptual
              immigrant Asian             framework
              American students           of human
              enrolled in an urban        beings using four
              ADN program.                existentials

Evans,        Compare/contrast            Theory of Human
2008          perceptions concerning      Caring of Watson
              barriers to success fam     and caring
              Hispanic/Latino and         curriculum of
              American Indian BSN         Bevis and Wktson.
              students with
              corresponding
              perceptions from a
              comparison group of
              Anglo students.

Dapremont,    Examine perceptions/        Theoretical Model
2011          experiences                 of Dropout
              contributing to the
              success for Black
              graduates who attended
              nursing degree
              programs with
              predominantly White
              students.

Sedgwick      Identify factors that       None stated
et al.,       influence minority
2014          nursing students' sense
              of belonging during
              clinical experiences.

Author,       Study Design                 Sample
Date

Tucker-       Descriptive using            44 minority nursing
Alien,        three-part survey            students enrolled in
1991          developed by                 nursing program at
              researcher: Minority         large, Midwest,
              Student Nurse                urban college of
              Questionnaire.               nursing: 20 Black,
                                           11 Hispanic,
                                           13 Asian/Pacific
                                           Islander (API).

Jordan,       Qualitative critical         Four African
1996          hermeneutic using            American nursing
              individual interviews        students enrolled in
                                           junior/senior year in
                                           predominantly White
                                           BSN program.

Langston-     Qualitative                  Nine senior Black
Moss,         phenomenological             female nursing
1997          using individual             students: 1 enrolled
              interviews.                  in BSN program,
                                           8 in 2-year technical
                                           college.

Mahat,        Descriptive using            107 junior BSN
1998          a demographic                students enrolled in
              questionnaire and            college of nursing In
              Critical Incident            Northeast; 60 White,
              Technique Tool to            15 Black, 14 Filipino,
              measure perceived            13 Hispanic, 4 other.
              stressors;
              96% content
              validity established
              by 2 clinical nurse
              educators.

Anfinson,     Qualitative pitot            Seven female/1 male
1999          including                    first-year ADN
              observation                  students. Five
              of clinical                  students' were White,
              experience/                  2 Black, and
              individual informant         1 Hispanic.
              interviews.

Aiken et      Qualitative                  Seven Black women
al., 2001                                  attending RN
                                           completion programs.

Villarruel    Qualitative using            Six focus groups with
et al.,       focus groups in six          37 female nurses of
2001          sites (San Jose/             mixed Hispanic
              San Francisco, CA;           ethnicity who were
              B Paso/San Antonio,          bom in US or
              TX; Springfield, MA;         emigrated from Latin
              New York City)               American countries.

France et     Qualitative                  Four Black students
al., 2004     phenomenological             enrolled in a
              using individual             BSN program
              interviews, field notes,     (entire Black student
              and the research             body in the program).
              assistant's journal.

Mills-        Descriptive design           Convenience sample
Wisneski,     using the                    of 66 female/5 male
2005          researcha-designed           Black junior BSN
              5-point Likert scale         students at
              followed by                  9 private/state
              open-ended                   universities in North
              question to explain          Atlantic and
              rating. No data for          Southern regions of
              tool validity/reliabilrty.   the United States.

Amaro et      Qualitative grounded         17 ethnically diverse
al., 2006     theory using in-depth        recent RN graduates
              individual interviews        from both ADN and
                                           BSN degree
                                           programs. 8 were
                                           Asian, 4 Latino,
                                           2 Portuguese,
                                           2 African American.

Gapper,       Qualitative                  Nine Asian American
2006          phenomenological             students in urban
              single-site method           ADN program.
              using in-depth
              interviews.

Evans,        Qualitative using            12 Hispanic/Latino,
2008          semistructured               2 American Indian,
              interviews                   18 Anglo students
                                           enrolled at 2
                                           private/2 public
                                           colleges and
                                           universities in
                                           Spokane area.

Dapremont,    Qualitative using            16 male/2 female
2011          semistructured               Black participants
              in-depth                     from four different
              interviews                   BSN/ADN nursing
                                           schools in the
                                           midsouthern
                                           United States.

Sedgwick      Mixed methods                461 students
et al.,       using the                    total with
2014          Belongingness                44 questionnaires
              Scale Clinical               completed by
              Placement                    2 Black students,
              Experience and               3 Latino, 9 First
              semi structured              Nation/Aboriginal,
              qualitative                  16 Asian, and
              interviews.                  11 other. Seven
                                           students volunteered
                                           to participate in semi
                                           structured interviews
                                           following the
                                           questionnaire.

Author,       Findings
Date

Tucker-       Ten Black students felt
Alien,        faculty were helpful in
1991          clinical area: 10 felt the
              opposite and that
              grading practices were
              unfair. Hispanic and API
              students viewed grading
              practices of clinical
              faculty as more fair than
              faculty in other areas.
              Hispanic students felt
              that lab sessions were
              organized to ensure
              minority student success;
              Black/API students
              disagreed.

Jordan,       Students reported
1996          feelings that educational
              practices never centered
              on racially diverse
              patients/void of
              opportunities to practice
              culturally appropriate
              nursing assessments.
              Blamed writers of the
              textbooks for lack of
              culturally competent
              material.

Langston-     Students reported
Moss,         stereotyped thinking by
1997          White peers in clinical
              setting. Negative
              comments by White
              nursing director of the
              clinical assignment floor.
              Health assessment tools
              biased. No Black clinical
              faculty. Unfair and more
              difficult clinical
              assignments/different
              consequences in clinical
              area/unfair grading
              practices.
              Continued

Mahat,        No significant correlations
1998          found in stressors/coping
              strategies of Filipino/
              Hispanics. Initial
              experiences identified as
              stresslul by White and
              Black students. Positive
              correlations found
              between interpersonal
              relationships/seeking
              social support coping
              strategies of both Black
              and White students.
              Negative correlation found
              between initial
              experiences/seeking
              social support among
              Black students.

Anfinson,     Two minority/2
1999          nonminority participants
              perceived no differences
              in clinical experiences.
              One minority/3
              nonminority perceived
              differences related to
              minority-racial status.
              Minority status of staff
              nurse may facilitate or
              Impede the students'
              communication with
              individual. Minority
              students perceived that
              clinical faculty made
              negative assumptions
              regarding their abilities
              In clinical setting.

Aiken et      Grouped according to
al., 2001     factors that encouraged/
              discouraged participation
              in the program; no
              factors encouraging
              participation. Those
              discouraging included
              seeing self as other/
              covert racism (e.g.,
              treatment compared to
              White peers)/faculty
              unwilling to touch Black
              students when
              demonstrating techniques
              in lab.

Villarruel    No clinical barriers
et al.,       identified. Bridges
2001          included having clinical
              experiences in Hispanic
              communities and
              perceived value of their
              bilingual language skills by
              clinical faculty and patients.

France et     Students reported being
al., 2004     the only one in the lab
              and last to be chosen
              because peas feel they
              don't know anything.
              Feeling like "the other."

Mills-        Students report that
Wisneski,     nurses at the clinical
2005          facility who are Black
              give them a Black
              perspective on nursing.

Amaro et      Several participants
al., 2006     denied prejudice or
              discrimination from
              nursing teachers but
              perceived prejudice,
              discrimination, or racism
              in clinical experiences
              from staff and clients.

Gapper,       Cultural differences
2006          impacted behavior and
              communication in the
              clinical setting.

Evans,        Hispanic students
2008          reported not coming to
              lab as they were only
              Hispanics in the class.
              Also reported repeated
              incidents of discrimination
              in clinical groups. Faculty
              racial profiling of students
              led to inappropriate clinical
              assignments. Lack of
              diversity and instruction
              with diverse patients.

Dapremont,    Participants expressed
2011          vital need for peer
              support from other Black
              students. These
              relationships were often
              formed during clinical
              experiences.

Sedgwick      All students viewed
et al.,       clinical placements as
2014          possible place to
              experience sense of
              belonging. First Nations/
              Aboriginal, Asian, Other
              felt discriminated against.
              Did not perceive they
              worked with nurses who
              shared professional and
              personal values. Identified
              that nurses they worked
              with, clinical instructors,
              and peer groups have the
              most influence, positive or
              negative, on clinical
              experiences.
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Author:Graham, Crystal L.; Phillips, Shannon M.; Newman, Susan D.; Atz, Teresa W.
Publication:Nursing Education Perspectives
Date:May 1, 2016
Words:5630
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